1011044

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PRF0010.1177/02676591211011044PerfusionZhang et al.

Original Paper

Perfusion

Perioperative, protective use of extracorporeal

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DOI: 10.1177/02676591211011044
https://doi.org/10.1177/02676591211011044
thoracic surgery journals.sagepub.com/home/prf

Yan Zhang , Ming Luo, Bo Wang, Zhen Qin and Ronghua Zhou

Abstract
Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used in patients undergoing complex thoracic
surgical procedures. However, studies reporting the clinical outcomes of these patients are limited to case reports,
without real consensus. Our aim was to evaluate the perioperative use of ECMO as respiratory and/or circulatory
support in thoracic surgery: indications, benefits, and perioperative management.
Methods: Between May 2013 and December 2018, we reviewed the clinical data of 15 patients (11 males and 4 females;
mean age: 47 years old; range, 25–73 years) undergoing ECMO-assisted thoracic surgery in our hospital.
Results: Of the 15 patients, 10 cases received peripheral veno-arterial (VA) ECMO and five cases received veno-venous
(VV) ECMO. Indications for ECMO were pulmonary transplantation with hard-to-maintain oxygenation (n = 5), traumatic
main bronchial rupture (n = 2), traumatic lung injury (n = 1), airway tumor leading to severe airway stenosis (n = 2), huge
thoracic mass infiltrated vena cava (n = 5). The ECMO duration was 1–51 hours. All patients were successfully extubated
and weaned from ECMO postoperatively. The main complications were hemorrhage (26.7%), infection (33.3%), acute
hepatic dysfunction (33.3%), and venous thrombosis (26.7%). There was only one hospital death and postoperative one-
year survival rate was 86%.
Conclusion: Our experience indicates that ECMO is a feasible method for complex trachea-bronchial surgery, huge
thoracic mass excision and lung transplantation, and the ECMO-related risks may be justified. With further accumulation
of experience with ECMO, a more sophisticated protocol for management of critical airway or heart failure problems
in thoracic surgeries can be derived.

Keywords
ECMO; thoracic surgery; ventilation; circulation; perioperative management

Background centers have now replaced conventional CPB by ECMO

Extracorporeal membrane oxygenation (ECMO) has
been used for decades to support cardiopulmonary dis-
eases refractory to conventional therapy.1 It was first long-
term utilized in 1972 to support an adult patient with
respiratory failure in setting of traumatic chest injury2
and subsequently become a common method in the
management of children and adults with both cardiac and
pulmonary diseases. Moreover, short-term support in
hypoxic patients for nontraditional indications such as
critical airway obstruction, traumatic main bronchial
rupture, pulmonary embolism, and lung resection with
compromised pulmonary function should be assisted by
ECMO.3 ECMO is also an effective alternative to cardio-
pulmonary bypass (CPB) in surgeries combined with
large mediastinal tumors compressing or invading the
heart, large vessels, and tracheobronchial tree. Several
for patients with respiratory and/or cardiac failure during
lung transplantation.4 For severe primary graft failure,
ECMO may be set up early on.
In recent years, ECMO use during thoracic surgical pro-
cedure is limited to case reports, without real general
standard. The application of ECMO in patients undergoing
Department of Anesthesiology, West China Hospital of Sichuan
University, Chengdu, Sichuan, P.R. China
Yan Zhang and Ming Luo contributed equally to this article. Yan Zhang
and Ming Luo are joint first authors.
Corresponding author:
Ronghua Zhou, Department of Anesthesiology, West China Hospital of
Sichuan University, No. 37, Guoxue Xiang, Wuhou District, Chengdu,
Sichuan 610041, P.R. China.
Email: wr.zhou@hotmail.com
2 Perfusion 00(0)

Table 1.  Patients’ demographics and perioperative characteristics.

Case Age (years) Sex Diagnosis Surgical procedures IO Bleeding IO RBCT PO RBCT
(ml) (u) (u)
1 32 M The right main bronchial rup- Thoracotomy, right main bron- 300 1.5 1.5
ture, severe bilateral pulmonary chial rupture anastomosis
contusions with severe edema
and infected pleural effusion,
right pulmonary atelectasis and
consolidation
2 73 M Idiopathic pulmonary fibrosis Right lung transplantation 100 0 1.5
3 59 M Right lung cancer, with dia- Radical resection of pulmonary 1200 6 2
phragm, liver, and IVC infringed carcinoma, PR, IVR
4 61 M Pulmonary fibrosis Double lung transplantation 1000 7.5 4
5 25 M High fall injury, severe steno- Tracheal stenosis resection 200 2 1.5
sis after tracheotomy, severe and reconstruction
craniocerebral injury
6 40 M High fall injury, multiple pen- Thoracotomy for foreign body 2000 4 2
etrating wounds removal, LWR, LSAR
7 46 M Airway lesions, severe airway Tracheal tumors resection, 500 2 13.5
stenosis thyroidectomy, tracheostomy,
tracheoplasty
8 42 M Silicosis, severe pulmonary Double lung transplantation 3000 23.5 8
hypertension
9 41 F Anterior mediastinal mass, Mediastinal neoplasm excision, 200 6 10.5
severely compressed the SVC, SVR, IVR
IVC, and trachea
10 29 F Right thigh synovial sarcoma Pulmonary lobectomy, partial 13,000 39.5 2
with pulmonary metastasis, pericardiectomy, PR, IVR, HE
invaded liver, and IVC
11 44 F Lung cancer with thoracic Mediastinal neoplasm excision, 500 0 0
metastasis PR, LWR, IVR
12 64 M Chronic obstructive pulmonary Left lung transplantation 800 1.5 5
disease
13 59 M Pulmonary fibrosis Double lung transplantation 450 1 2
14 35 F Airway stenosis, postoperative Resection of thyroid and tra- 1500 6 0
metastasis of thyroid cancer cheal tumors, thyroidectomy,
tracheostomy, tracheoplasty
15 52 M Posterior mediastinal mass, Mediastinal neoplasm excision, 2000 15 2
severely compressed the SVC, PR, LWR, IVR
IVC
IO: intraoperative; PO: postoperative; RBCT: red blood cells transfusion; PR: phrenectomy and reconstruction; LWR: lung wedge resection; LSAR:
left subclavian arteriovenous repair; SVC: superior vena cava; IVC: inferior vena cava; SVR: superior vena cava replacement; IVR: inferior vena cava
replacement; HE: hepatectomy.

thoracic surgeries in West China hospital has gained great
clinical outcomes, with postoperative 1-year survival rate
exceeds 80%. Here, we report the results and experience of
ECMO support during thoracic surgery in our center.
Patients and methods
Demographics
This is a single center retrospective study. The study was
approved by the local ethics committee (Biomedical
Research Ethics Committee, West China Hospital of
Sichuan University) and the need for written informed
consent from the patients was waived as a result of using
the medical records obtained from previous clinical
practice. We contacted 15 thoracic surgeries in West
China Hospital with access to ECMO, including
Wenjiang Branch Hospital and Shangjin Branch
Hospital. Patients’ demographics and perioperative
characteristics are summarized in Table 1.
Implementation of ECMO
Most cases involved elective surgery and planned
ECMO support. Three emergency situations which
included critical preoperative conditions, such as air-
way collapse or severe lung injury caused by high fall
injury (case 1, 5, 6) and critical airway stenosis caused
by airway tumor (case 7, 14) involved temporarily
ECMO support. As to the emergency cases, ECMO
Zhang et al. 3

Table 2.  Intraoperative details of ECMO application.

Case Indication for ECMO Mode of Cannulation Cannula Run time Intraoperative
ECMO site size (hours) ECMO weaning

A V
1 A complex lower tracheal reconstruction VA FAV 19 24 9 Success
2 One-lung ventilation with hard-to-maintain VV FJV 17 22 48 Failure
oxygenation
3 Block the IVC VV FJV 17 22 5.5 Success
4 Double lung transplantation, severe pulmonary VA FAV 19 24 9 Success
heart disease
5 Critical airway stenosis with hard-to-maintain VA FAV 19 24 4 Success
oxygenation
6 Double lung injury, uncorrected hypoxemia VA FAV 19 24 12 Success
7 Airway tumor invading distal trachea and carina, VA FAV 19 24 48 Failure
critical airway stenosis
8 Double lung transplantation, severe pulmonary VA FAV 17 24 51 Failure
hypertension
9 Block the SVC and IVC VV FJV 17 22 4 Success
10 Block the IVC VV FJV 17 22 7 Success
11 Block the IVC VV FJV 17 22 1 Success
12 One-lung ventilation with hard-to-maintain VA FAV 17 22 3 Success
oxygenation, severe pulmonary heart disease
13 Double lung transplantation, severe pulmonary VA FAV 19 24 8 Success
hypertension
14 Severe critical airway stenosis caused by tumor VA FAV 17 22 3 Success
15 Block the SVC and IVC, Circulatory collapse VA FAV 19 24 6 Success
ECMO: extracorporeal membrane oxygenation; SVC: superior vena cava; IVC: inferior vena cava; FJV: femoral and internal jugular vein; FAV: femoral
artery and vein.

support was set up preoperatively under local anesthe-
sia, and after full flow of ECMO, anesthesia was
induced. The other cases of lung transplantation (n = 5),
huge mediastinal mass (n = 3), right thigh synovial sar-
coma with pulmonary metastasis (n = 1), and lung can-
cer (n = 1) were subjected to ECMO cannulation just
after the anesthesia induction. The mode of ECMO of
each case is in Table 2. In brief, VV ECMO, from femo-
ral vein to internal jugular vein (or subclavian vein),
was preferred for respiratory failure in thoracic surger-
ies; while VA ECMO, from femoral vein to femoral
artery, was used usually when patients need circulatory
support based on clinical and echocardiogram assess-
ment in addition to respiratory support. The types of
venous cannula (VFEM, Edwards Lifesciences, USA),
the arterial cannula (Bio-Medicus®, Medtronic, USA)
which were selected, and the cannula size of each
patient are summarized in Table 2. ECMO in all the
cases were established in supine position. After ECMO
full flow, the patients would be positioned in lateral or
as required according to the surgery. For thoracic sur-
geries undertaken in lateral position, ECMO cannula-
tion was more likely to be in the surgery side. For
mediastinal tumors and thrombosis infiltrating into the
internal jugular vein, the vessels on the non-thrombosis
side were selected for ECMO cannulation.
Before cannulation, a single dose of heparin (50–100 U/
kg) was administered intravenously to avoid thrombosis
in the cannulas before ECMO bypass initiation (venous
and arterial cannulas are not heparin coated in China).
After full flow of ECMO, the excessive heparinization will
be antagonized by the same amount of protamine to
reduce bleeding during surgery. In the meantime, contin-
uous heparin (4–8 U/kg/h) infusion was used to maintain
the target activated coagulation time (ACT) of 140–
180 seconds during ECMO. The principles of appropriate
anticoagulation in our hospital are shown in Table 3.
Appropriate ECMO flowrate from 2 to 4 l/min was main-
tained after position set up and was modulated by periph-
eral oxygen saturation. The mean blood pressure (MBP)
was maintained over 60 mmHg. Low doses of vasoactive
drugs and inotropic drugs were administrated as needed.
Right radial arterial blood gas was measured every 15 min-
utes to keep arterial partial pressure of oxygen (PaO2)
between 120 and 190  mmHg (16.0–25.3  kPa) during
ECMO. The body temperature was maintained at 36–
36.5°C by a heat exchanger. Intraoperative lung protective
mechanical ventilation was performed. The mechanical
ventilation was set as: the pressure control mode with
pressure of 10 cm H2O, fraction of inspiration oxygen
(FiO₂) of 0.5, inspiratory/expiratory (I/E ) ratio of 1:2, tidal
volume (TV) of 6 ml/kg, positive end expiratory pressure
4 Perfusion 00(0)

Table 3.  The five a principle of perioperative ECMO management.

Principle Perioperative management

Adequate tissue perfusion ECMO flowrate should be maintained between 2 and 4 l/min, with MBP > 60 mmHg, HCT
30%–35%, PaO2 120–190 mmHg (16.0–25.3 kPa), and SvO2 level ⩾70%.
Peripheral blood gas monitoring through the right radial artery should employed routinely to
detect coronary and/or cerebral hypoxemia and NIRS could timely detect cerebral hypoperfusion.
Accurate protective Low TV, high PEEP, and recruitment maneuvers.
pulmonary ventilation
Appropriate Normally, ACT may be maintained between 160 and 180 seconds; In patients with high risk of
anticoagulation bleeding, ACT target should be maintained lower than standard value; With the use of heparin
coating ECMO circuit, anticoagulation was not necessary in the case of full flow assistance in the
first day of ECMO support.
Available anti-inflammation A combination of large doses of ulinastatin and meprednisolone may be administered
intraoperatively in patients with severe inflammation.
Accurate evaluation for The criteria for weaning from VV ECMO is improvement in pulmonary function while weaning from
ECMO weaning VA ECMO is cardiopulmonary function good enough when the blood flow was reduced to 1.0 l/
min, with SvO2 ⩾ 70%, SpO2 ⩾ 95%, MBP >60 mmHg, stable vital signs, and internal environment.
ECMO: extracorporeal membrane oxygenation; MBP: mean blood pressure; HCT: hematocrit; PaO2: arterial partial pressure of oxygen; SvO2:
mixed venous oxygen saturation; NIRS: near infrared spectroscopy; TV: tidal volume; PEEP: positive end expiratory pressure; ACT: activated
coagulation time.

(PEEP) of 6–8 cm H2O, respiratory rate of 10 breaths/min
and end-tidal carbon dioxide (ETCO₂) between 25 and
40 mmHg (3.3–5.3 kPa). During operation, appropriate
colloids or crystalloids infusion and blood products trans-
fusion were considered to maintain stable hemodynamics.
After the key procedures been done, ECMO flowrate was
gradually brought down to shut-off if the patients had sat-
isfied respiratory and cardiac function.
Results
Patients’ characteristics and details of
ECMO application
A case series of ECMO used as a life-support tool are
summarized in Tables 1 and 2. Of 15 patients, 11 were
males, 4 were females. The mean age was 47 (range, 25–
73) years. Ten patients were subjected to peripheral VA
ECMO and five of VV ECMO. Mean duration of ECMO
was 15 ± 18 hours (range: 1–51 hours). Indications for
ECMO were pulmonary transplantation with hard-to-
maintain oxygenation during one-lung ventilation
(n = 5), traumatic main bronchial rupture (n = 2), trau-
matic lung injury (n = 1), airway tumor leading to severe
airway stenosis (n = 2), huge thoracic mass infiltrated
vena cava (n = 5). All patients were successfully weaned
from ECMO. One patient of huge thoracic masses died
on day 41 after surgery, and the other 14 patients were
successfully discharged from hospital.
ECMO weaning
The details of ECMO application of 15 patients are shown
in Table 2. Twelve patients were successfully weaned from
ECMO at the end of the operation. The other three
patients (case 2, case 7, case 8) were transferred to respira-
tory intensive care unit (RICU) with the support of
ECMO. Case 2 could not be disconnected from the
ECMO circuit after single right lung transplantation
because of unrecovered right lung function. Case 7 was a
patient with airway tumor invading distal trachea and
carina. After resection of the affected tracheal ring and
tracheal tumor, the residual tracheal stump was very close
to carina (just about only 0.5 cm) which could not allow a
distal endotracheal intubation to restore ventilation. So,
ECMO was continued during the bilateral cervical lymph
node dissection and free skin flap repair, which lasted for
6 hours. At the end of surgery, tracheostomy was per-
formed and a disposable tracheal tube was inserted.
However, oozing blood from the surgical wounds into
both lungs led to severe atelectasis. Thus, the patient was
transferred to RICU with the assistance of ECMO. Case 8
was a patient with severe pulmonary arterial hyperten-
sion (PAH) followed by silicosis had chronically right
ventricle dysfunction and underfilled left ventricle. After
bilateral sequential lung transplantation with normal pul-
monary vascular resistance, the small left ventricle can-
not handle this dramatically increased volume load
immediately, which led to postoperative prolonged VA
ECMO because of left ventricular failure.
Perioperative transfusion
The most common intraoperative complication was
bleeding. The perioperative transfusion of 15 patients is
shown in Table 1. Of 15 patients, the total blood loss
more than 800 ml occurred in 7 patients. Two patients
(case 8, 10) received over 20 units of red blood cells
transfusion intraoperatively. As to case 8, silicosis and
severe calcification of lung tissue led to difficult right
Zhang et al. 5
pneumonectomy and intraoperative massive hemor-
rhage. As to case 10, the intraoperative massive bleeding
was caused from the large wound area during the com-
plicated malignant tumor resection.
Another two patients (case 7, 9) received over 10 units
postoperatively. Case 7 suffered disseminated intravascu-
lar coagulation (DIC) after the tracheal tumor resection
and bilateral cervical lymph node dissection. However,
when ECMO was discontinued, the severe atelectasis
recovered and the coagulation state improved quickly.
Case 9 was subjected to reoperation the next day for post-
operative bleeding because of the large surgical wound.
Postoperative complications and in hospital
outcomes
The median postoperative assisted ventilation time was
3 days (range: 1–11 days), and two patients required
prolonged mechanical ventilation (range: 7–11 days)
over a tracheostomy due to airway rupture (case 1, case
5). The median intensive care unit stay was 6 days
(range: 2–27 days), and the median hospital stay was
29 days (range: 9–125 days). There was one hospital
death in case 3 on day 41 after surgery, who developed
right lower limb edema on the fifth day after operation
and suffered cardiac arrest as a result of shedding of
thrombi in right external iliac vein and right lower limb
vein, which was confirmed by ultrasound.
Postoperative complications are detailed summarized
in Table 4. In general, the main complications were hem-
orrhage (26.7%), infection (53.3%), acute hepatic dys-
function (33.3%), and venous thrombosis (26.7%). Severe
complications occurred in three persons (case3, 7, 8).
Case 7 developed ECMO related hemolysis, coagulation
disorders, fortunately, the bleeding was reduced after
ECMO weaning. Case 8 developed coagulation disorders,
multiple organ failure, septic shock 5 days after surgery
because of the massive transfusion and infection.
One-year outcomes
The follow-up time was at least 1 year. Overall, 12 of 15
patients (80%) survived at 1-year follow-up. In addition
to the hospital death (case 3) described above, the rest
two were late death: one was due to the systemic tumor
metastasis during chemotherapy for right thigh synovial
sarcoma (case 10), and the other was due to intense
immune rejection after double lung transplantation
(case 4). All patients (n = 4) undergoing airway surgery
remained alive and two of them (case 7, 14) with tumor
lesions accepted routine radiotherapy or chemotherapy.
As to patients with lung transplantation, most of them
required reintervention after lung transplantation due to
postoperative pulmonary infection (n = 5) or anasto-
motic stenosis (n = 1). Case 6, with multiple penetrating
wounds, recovered quickly after operation. Postoperative
prognosis in patients with lung cancer and mediastinal
masses (n = 5) is not good after 1-year follow-up. Case 11
and 15 were admitted to the oncology department of our
hospital for routine chemotherapy several times. Case 9
who needed long-term ventilator assistance was read-
mitted to our hospital because of power failure at home.
Discussion
Protective use of ECMO in complex
thoracic surgery
As we expected, ECMO provided a satisfactory oxygen-
ation and a relatively stable hemodynamics in all patients,
avoiding hypoxia and circulatory collapse at the period
of one-lung ventilation and drastic blood pressure fluc-
tuation. Only three patients (20.0%) required prolonged
assistance of ECMO until their cardiopulmonary func-
tion has recovered. In our current study, severe compli-
cations occurred in three patients (20%), which are
similar to the incidence of major complications reported
by recent studies.5 One patient died from cardiac arrest
as a result of right external iliac vein and right lower limb
vein thrombus shedding. The other two patients com-
bined with severe complications were successfully man-
aged and discharged from the hospital. Moreover,
one-year survival rate in our study was 80%. These data
indicate that our program of perioperative, protective
use of ECMO has a compassionate, aggressive posture
giving critically ill patients a chance of undergoing com-
plex thoracic surgery.
ECMO support in complicated thoracic surgery has
clear advantages. For patients undergoing emergency air-
way surgery, the use of VA-ECMO has several advantages
in these cases. Firstly, it provides a clear, un-obstructed
operative field, facilitating precise dissection and recon-
struction. In addition, it provides sufficient oxygenation
and hemodynamic stability during surgery. As to the
cases of huge thoracic masses invading superior/inferior
vena cava, ECMO support could not only resolve the
problem of venous return but also helped to maintain the
stable hemodynamics during vena cava clamping.
Besides, considering resection of locally advanced tho-
racic tumors invading heart or large vessels always leads
to massive bleeding, quick transfusion through ECMO
actually facilitates volume resuscitation and maintains
perfusion of vital organs. In terms of patients receiving
lung transplantation, ECMO is not only an important
mean of intraoperative cardiopulmonary support but also
a bridge waiting for recovery of grafting lung function.
Although some centers still use conventional CPB for
support during thoracic surgery, several disadvantages
limit its use. In contrast to ECMO, which also provides
hemodynamic stability, CPB requires higher levels
of anticoagulation and uses a venous reservoir with an
6 Perfusion 00(0)

Table 4.  Perioperative mortality and morbidity.

Case Extubation ICU stay Hospital Postoperative complications Survival Survival

(POD) (days) stay (days) (>60 days) (>1 year)
1 11 12 51 None Alive Alive
2 4 6 29 Pneumonia, DVT of lower extremity Alive Alive
3 3 11 41 DVT of right lower extremity, multiple organ failure Death Death
4 2 12 125 Pulmonary aspergillosis, cephalic vein thrombosis Alive Death
5 7 27 27 None Alive Alive
6 4 5 38 None Alive Alive
7 4 9 35 Coagulation disorders, bleeding, hepatic dysfunction, Alive Alive
urinary tract infection, DVT of upper extremity
8 5 14 23 Coagulation disorders, bleeding, multiple organ failure, Alive Alive
infection
9 4 10 34 Bleeding Alive Alive
10 2 5 41 Acute hepatic dysfunction Alive Death
11 1 3 27 Acute hepatic dysfunction Alive Alive
12 1 3 18 None Alive Alive
13 1 3 9 None Alive Alive
14 1 2 9 None Alive Alive
15 1 2 24 Bleeding, pneumonia Alive Alive
POD: postoperative day; ICU: intensive care unit; DVT: deep vein thrombosis.

air-blood interface.6 This is thought to contribute to the
higher incidence of hemorrhage and systemic inflamma-
tory reactions, especially during longer pump runs. To
our knowledge, bleeding is a major complication
during anticoagulation, with increased morbidity and
mortality.7 In our series, the severe bleeding occurred in
26.7% of patients, and the situation was effectively under
control once heparin pumping was discontinued.
Compared to CPB, ECMO can provide days to weeks of
support to patients with respiratory, cardiac, or com-
bined cardiopulmonary failure. Most importantly, care-
ful critical care is integral to managing and preventing
postoperative complications assisted by ECMO. We have
summarized these particular management activities as
tacking “the five A” principle (Table 3) in our hospital.
Thus, considering the operation difficulty and the high
risk of bleeding, ECMO can provide a safe and effective
support in these most complicated thoracic surgeries.
Indications of ECMO in thoracic surgery
Indications of ECMO assisted thoracic surgery were
summarized as following:
(1) Difficult airway: For difficult airway including air-
way tumor invading distal trachea and carina (case
7) (Figure 1), traumatic airway (case 1), severe air-
way stenosis (case 5, 14) that conventional endotra-
cheal intubation and rigid bronchoscopy may be
impossible to maintain oxygenation or even dan-
gerous,8 the use of ECMO in our hospital can avoid
complete airway obstruction and provide clear
surgical exposure.
(2) Respiratory failure: Application of ECMO in
adults with respiratory failure is mainly reported
in terms of ARDS treatment9 or in the setting of
bridge to lung transplantation.10 As to our study,
one patient with acute respiratory failure (case 6)
and five patients with chronic respiratory failure
waiting lung transplantation, all underwent sur-
gery with the ECMO support. As to patients with
single lung transplantation (case 2, 12), they need
ECMO support considering the oxygenation
could not be maintained with one-lung ventila-
tion during operation. In addition to being an
important mean of intraoperative cardiopulmo-
nary support, ECMO can also be used for the
treatment of postoperative primary graft dys-
function (PGD) and being a bridge waiting for
recovery of grafting lung function.
(3) Heart dysfunction and severe pulmonary hyper-
tension (PH): As to double lung transplantation
(case 4, 8, 13) of pulmonary fibrosis or silicosis, in
addition to hypoxemia, they also had right heart
dysfunction and severe PH. So, VA ECMO was
used both for both respiratory and circulatory
support during lung transplantation. Moreover,
the long course of pulmonary fibrosis and severe
PH can also lead to small left heart. Due to chron-
ically underfilled left ventricle, the untrained left
ventricle cannot handle the increased volume
load immediately after lung transplantation, and
thus VA ECMO can also provide left heart assis-
tance.
(4) Huge thoracic masses (e.g. mediastinal mass, pul-
monary metastasis, lung cancer).11,12 Resection of
Zhang et al. 7
Figure 1.  Preoperative findings in case 7: (a) the obviously thickened wall of the trachea and uneven enhanced mass by CT scan
and (b) the trachea lumen was narrowed linearly resulting from a mass resulting from a mass about 1.5–3.8 cm below the glottis by
bronchoscopy.
CT: computed tomography.
locally advanced thoracic tumors may occasion-
ally be complex or even impossible using conven-
tional ventilation,11 the majority of our cases
(n = 5) were combined with heart or great vessel
and pulmonary resection. Moreover, for patients
with thoracic masses involving the superior and
inferior vena cava, ECMO bypass also avoids vena
cava reflux syndrome.
Choice of ECMO mode
The choice of ECMO depends on the degree of urgency,
necessity of circulatory support as well as surgical meth-
ods. According to the type of surgical procedure, ECMO
is mainly divided into VA ECMO and VV ECMO.13 In
the cases we collected, VV ECMO was the first choice
for thoracic surgery; considering this is associated with
a lower incidence of arterial injury, neurologic events
and hemodynamic disturbance.14 VA ECMO was only
considered if circulatory assistance was needed or in
emergency situation. For lung transplantation, both VV
ECMO and VA ECMO have been in practice. The con-
siderations for the choice of ECMO mode depends on
the presence of PH, the intraoperative respiratory func-
tion and hemodynamic stability, as well as the possible
subsequent left heart dysfunction after lung transplanta-
tion.15 As to case 8 (Figure 2) and case 13 with severe
PH, VA ECMO inevitably becomes our first choice. In
addition, VA ECMO rather than VV ECMO was chosen
to interrupt edema formation by reducing pulmonary
blood flow and pulmonary capillary pressure when pul-
monary artery of transplanted lung was opened and to
alleviate pulmonary ischemia reperfusion injury and
anastomotic bleeding.
Limitation of the study
Our case series had several limitations. Firstly, this was
a retrospective study and therefore presents selection
biases. Secondly, we included a very small number of
patients because there are few hospitals in our country
that can perform this kind of complex surgery. Most
importantly, because the patients were in a critical con-
dition, ECMO was indispensable for the surgical proce-
dures. Therefore, there was no way to establish a control
group for such patients. Moreover, the situations of
patients and surgeries done in patients also varied.
Conclusion
In conclusion, ECMO can be considered as a feasible
method for complex thoracic surgery based on our
experience, and the ECMO-related risks may be justi-
fied. ECMO provides temporary cardiorespiratory sup-
port for patients with severe respiratory or cardiac
failure refractory to conventional therapy. The correct
selection of ECMO type, adequate tissue perfusion,
accurate pulmonary protective ventilation, appropriate
anticoagulation, available anti-inflammatory and accu-
rate evaluation of ECMO weaning are crucial to ensure
patient safety and reduce ECMO-related complications.
With further accumulation of experience with ECMO, a
more sophisticated protocol for management of critical
airway or heart failure problems in airway and thoracic
surgeries can be derived.
8 Perfusion 00(0)
Figure 2.  Preoperative findings in case 8: (a) Silicosis by lung CT scan. Severe Pulmonary fibrosis with multiple pneumatoceles.
(b) Severe pulmonary hypertension by echocardiography. Pulmonary hypertension was due to restrictive lung disease and was
estimated using tricuspid regurgitation pressure gradient measurements.
Author contributions
Yan Zhang have made substantial contributions to the con-
ception and design of the work, and was a major contributor
in writing the manuscript. Ming Luo designed the work and
helped collect the clinical data of patients. Zhen Qin also col-
lected the clinical data of patients undergoing ECMO-assisted
airway or thoracic surgery. Bo Wang analyzed and interpreted
the patients’ data. Ronghua Zhou reviewed and revised the
article. All authors read and approved the final manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iDs
Yan Zhang https://orcid.org/0000-0003-2146-1052
Ronghua Zhou https://orcid.org/0000-0002-4069-0136
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