Received: 14 August 2020 | Revised: 26 August 2020 | Accepted: 4 September 2020

DOI: 10.1111/jocs.15029

HOW TO DO IT

Intraoperative management of a hybrid extracorporeal

membrane oxygenation circuit for lung transplantation

Archer Kilbourne Martin MD1 | Barry A. Harrison MD1 | Ashley Virginia Fritz DO1 |
Kevin P. Landolfo MD, MSc2 | Ian A. Makey MD2 | Basar Sareyyupoglu MD2 |
Thomas E. Brown CCP2 | James L. JohnsonJr CCP2 | Si M. Pham MD2 |
Mathew Thomas MD2

1
Division of Cardiovascular and Thoracic
Anesthesiology, Mayo Clinic, Jacksonville,
Florida, USA
2
Department of Cardiothoracic Surgery,
Mayo Clinic, Jacksonville, Florida, USA
Correspondence
Archer Kilbourne Martin MD, Division of
Cardiovascular and Thoracic Anesthesiology,
Mayo Clinic, 4500 San Pablo Rd Jacksonville,
Florida, 32224, USA.
Email: Martin.Archer@mayo.edu
Abstract
Background
The use of extracorporeal circulation (ECC) for intraoperative cardiopulmonary
support during lung transplantation has been increasing in the recent years. Our
group previously described a novel hybrid extracorporeal membrane oxygenation
(ECMO) circuit for use in lung transplantation.
Technique
Our approach for intraoperative management of our novel hybrid ECMO circuit for
lung transplantation is driven by two main goals: The first is to deliver management
that ensures an appropriate balance between the native and ECMO cardiac outputs
in order to provide a stable environment that promotes attenuation of ischemic‐
reperfusion injury during implantation. The second is to provide a stable hemody-
namic environment that results in an appropriate global perfusion guided by
multiple monitors and an organ systems‐based approach during implantation.
Comments
Our novel technique for intraoperative management of this circuit during lung
transplantation is described.

KEYWORDS
anesthesiology, cardiopulmonary bypass, ECMO, extracorporeal circulation,
lung transplantation

Perioperative management of lung transplantation has recently
evolved with the increasing use of intraoperative extracorporeal
circulation (ECC) reported in the literature.1 Intraoperative ECC for
management of lung transplantation can be achieved with extra-
corporeal membrane oxygenation (ECMO) circuit, cardiopulmonary
bypass (CPB) circuit or a hybrid ECMO‐CPB circuit.2 We previously
described a novel design for an intraoperative hybrid ECMO circuit
that is both cost‐effective and facilitates conversion to CPB if neces-
sary (Figures 1 and 2).2 Our novel technique for intraoperative man-
agement of the hybrid ECMO‐CPB circuit, including considerations for
monitoring and an organ‐based management approach including
cardiac, respiratory, and neurological systems is described.
1 | TECHNIQUE
1.1 | Monitoring considerations
Before surgery, the surgical and anesthesia teams formulate a plan
regarding the surgical approach, cannulation sites, need for and type

3560 | © 2020 Wiley Periodicals LLC wileyonlinelibrary.com/journal/jocs J Card Surg. 2020;35:3560–3563.

MARTIN ET AL.
F I G U R E 1 Diagram showing the hybrid bypass circuit for
venoarterial ECMO during lung transplantation. “X” marks show the
clamps placed to bypass the venous reservoir for ECMO. These
clamps are released, and the hybrid circuit is clamped to convert to
standard cardiopulmonary bypass. Used with permission from
Thomas et al. ECMO, extracorporeal membrane oxygenation.
ECMO, extracorporeal membrane oxygenation
F I G U R E 2 Intraoperative photograph of the hybrid circuit during
ECMO. Used with permission from Thomas et al. ECMO,
extracorporeal membrane oxygenation
| 3561
of ECC to be used. Prior to induction of anesthesia, a variety of
monitors are placed on the patient including standard American
Society of Anesthesiologists monitors and a combination bilateral
cerebral oximetry/anesthetic depth monitor (Masimo O3TM Regional
Oximetry with SedlineTM Brain Function Monito; Masimo. The timing
of placement of the radial arterial line is at the discretion of the
anesthesiologist and may be placed before induction of anesthesia in
the setting of severe ventricular dysfunction or when hemodynamic
compromise is anticipated upon the application of positive pressure
ventilation after endotracheal intubation.3 After induction of an-
esthesia and endotracheal intubation with a dual lumen endotracheal
tube, we place a femoral arterial line, central venous catheter, pul-
monary arterial catheter, end‐tidal carbon dioxide (ETCO2) monitor,
and transesophageal echocardiogram (TEE) probe. A TEE probe is
placed in every lung transplant to guide ECMO cannula placement,
monitor biventricular function, and assess the patency of pulmonary
vasculature both before and following surgical anastomoses.4 After
initiation of veno‐arterial ECMO (VA‐ECMO), we obtain whole blood
lactate, arterial blood gas (ABG), and activated clotting time (ACT)
every 30 min. In addition, we check a fibrinogen and prothrombin
time/international normalized ratio (PT/INR) every 2 h. In addition to
these structured blood draws, we use an in‐line device (Terumo CDI
550; Terumo Cardiovascular) to monitor real‐time trends of pH,
partial pressures of oxygen and carbon dioxide (PO2 and PCO2),
potassium, oxygen delivery (DO2), and hemoglobin within the hybrid
ECMO‐CPB circuit.
1.2 | Cardiac considerations
As described in our previous article,2 we aim to divert the majority of
calculated flow target cardiac output away from the pulmonary system
into the VA‐ECMO output, consistent with previously published re-
ports.5 The ECC circuit reduces native cardiopulmonary blood flow to
facilitate surgical exposure and dissection and attenuates ischemic‐
reperfusion injury.5 Maintaining a balance between the ECMO flows
and native cardiac output is a necessity to achieve appropriate systemic
perfusion, avoidance of intracardiac clot formation, and provide con-
trolled reperfusion of implanted donor grafts. Communication between
the surgical and anesthesia teams is paramount. TEE, ETCO2, and the
presence of pulsatility within the arterial and pulmonary arterial wa-
veforms are used to determine the ideal circuit and native blood flow.
Surgical manipulations of the heart may cause abrupt changes in
cardiac preload and contractility. Ongoing assessment of preload
within the system is vital to avoid ECMO suction events (“chattering
in the lines.”)2 Due to the significant diversion of cardiac output to
the hybrid ECMO circuit, the TEE is unable to accurately assess
cardiac preload while on ECMO, yet remains useful as a direct
monitor of cardiac contractility. We utilize ETCO2 as a semi‐
quantitative/qualitative monitor of system preload based on the
principle of ETCO2 correlating with cardiac output.6,7 During im-
plantation of the donor lung, mechanical ventilation is applied to the
contralateral side via a double‐lumen endotracheal tube. A value
3562 | MARTIN ET AL.

of >20 mm Hg as a goal value for our ETCO2 during hybrid ECMO
was chosen based on trauma literature which notes that value as a
threshold of adequate cardiac output during successful cardio-
pulmonary resuscitation.6 Pulsatility in both the pulmonary arterial
and systemic arterial waveforms confirms biventricular output and
provides a constant assessment of systemic afterload. The loss of
pulsatility waveforms is associated with derangements of balance
between the native and mechanical cardiac outputs, including
decreased biventricular contractility, inadequate preload or in-
appropriately high ECMO target flows.
1.3 | Pulmonary considerations
Management of the pulmonary system during hybrid ECMO includes
application of information obtained from cardiac monitors as well as
evidence‐based maneuvers to decrease the risk of developing
primary graft dysfunction (PGD) during the perioperative period. Ade-
quate ETCO2 and pulmonary arterial pulsatility are indicators of right
ventricle cardiac output ensuring controlled perfusion of the newly
implanted graft during hybrid ECMO. Post lung implantation, the pul-
monary venous cuff is evaluated with pulse wave Doppler (PWD) via
TEE to qualitatively detect the presence of cardiac output within the
lung and to identify potential pulmonary vein obstruction. Mechanical
ventilation of the lungs on ECMO is based on evidence from the lit-
erature, with the goal of minimizing injury to the implanted grafts being
achieved using a lung‐protective approach with a fraction of inspired
1,8
oxygen (FiO2) <40%. We also administer inhaled anesthetic via both
the hybrid ECMO circuit and the anesthesia machine, as the use of
inhaled anesthetics has been shown to decrease the formation of pul-
monary edema and improve partial pressure of oxygen/FiO2 ratios in
animal lung transplantation models.1
1.4 | Neurological considerations
The use of a combination of bilateral cerebral oximetry/anesthetic
depth monitor during hybrid ECMO allows for monitoring of anes-
thetic depth and ensuring adequate cerebral oxygenation. Anesthetic
depth must be monitored and titrated, due to the use of inhaled
anesthetic in both the mechanical (hybrid ECMO) and native (lungs
via the anesthesia machine) cardiac outputs to assure both an ade-
quate depth of anesthesia and to provide theoretical protection
against the development of PGD. Hybrid ECMO cannulation can be
either central or peripheral, and the use of cerebral oximetry mon-
itoring provides information regarding both cerebral perfusion and
oxygenation in hopes to avoid differential hypoxemia (north‐south
syndrome) associated with peripheral VA‐ECMO.1
2 | CO M ME N T S
We previously described a hybrid ECMO‐CPB circuit that provides
lung transplantation teams the ability to provide ECC via either VA‐
ECMO or CPB.2 While the goals for intraoperative management of
ECMO include maintenance of systemic perfusion and controlled re-
perfusion of the newly implanted lungs, achieving the balance be-
tween native and mechanical cardiac outputs can be challenging.
Despite these challenges, successful implementation of VA‐ECMO is
important as it can provide theoretical attenuation of the ischemic‐
reperfusion injury and improved perioperative outcomes.5 As sum-
marized in Table 1, the use of an organ system‐based approach based
on best evidence and anesthetic monitors that are multi‐faceted yet
complementary in design has enabled the use of the hybrid ECMO
circuit for intraoperative ECC since September 2017. Future concepts
of investigation for intraoperative management of the hybrid circuit

TABLE 1 Summary of intraoperative management goals for the hybrid ECMO‐CPB circuit
Key Monitors Hematologic Cardiopulmonary Neurological

A. Continuous 1. ACT: 180‐220 s 1. ECMO target flow (as % of 1. Maintain baseline cerebral
1. Arterial line 2. INR: ≤1.5 calculated cardiac output): oximetry
2. Pulmonary arterial catheter 3. Fibrinogen >200 mg/dl – 80% at initiation; 2. Provide inhaled anesthetics
3. Anesthetic depth monitor 4. Normal acid‐base balance – decreased to 50% after via both ECMO circuit and the
4. Cerebral oximetry 5. Hematocrit >27% first lung is implanted anesthesia machine.
5. TEE probe 6. Platelet count: 2. Adequate cardiac contractility
6. In‐line blood parameter monitor 100,000/mm3 on TEE
7. Urinary catheter 3. ETCO2 >20 mm Hg
B. Intermittent (q30 min) 4. Pulsatile systemic arterial &
6. Whole blood lactate pulmonary arterial waveforms
7. Arterial blood gas 5. Lung protective approach for
8. ACT intraoperative ventilation
6. Maintain FiO2 <40% during
C. Intermittent (q2 h) reperfusion
9. PT/INR 7. Provide inhaled anesthetic via
10. Fibrinogen level ECMO circuit and anesthesia
machine
8. Maintain adequate urine
output (>0.5 ml/kg/h)

Abbreviations: ACT, activated clotting time; INR, international normalized ratio; MAP, mean arterial pressure; PT, prothrombin time;
TEE, transesophageal echocardiogram.
MARTIN ET AL.
include the utility of goal‐directed perfusion using DO2 and TEE‐
guided quantification of native cardiac output through the implanted
grafts. Appropriately designed studies, both within our institution and
in coordination with other centers, are needed to assess the efficacy
of our approach for lung transplantation.
C O NF L IC T O F IN T E R ES T S
The authors declare that there are no conflict of interests.
AUTHOR CONTRIBUTIONS
Concept/design, drafting article, critical revision of the article, and ap-
proval of the article: Archer K. Martin, Barry A. Harrison, Ashley V.
Fritz, Kevin P. Landolfo, Ian A. Makey, Basar Sareyyupoglu, Thomas
E. Brown, James L. Johnson, Si M. Pham, and Mathew Thomas.
ORCID
Archer Kilbourne Martin http://orcid.org/0000-0002-6179-1876
Ashley Virginia Fritz http://orcid.org/0000-0003-4664-2896
Si M. Pham http://orcid.org/0000-0001-7396-8344
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Hybrid Extracorporeal Membrane Oxygenation Circuit [published online
ahead of print March 27, 2020]. ASAIO Journal. 2020. http://dx.doi.org/
10.1097/mat.0000000000001157
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How to cite this article: Martin AK, Harrison BA, Fritz AV,
et al. Intraoperative management of a hybrid extracorporeal
membrane oxygenation circuit for lung transplantation. J Card
Surg. 2020;35:3560–3563.
https://doi.org/10.1111/jocs.15029
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