Incidence and Risk Factors for Early Major Neurologic Complications in Lung Transplantation: From Restrictive Cardiopulmonary Bypass to ECMO by Criteria

BACKGROUND: Intraoperative hemodynamic instability and hypoxemia may contribute to early major neurologic complications (EMNC) following lung transplantation. Mechanical circulatory support can mitigate cerebral hypoperfusion, but cardiopulmonary bypass (CPB) is an independent risk factor for EMNC. This study examines the incidence of EMNC transitioning from a restrictive CPB strategy to criteria-based use of extracorporeal membrane oxygenation (ECMO-BC). METHODS: We conducted a single-center retrospective cohort study on 389 lung transplant recipients comparing patients managed with restrictive CPB (PRE-ECMO, 2012-2017, n = 288) to those managed with criteria-based ECMO (ECMO-BC, 2022-2024, n = 101). The incidence of EMNC was compared between groups. RESULTS: EMNC occurred in 29 of 280 patients in the PRE-ECMO group and in 5 of 101 patients in the ECMO-BC group (10% versus 5%; P = 0.152), with 78 versus 8 total events, corresponding to an incidence rate ratio of 3.5 (95% confidence interval [CI], 1.7-7.4, P < 0.001). Ischemic stroke was significantly less frequent in the ECMO-BC group (2% versus 9%; P = 0.022). Intraoperative mechanical circulatory support was used in 20% of PRE-ECMO and 43% of ECMO-BC cases (P < 0.001). Patients in the ECMO-BC group were older, had more cardiopulmonary comorbidities, greater intraoperative blood loss (2489 versus 1861 cc; P < 0.001), and more severe primary graft dysfunction at 24 and 72 h (P < 0.001). CONCLUSIONS: Transition to ECMO-BC was associated with lower EMNC events and fewer ischemic strokes, but increased intraoperative blood loss and worse early graft function, generating hypotheses for prospective studies that define optimal ECMO indications in lung transplantation.