Technical Considerations in the Complex Recipient

Lung transplantation is now the established treatment modality for end-stage lung parenchymal and vascular disease. The most common indications in lung transplantation are chronic obstructive pulmonary disease/emphysema, interstitial lung disease, alpha-1 antitrypsin, cystic fibrosis, and pulmonary arterial hypertension; together these represent 85% of the patients receiving transplantation. Many centers utilize venoarterial extracorporeal membrane oxygenation (ECMO), rather than CPB, for lung transplantation. This strategy allows for a lower activated clotting time of 180-250 seconds and may result in less bleeding. Intraoperative management of a frozen chest and the associated pneumonectomy can be challenging. In such situation, a wide thoracotomy is recommended. Since the beginning of the COVID-19 pandemic, millions of patients have sustained different degrees of lung injury. Some patients develop COVID-related acute respiratory distress syndrome, requiring mechanical ventilation and at times support with VV ECMO.