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ECMO for bridging lung transplantation

European Journal of Medical Research volume 29, Article number: 628 (2024) Cite this article

Abstract

Background

With the shift in donor lung allocation from blood type and waiting order to the use of the lung allocation score (LAS) system, there are increasingly more cases of ECMO bridging lung transplantation. However, there are still some problems in case selection, implementation, and management.

Methods

We analyzed and summarized a series of data on ECMO bridging lung transplantation through an extensive literature review.

Results

The improvement of the lung transplant allocation system and the progress of ECMO technology have made the ECMO bridge to lung transplant more widely used in clinical practice. The selection of bridge patients is a crucial link in the success of transplantation, and accurate assessment of the patient before transplantation is necessary. The advantages and disadvantages of different bridge strategies exist, and the appropriate bridge strategy should be selected based on the patient's situation. Bleeding and thrombosis complications often occur during ECMO circulation, and there is currently no optimal anticoagulation strategy. The predictive score for bridge post-outcome is still subject to certain limitations.

Conclusions

ECMO bridging lung transplantation is suitable for patients waiting for lung transplantation when other respiratory support is ineffective or when hemodynamic instability occurs the disease is severe and the donor organ is easily obtainable. Patients aged 65 years or older, or have reversible multiple organ dysfunction should not be included as contraindications for ECMO bridging lung transplantation.

Introduction

Lung transplantation is an effective treatment for end-stage lung disease. Since the first lung transplantation trial by Hardy et al. in 1963 [1], after the success of Cooper's group in 1983, lung transplantation has continued to evolve. According to The International Society for Heart and Lung Transplantation (ISHLT), 67,493 lung transplants were performed worldwide from 1992 to 2018 [2]. As the number of lung transplants increased, a critical problem was revealed: a shortage of donor organs, with the number of people waiting for lung transplants far exceeding the number of donors. In May 2005, a major reform was implemented in the United States, transforming the previous system of allocating donor lungs based on blood type and waiting order into a lung allocation score (LAS) system that allocates lungs based on urgent need and patients with the most favorable graft outcome [3]. This change has been successful in reducing the number of deaths on the waiting list. Thus, with the implementation of the LAS system, which has led to a gradual increase in the clinical urgency of waiting for lung transplant recipients, the number of patients waiting for transplantation in the ICU has increased, often requiring high levels of respiratory support measures [4].Mechanical ventilation can increase LAS scores and shorten the waiting time for lung transplantation, but sometimes mechanical ventilation alone fails to achieve bridging, because many patients are not able to satisfy basic respiratory support with mechanical ventilation alone; mechanical ventilation often requires concomitant sedation, and both mechanical ventilation itself and sedation can cause complications that can hasten patient death [5]. Moreover, end-stage patients are usually accompanied by pulmonary hypertension and restrictive pulmonary ventilation dysfunction, and these conditions complicate the management of mechanical ventilation [6]. Due to the high mortality rate of early ECMO, ECMO bridging was included as a relative contraindication for lung transplantation. Nevertheless, in recent years, ECMO technology and management have been constantly improving. An increasing amount of evidence indicates that it might be a better approach to enable patients to wait smoothly for donor lungs with the support of ECMO [7, 8]. This review aims to summarize the implementation and management of ECMO in bridging lung transplantation to provide a reference for the lung transplantation bridge.

History of ECMO-bridged lung transplantation

Bridging history

ECMO bridging for lung transplantation refers to the scenario where patients with end-stage lung disease, who are on the waiting list for lung transplantation and cannot be maintained on mechanical ventilation alone due to inadequate pulmonary ventilation or gas exchange, require ECMO support to sustain life until a suitable donor lung becomes available. ECMO is a special extracorporeal circulation device, and its main components are a centrifugal pump, an extracorporeal membrane oxygenator, a pipeline system, a monitoring system, and other auxiliary devices. The ECMO principle involves centrifugal pump suction through the blood-inducing catheter of venous blood from the patient’s body, through the oxygenation of arterial blood via the extracorporeal membrane oxygenator, which is then returned to the patient's body, through venous return, called V–V ECMO, called V–V ECMO to assist the function of the lungs, and V–A ECMO to assist the function of the heart and partially assist the function of the lungs [9]. ECMO-bridged lung transplantation can be traced back as far as 1977 when Vieth first reported that patients who were bridged with ECMO prior to lung transplantation were successfully weaned from mechanical ventilation after receiving the transplant and died on postoperative day 10 from infectious complications; bronchial anastomotic fistulae [10]. Subsequent ECMO-bridged lung transplantation reported by various centers did not have satisfactory results [11]. Higher mortality and complication rates have led to the widespread belief that ECMO bridging is a relative contraindication to lung transplantation [12]. In recent years, ECMO-bridged lung transplantation has become popular, with the proportion of patients bridged through the bridge increasing from 3.4% in 2012 to 5.2% in 2017 [13]. Multiple factors have prompted the implementation of ECMO-bridged lung transplantation. First, with respect to the release of the LAS score, Hannah et al. retrospectively examined all adult lung transplant patients in the United Network for Organ Sharing (UNOS) database between 2000 and 2019 and reported that the use of ECMO bridging increased yearly after the implementation of the LAS score, whereas prior to that, the number of patients who received ECMO support annually was extremely low [14]. Second, technological developments in ECMO loops have provided assurances of patient safety and efficiency, with miniaturized, low-resistance polymethyl pentene oxidizers replacing older silicone membrane oxidizers, allowing for more efficient gas exchange with less thrombosis, thus reducing platelet and plasma protein consumption, as well as enabling convenient patient transport with the machine and ambulatory ECMO. Furthermore, the centrifugal pump replaces the old roller pump, which reduces blood cell damage and ensures a lower failure rate during long-term operation [15]. The last point is that initially, V–A ECMO was adopted as the preferred bridging strategy. With the development of treatment strategies, the preferred bridging therapy was changed from V–A ECMO to V–V ECMO, and this alteration significantly enhanced the treatment outcomes and survival prognosis of patients. The aforementioned technological advances, as well as updated critical care concepts and clearer patient selection criteria for ECMO-bridged lung transplantation, have led to increasing interest in and acceptance of ECMO-bridged lung transplantation.

Lung donor allocation

The allocation system for lung transplants in the United States has undergone several major changes throughout history. Initially, in 1990, the system prioritized waiting time and ABO blood type compatibility to determine transplant priority. Still, this method did not fully consider the medical urgency of the patient and the expected post-transplant survival rate [16]. In 1998, the Department of Health and Human Services (DHHS) pushed for the implementation of final rules, further emphasizing the importance of donor lung allocation following medical urgency and post-transplant survival rate [17]. The introduction of the Lung Allocation Score system in 2005 was a significant turning point, as it revolutionized organ allocation by balancing donor–recipient compatibility, medical urgency, and expected survival rate. After implementing the LAS system, lung transplants increased, and the waiting list death rate significantly decreased [17]. However, even though the LAS system was more fair than the old system in terms of allocation, it still relied on strict geographic allocation boundaries, which limited the flexibility of organ allocation. To address these issues, the United States implemented the Comprehensive Allocation Score (CAS) system in March 2023. The CAS system abandoned rigid geographic boundaries and introduced a comprehensive scoring mechanism based on multiple factors, including medical urgency, post-transplant survival rate, candidate biological characteristics, patient acquisition, and placement efficiency [18]. This new approach aims to optimize organ allocation by more carefully considering geographic factors and medical needs, reducing the waiting list death rate, and fairly allocating donor lungs. The transition from the initial allocation system to CAS marks an important step toward a more fair and effective lung transplant allocation system.

Selection of patients

Careful selection of patients undergoing ECMO-bridged lung transplantation is necessary to maximize patient prognosis as well as to make rational use of scarce lung donor resources. A multidisciplinary team of experienced surgeons, anesthesiologists, ECMO specialists, and pulmonologists can be critical in selecting appropriate patients for ECMO-bridged lung transplantation [19, 20]. The most recent ISHLT guidelines suggest considering the use of ECMO as a bridge to lung transplantation when oxygen saturation is less than 90% when using high-flow non-invasive oxygenation devices, when hemodynamic instability is present when using positive-pressure ventilation (which confirms the diagnosis of lung injury and secondary organ failure), and when it is impossible to provide adequate physiotherapy with current support [19]. Disease severity and donor organ availability determine the correct timing of bridging. Long-term ECMO bridging for lung transplantation support can lead to satisfactory outcomes after lung transplantation [16, 21]; however, when the duration of bridging is shorter, the outcome may be better. The initiation of graft bridging increases the risk of poor outcomes when donor organs are unlikely to be matched within a few weeks [22, 23]. All factors that may limit donor matching, such as hypersensitivity reactions, small chest size, or the need for combined multiorgan transplantation, can prolong the duration of ECMO as a bridge, so multiple factor considerations are important in patient selection [24].

Age

The age of candidates for preoperative ECMO bridging for lung transplantation has been controversial. In recent years, a multicenter survey study in the United States showed that nearly half of the centers listed age > 65 years as an absolute contraindication to ECMO bridging for lung transplantation [25]. However, the 2006, 2014,and 2022 editions of the International Society for Heart and Lung Transplantation Expert Consensus do not list age as an absolute contraindication to ECMO as a bridge to lung transplantation. When receiving ECMO support, older patients appear to have worse outcomes than younger patients due to complications such as infection and bleeding. Several studies before 2014 explored the relationship between age and postoperative survival, with older patients demonstrating poorer outcomes after ECMO-bridged lung transplantation and increased mortality rates with increasing age [26,27,28,29]. However, the number of ECMO-bridged lung transplants used has increased significantly since 2014. Previously, small sample sizes and immature bridging experiences may have led to biased results [7]. Alice et al. demonstrated that the outcomes for patients aged 65 years and older who underwent ECMO as a bridge to lung transplantation were significantly inferior compared to those who received mechanical ventilation as a bridge or did not undergo lung transplantation at all. The adverse outcomes observed in the elderly cohort receiving ECMO may be attributed to a higher incidence of perioperative complications, along with an exacerbated degree of frailty resulting from the necessity for increased sedation during ECMO [30]. Despite the suboptimal prognosis of ECMO bridging in elderly patients, the results of most studies suggest that age should only be considered a risk factor rather than including age as an absolute contraindication and that the conditions for bridging in elderly patients should be carefully selected and evaluated to create opportunities for transplantation. A blanket rejection of transplantation bridging in elderly patients is not justified from an ethical point of view.

Pulmonary hypertension

The severity of end-stage lung disease depends on the type of patient's disease class, and differences in the pathomechanisms of the different underlying diseases are crucial for the selection of an appropriate bridging strategy. Organ allocation varies according to disease diagnosis, with chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF),and cystic fibrosis (CF) accounting for more than 75% of the likelihood of lung transplant [31], and pulmonary arterial hypertension (PAH) accounting for only 3% of the likelihood of lung transplantation. The survival rate after lung transplantation is affected differently by different underlying lung diseases. The early post-transplant mortality rate of patients with PAH is higher [32], because end-stage PAH patients are more likely to develop severe right heart failure compared to patients with lung parenchymal disease-induced pulmonary failure [33], and the feasibility of using V–A ECMO bridge in PHA patients has been proven [34, 35]. However, patients with severe PAH during V–V ECMO bridge often have poor prognosis after conversion to V–A ECMO [32, 36], and further research is needed to determine the more appropriate conversion timing or ECMO flow transition pattern.

Organ failure

Multiorgan failure is an absolute contraindication of ECMO-bridged lung transplantation. Several studies have consistently suggested that ECMO bridge should only be considered for patients with good overall functional status who have not yet experienced a decline in lung function and have been carefully screened and that treatment should be discontinued if multiple organ failure occurs [36,37,38]. Weig’s study showed that ECMO bridge therapy was feasible for patients with acute infectious-induced cardiopulmonary failure as long as they did not experience organ failure other than cardiopulmonary failure [5]. However, organ failure (other than lung failure) due to hypoperfusion and organ congestion, such as acute prerenal renal failure or hypoxic liver damage, may improve after ECMO initiation. Therefore, reversible organ dysfunction should not be considered a contraindication to ECMO bridging [39].

Bridging strategies

The classic ECMO models are veno-venous (V–V ECMO) for respiratory support and veno-arterial (V–A ECMO) for circulatory and respiratory support (Table 1).

Table 1 Common techniques for extracorporeal membrane oxygenation cannulation
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V–V ECMO

Bridging lung transplantation using V–V ECMO is currently the most commonly used modality. This becomes the preferred bridging strategy in patients with simple hypoxemia or refractory acidosis, even if these patients have received maximal ventilatory support, which still does not allow for normal gas exchange, especially when hemodynamic instability or right ventricular insufficiency is present, according to a consensus of experts from the American Association for Thoracic Surgery, which states. As a result of these conditions, patients may develop end-organ failure, which can exacerbate

organ damage by further destabilizing hemodynamics [40]. V–V ECMO support is both simple and reliable, because it involves directing the patient's venous outflow (deoxygenated blood) through a cannula to an oxygenator and cannulating the patient's subclavian or internal jugular vein back to the patient's body (oxygenated blood) [41] (Fig. 1). The other more common method is femoral–femoral vein cannulation, both of which provide adequate oxygenation, but femoral–femoral vein V–V ECMO carries a greater risk of recirculation, and errors in cannulation position or depth may lead to a poor self-circulation of the ECMO, whereby blood returning to the internal catheter flows into the draining catheter without going through the body's circulation [42]. Moreover, both methods require the patient to be bedridden for long periods of time, and inguinal cannulation allows for an increased incidence of complications such as tube infection and bleeding, which are often fatal [43].

Fig. 1
figure 1

V–V ECMO, vein–vein extracorporeal membrane oxygenation cannulation intubation diagram. The patient’s inferior vena cava blood is drained to the oxygenator, oxygenated and then returned to the patient via the internal jugular vein

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V–A ECMO

There are limited data on V–A ECMO bridging to lung transplantation, and V–A ECMO is increasingly being used as a lung transplant bridge as an increasing number of patients requiring lung transplantation for pulmonary fibrosis and vascular lung disease develop cardiac insufficiency or poor systemic perfusion [8, 44]. Several studies have demonstrated [20, 45,46,47] that the options available for cannulation of peripheral V–A ECMO include axillary artery cannulation, central cannulation, and femoral artery cannulation. The most common of these is the transfemoral venous–femoral arterial, V–A ECMO-supported system, where a venous cannula is used to divert oxygen-depleted blood out of the body for delivery to the ECMO oxygenator, whereas an arterial cannula delivers oxygen-enriched blood back to the body after oxygenation by the oxygenator and bypasses the pulmonary circulation. The advantage of this method of cannulation is that it is easy to perform, but the probability of Harlequin syndrome is greatly increased in this mode of cannulation due to the mixing of blood pumped by the heart with blood returned from outside the body in the middle of the aorta so that the upper body is perfused with oxygen-poor blood pumped by the left ventricle, while the lower half of the body is perfused by fully oxygenated blood. To prevent the occurrence of this complication, the use of axillary artery cannulation or central cannulation can be contemplated. This approach can reduce the incidence rate of the Harlequin syndrome [48]. It should be noted that severe pulmonary arterial hypertension is frequently associated with right heart failure. V–A ECMO can reduce the volume of blood returning to the right heart, leading to a significant decrease in pulmonary blood flow. In patients with severe hypoxemia, this often exacerbates the Harlequin syndrome, hence patients with severe pulmonary hypertension complicated by severe hypoxemia are not recommended to use V–A ECMO for support. However, when the Harlequin syndrome occurs, merely adjusting the cannula position typically requires surgery or median sternotomy, and there is a possibility that the problem cannot be resolved. Consideration can be given to placing an additional inflow arterial cannula in the internal jugular vein or subclavian vein, that is, adopting the "V–A–V" configuration, which is a combination of V–V and V–A ECMO. In the V–A–V mode, the oxygenated blood is, respectively, returned to the aorta and the right atrium. Nevertheless, since the resistance of the pulmonary circulation is usually lower than that of the systemic circulation, there is a risk of preferentially directing the arterial reflux blood to the lungs rather than the entire body. Therefore, close monitoring of the flow is necessary, and partial blocking of the blood flow pipeline entering the pulmonary circulation may be required when necessary to ensure the optimization of the flow distribution between the two inflow channels [49].

Other strategies

The Avalon venous cannula (MAQUET Cardiovascular, LLC, Wayne, NJ) has been increasingly adopted by centers in ECMO bridging [50], this cannula is a single cannula inserted percutaneously into the right internal jugular vein or the left subclavian vein, which has been designed to drain unoxygenated blood through two drainage ports in the superior vena cava and inferior vena cava, respectively, whereas oxygenated blood is passed through the return port located in the right atrium towards the tricuspid valve into the pulmonary circulation, which minimizes recirculation at adequate flow [41]. Since only a single cannula performs both drainage and return functions, blood flow is not comparable to that of a double venous cannula; therefore, it is usually not able to support patients with severe hypoxemia and may be more appropriate for patients with hypercapnia or less severe hypoxic respiratory failure. However, it also creates the conditions for ambulatory ECMO. Prolonged bed rest can lead to muscle loss even in the healthiest people, regardless of age [52]. Training and activity through getting out of bed is important for lung transplant candidates, and being able to get out of bed is one of the advantages of ambulatory ECMO [53], another being that being able to breathe spontaneously maintains respiratory muscle tone and diaphragmatic function [51]. In a retrospective study by Kim and his colleagues comparing lung function 6 months after lung transplantation based on the autonomic respiratory status of patients using ECMO as a bridge to LTx, lung function was greater in the autonomic respiratory group than in the nonconscious group [54]. The prolonged use of tracheal intubation disrupts the natural defense barrier of the airway and increases the risk of pneumonia [55], and infections in the lungs increase the risk of lung graft bridging failure and are also associated with mortality after lung transplantation. A study using awake ECMO as a bridge to heart transplantation [56] showed a lower incidence of pneumonia in this group than in the nonawake ECMO group. Some complications related to endotracheal intubation or sedation were effectively avoided [51]. It can help patients to participate in their own clinical decisions.

Complications

Complications arising from ECMO support are very common and mainly include bleeding, infection, renal failure, air embolism or thromboembolism, stroke,and limb ischemia [57,58,59]. This depends on the type of ECMO support (V–A or V–V) and the cannulation strategy used [60], with V–A ECMO having a higher complication rate than V–V ECMO due to the need for peripheral arterial cannulation to obtain adequate flow [40].Systemic anticoagulation remains an important component of ECMO management to maintain the loop-free of thrombus, and anticoagulation therapy is usually adjusted according to the presence of clots in the circulation, coagulation disorders at the time of ECMO support, and bleeding [61]. In addition, optimal anticoagulation is to achieve a balance between bleeding and coagulation; however, what constitutes an optimal anticoagulation strategy is currently unclear [62]. The most common complication of ECMO is bleeding, the causes of which are multifactorial, secondary to prophylactic or therapeutic anticoagulation necessary for ECMO support but also to thrombocytopenia and fibrinolysis occurring as a result of contact with the ECMO loop [63, 64]. Using appropriate measures to ensure a platelet count greater than 50,000/mm2 and maintaining a target activated clotting time (ACT) can reduce the risk of bleeding. Prompt intervention is essential in the event of major bleeding.

The incidence of systemic thromboembolism has been reported to be 15%, and the risk of deep vein thrombosis may be increased and associated with femoral artery cannulation [24]. Oxygenator thrombosis manifests itself as an abnormal increase in oxygenator inlet pressure, and subsequently, this obstruction can lead to changes in blood flow through the device, which, if excessive, may impair gas delivery or even require replacement of the oxygenator [65]. This thrombosis poses a risk to the patient in two ways: first, the effects of hypoxemia itself (e.g., tissue hypoxia, reduced cardiac output, and exacerbation of pulmonary hypertension), which may be caused by oxygenator malfunctions [66,67,68]; and, second, the other risks (e.g., interruptions in ECMO support, blood loss, or contamination) that may result from oxygenator replacement. In the United States, one patient is reported to die each month as a result of emergency oxygenator replacement, and some patients have permanent injuries as a result of oxygenator replacement or oxygenator failure [69].

Commonly used anticoagulants include ordinary heparin (UFH) and direct thrombin inhibitors (bivalirudin and argatroban) [70]. UFH, the mainstream anticoagulant used in ECMO in children and adults, is effective, rapidly active, inexpensive, and easy to antagonize; however, its use is often accompanied by a series of complications, including bleeding, heparin-induced thrombocytopenia (HIT), and heparin resistance (HR) [71]. Direct thrombin inhibitors, on the other hand, may have advantages over regular heparin in terms of controllability of anticoagulation monitoring, anticoagulant efficacy, and safety [72]. The selection of appropriate anticoagulant drugs and anticoagulation monitoring indicators is important for reducing the incidence of coagulation complications.

Prognostic prediction

With a high shortage of donor lungs, the selection of patients who can maximize the benefit of ECMO-bridged lung transplantation becomes crucial. This is because large lung transplant centers have demonstrated that the survival of ECMO-bridged lung transplant patients is comparable to that of nonbridged patients [34, 73]. However, the level of variation across centers prevents bridging experience from being directly transferable, and there are still uncertainties that lead to poor outcomes after bridging, making rational prognostic risk assessment an indispensable part of the process. Currently, commonly used scoring tools, such as the Sequential Organ Failure Assessment (SOFA), the Simplified Acute Physiology Score III (SAPS III), and the Acute Physiology and Chronic Health Evaluation II (APACHE II), have been widely used in the risk assessment of critically ill patients and have shown particular strength in predicting in-hospital mortality [74]. Prior to the availability of the stratification risk analysis in bridging patients to lung transplant on ECMO (STABLE) score published by Habertheuer et al. for ECMO, there had not yet been a specific score used to assess in-hospital and post-transplant mortality in patients after bridging lung transplantation on ECMO. The STABLE score is based on six pretransplant variables: age, waiting list days, waiting list dialysis, transplant center capacity, mechanical ventilation, and total bilirubin, with high scores representing higher in-hospital mortality [75] (Table 2). As the only scoring system currently available that specifically assesses bridging, there are limitations such as age restriction and single device assessment that make it not well suited to the entire population.

Table 2 Stable risk score
Full size table

Faccioli first validated and compared the accuracy of the SOFA, SAPS III, and APACHE II in predicting prognosis and mortality in ECMO-bridged lung transplant patients. SOFA scores higher than or equal to 9 were significantly associated with poor short-term post-transplant prognosis. The SOFA, SAPS III, and APACHE II scores were less accurate at predicting in-hospital mortality in transplanted patients, which is in line with the findings of a previous study [76]. However, the small sample size, the lack of a control group, and the fact that the scores were not continuously assessed in real time make our ability to predict the prognosis of patients receiving ECMO-bridged lung transplantation challenging.

Accurate prognostic scores enable better selection of bridging patients, help clinical decision-making, and improve posttransplantation outcomes. Several of the above scoring systems lacked large sample sizes in the population of patients who underwent ECMO-bridged lung transplantation, and there are few studies related to prognostic prediction scores for patients who underwent ECMO-bridged lung transplantation; further research is needed to improve our ability to predict outcomes more accurately.

Conclusion and outlook

The use of an ECMO bridge as a bridge to lung transplantation has been a great success and has benefited from technological advances in the components of the ECMO circuit as well as the maturation of management experience. ECMO as a bridge to transplantation is not suitable for all patients, and careful selection of patients is a key factor in the success of the bridge, where factors such as age and type of disease remain controversial. The appropriate choice of anticoagulants during bridging, required anticoagulation monitoring, real-time assessment of the patient's status, maximization of the possibility of avoiding complications, and aggressive management of complications such as thrombosis or bleeding can be effective in improving the patient's prognosis. The existing STABLE score, as the only score that specifically evaluates the prognosis of ECMO-bridged lung transplantation, is better able to help us determine the necessity of initiating ECMO support and to predict the patients’ prognosis, but it has limitations, and future studies with large sample sizes are needed to test its accuracy. The selection and management of lung transplant candidates bridged with ECMO is both challenging and complex, and an experienced multidisciplinary team is needed to guide this process effectively. Within the limitations of transplant center capacity, support modalities, and intubation strategies should be individualized to each patient's physiologic need.

Data availability

No datasets were generated or analysed during the current study.

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Authors and Affiliations

  1. School of Medicine, Zhejiang Chinese Medical University, Hangzhou, 310053, People’s Republic of China

    Chuhan Zhang

  2. Key Laboratory of Artificial Organs and Computational Medicine in Zhejiang Province, Shulan International Medical College, Zhejiang Shuren University, Hangzhou, 310022, People’s Republic of China

    Qingjing Wang

  3. Department of Critical Care Medicine, Shulan Hangzhou Hospital, Shulan International Medical College, Zhejiang Shuren University, Hangzhou, 310022, People’s Republic of China

    Anwei Lu

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Chuhan Zhang: Writing—original draft. Qingjing Wang: Writing—editing. Anwei Lu: Supervision. All the authors gave final approval and agree to be accountable for all aspects of the work. Anwei Lu: supervision. All the authors gave final approval and agreed to be accountable for all aspects of the work.

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Zhang, C., Wang, Q. & Lu, A. ECMO for bridging lung transplantation. Eur J Med Res 29, 628 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40001-024-02239-y

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European Journal of Medical Research

ISSN: 2047-783X

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