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Lung Transplant Anesthesia: RV Failure, ECMO, and Graft Dysfunction [ Case Discussion ](https://mdster.com/blog?category=case-discussion) Lung Transplant Anesthesia: RV Failure, ECMO, and Graft Dysfunction ===================================================================== A case discussion of circulatory collapse during bilateral lung transplantation [ MDster Editorial Team ](https://mdster.com/about) · Oct 28, 2026 · 6 min read · 47 [ Reviewed by Dr. Ali Ragab, MBBCH, MSc, MCAI ](https://mdster.com/medical-reviewers/dr-ali-ragab) [Editorial Policy](https://mdster.com/editorial-policy) \| [Corrections Policy](https://mdster.com/corrections) [ Anesthesiology ](https://mdster.com/blog?tag=anesthesiology) [ Right ventricular failure ](https://mdster.com/blog?tag=right-ventricular-failure) [ ECMO ](https://mdster.com/blog?tag=ecmo) [ Pulmonary Hypertension ](https://mdster.com/blog?tag=pulmonary-hypertension) [ Lung Transplantation ](https://mdster.com/blog?tag=lung-transplantation) [ Primary Graft Dysfunction ](https://mdster.com/blog?tag=primary-graft-dysfunction) ![Lung Transplant Anesthesia: RV Failure, ECMO, and Graft Dysfunction](https://mdster.com/storage/blog/images/lung-transplant-anesthesia-rv-failure-ecmo-and-graft-dysfunction.png) Share this article Share this post On this page 1. [ The case: an RV with little reserve ](#the-case-an-rv-with-little-reserve) 2. [ Why induction and dissection are hazardous ](#why-induction-and-dissection-are-hazardous) 3. [ Deterioration during dissection: diagnose while mobilizing rescue ](#deterioration-during-dissection-diagnose-while-mobilizing-rescue) 4. [ Read the physiology, then check the circuit ](#read-the-physiology-then-check-the-circuit) 5. [ Why VA ECMO fits this moment ](#why-va-ecmo-fits-this-moment) 6. [ After reperfusion: distinguish graft injury from obstruction ](#after-reperfusion-distinguish-graft-injury-from-obstruction) 7. [ Examine the pulmonary venous anastomosis ](#examine-the-pulmonary-venous-anastomosis) 8. [ Protect a vulnerable graft ](#protect-a-vulnerable-graft) 9. [ Key Points for Board Exams ](#key-points-for-board-exams) 10. [ Frequently Asked Questions ](#blog-faqs) 11. [ References ](#references-heading) On this page 1. [ The case: an RV with little reserve ](#the-case-an-rv-with-little-reserve) 2. [ Why induction and dissection are hazardous ](#why-induction-and-dissection-are-hazardous) 3. [ Deterioration during dissection: diagnose while mobilizing rescue ](#deterioration-during-dissection-diagnose-while-mobilizing-rescue) 4. [ Read the physiology, then check the circuit ](#read-the-physiology-then-check-the-circuit) 5. [ Why VA ECMO fits this moment ](#why-va-ecmo-fits-this-moment) 6. [ After reperfusion: distinguish graft injury from obstruction ](#after-reperfusion-distinguish-graft-injury-from-obstruction) 7. [ Examine the pulmonary venous anastomosis ](#examine-the-pulmonary-venous-anastomosis) 8. [ Protect a vulnerable graft ](#protect-a-vulnerable-graft) 9. [ Key Points for Board Exams ](#key-points-for-board-exams) 10. [ Frequently Asked Questions ](#blog-faqs) 11. [ References ](#references-heading) A blood pressure of 65/40 mmHg, rising CVP, and SpO₂ of 82% during lung dissection signal impending circulatory collapse—not simply difficult oxygenation. In a recipient with severe pulmonary hypertension and a failing RV, the team must identify reversible causes while preparing extracorporeal support. The case: an RV with little reserve ----------------------------------- A 54-year-old man with idiopathic pulmonary fibrosis requires 5 L/min oxygen before bilateral sequential lung transplantation. Preoperative echocardiography shows a dilated, hypokinetic RV, severe tricuspid regurgitation, and estimated PASP of 75 mmHg. After carefully titrated induction and intubation, TEE shows septal displacement into the LV; profound hypotension and hypoxemia develop during first-lung dissection. ### Why induction and dissection are hazardous The pressure-loaded RV depends on systemic pressure for coronary perfusion. Induction-related vasodilation can therefore reduce RV perfusion just as positive-pressure ventilation, hypoxemia, or hypercapnia increases afterload. Further RV dilation shifts the septum leftward, restricting LV filling and amplifying hypotension. Before induction, agree on the threshold for initiating support—not merely whether ECMO is available. In severe cardiopulmonary failure, ISHLT advises considering extracorporeal support *before* induction when collapse is likely. [\[1\]](#cite-1 "Reference [1]") Practical induction goals are to: - Preserve systemic pressure and RV contractility with titrated anesthetic dosing and vasopressor support. - Maintain sufficient preload without reflexively treating a high CVP with fluid. - Avoid hypoxemia, hypercapnia, acidosis, excessive airway pressures, and loss of atrioventricular synchrony. - Use TEE and arterial pressure trends to assess whether an intervention improves forward flow, rather than CVP alone. Deterioration during dissection: diagnose while mobilizing rescue ----------------------------------------------------------------- ### Read the physiology, then check the circuit Rising CVP with falling arterial pressure suggests worsening RV output, but it does not establish the cause. Immediately tell the surgeon, request relief of manipulation or temporary vascular compression if feasible, confirm ETT position and ventilation, obtain an ABG, and reassess the RV and LV with TEE. Resuscitation and preparation for cannulation should proceed in parallel. The focused differential includes: - **Acute RV afterload increase:** hypoxic pulmonary vasoconstriction, hypercapnia, high intrathoracic pressure, or pulmonary artery clamping. - **Mechanical or ventilatory problem:** ETT displacement, one-lung ventilation failure, pneumothorax, or airway obstruction. - **Obstructed filling or impaired contractility:** surgical compression, tamponade, hemorrhage, ischemia, or arrhythmia. Escalate systemic vasopressor support while correcting gas exchange and reversible surgical causes. An inhaled pulmonary vasodilator or carefully titrated inotrope may improve RV output, but neither should delay extracorporeal rescue when shock and hypoxemia persist. ### Why VA ECMO fits this moment **Venoarterial (VA) ECMO** provides circulatory and gas-exchange support; venovenous (VV) ECMO cannot directly rescue refractory RV-related shock. For this unstable recipient, activate the agreed VA ECMO cannulation plan rather than repeatedly escalating vasopressors. ISHLT favors VA ECMO over routine CPB for standard intraoperative lung transplantation, while retaining CPB for selected situations, particularly concomitant cardiac surgery. Comparative outcomes largely come from nonrandomized data, so the choice remains contextual. [\[2\]](#cite-2 "Reference [2]") The preinduction briefing should specify the trigger for cannulation, cannulation sites and surgical access, circuit readiness, anticoagulation and bleeding strategy, and whether support might continue postoperatively. It should also assign who makes—and communicates—the decision to initiate support. > **Clinical pearl:** In severe pulmonary hypertension, hypotension can worsen RV ischemia and further reduce LV preload. Restore systemic perfusion, but do not mistake a rising CVP for a request for more fluid. After reperfusion: distinguish graft injury from obstruction ------------------------------------------------------------ ### Examine the pulmonary venous anastomosis New hypoxemia or graft edema after implantation is not automatically primary graft dysfunction (PGD). TEE should assess pulmonary venous patency alongside ventricular function; bronchoscopy, imaging, and operative findings help identify airway, pleural, or vascular complications. Anastomotic color-flow turbulence, a narrowed lumen, and peak systolic venous velocity above 1 m/s raise concern for significant obstruction. Look also for loss of normal phasic flow, visible thrombus, or kinking. **Velocity alone is not definitive:** high flow after reperfusion may accelerate an otherwise patent vein, so integrate multiple views and surgical findings before requesting revision. [\[3\]](#cite-3 "Reference [3]") ### Protect a vulnerable graft PGD reflects early graft injury characterized by pulmonary edema and impaired oxygenation after transplantation. ISHLT grade 3 requires radiographic pulmonary edema and PaO₂/FiO₂ below 200; formal grading occurs at T0, T24, T48, and T72, with T0 measured from reperfusion of the **second** lung in bilateral transplantation. Hypoxemia during first-lung dissection is therefore not PGD. [\[4\]](#cite-4 "Reference [4]") If severe graft injury develops after reperfusion: 1. Exclude correctable causes, especially pulmonary venous obstruction, LV dysfunction, aspiration, and fluid overload. 2. Use lung-protective ventilation with low tidal volumes based on **predicted**, not actual, body weight; titrate PEEP against oxygenation and RV hemodynamics. 3. Maintain perfusion while avoiding unnecessary fluid. Consider diuresis or renal replacement therapy when congestion persists and perfusion permits. 4. Consider inhaled nitric oxide for pulmonary vasodilation and RV afterload reduction, recognizing that it is supportive rather than definitive PGD therapy. 5. Escalate early to ECMO if support remains inadequate. For **isolated new-onset PGD**, ISHLT prefers VV ECMO; persistent cardiocirculatory failure favors VA ECMO. [\[5\]](#cite-5 "Reference [5]") Observational studies associate intraoperative CPB, greater transfusion, and increased fluid administration with severe PGD; these associations do not prove that withholding necessary support prevents injury. Reperfusion FiO₂ has also been identified as a potentially modifiable risk factor. The goal is deliberate blood-product and fluid use—not a fixed-volume prohibition in a bleeding, underperfused patient. [\[6\]](#cite-6 "Reference [6]") Key Points for Board Exams -------------------------- - Falling blood pressure plus rising CVP in severe pulmonary hypertension should prompt immediate assessment for RV failure and reversible obstruction. - Refractory **shock with hypoxemia** calls for VA, not VV, ECMO support. - A pulmonary venous velocity above 1 m/s is a warning sign, not a stand-alone diagnosis of stenosis. - Grade 3 PGD requires edema on imaging and PaO₂/FiO₂ below 200; in bilateral transplantation, grading begins after second-lung reperfusion. - After implantation, match ECMO configuration to the dominant failure: VV for isolated graft respiratory failure, VA when circulation also needs support. The decisive move in this case is simultaneous troubleshooting and early activation of the planned rescue circuit. Once circulation is secured, reassess the anastomoses and graft systematically; treating every postoperative opacity as PGD risks missing a correctable surgical problem. Frequently Asked Questions ---------------------------- ### Why is VV ECMO insufficient when this patient deteriorates during dissection? VV ECMO supports gas exchange but does not directly provide systemic circulatory support. Refractory RV-related shock requires VA ECMO or another appropriate circulatory support strategy. ### Does a pulmonary venous Doppler velocity above 1 m/s mandate surgical revision? No. It raises suspicion, particularly with turbulence or loss of phasic flow, but must be interpreted alongside anatomy, flow conditions, and surgical findings. ### Can hypoxemia after reperfusion of the first lung be labeled grade 3 PGD? Not from hypoxemia alone. Formal bilateral-transplant grading starts after second-lung reperfusion and requires radiographic edema plus the qualifying PaO₂/FiO₂ ratio. ### Which ECMO configuration is preferred if severe PGD develops without shock? Current ISHLT consensus favors VV ECMO for isolated new-onset graft respiratory failure; VA ECMO is appropriate when significant cardiocirculatory failure coexists. References (8) ------------------ 1. 1. [ www.ishlt.org/education-and-publications/standards-guidelines-detail/peri-operative-management-of-patients-with-pulmonary-hypertension-and-right-heart-failure-undergoing-surgery ](https://www.ishlt.org/education-and-publications/standards-guidelines-detail/peri-operative-management-of-patients-with-pulmonary-hypertension-and-right-heart-failure-undergoing-surgery) [↩](#cite-ref-1-1 "Back to text") 2. 2. [ www.ishlt.org/docs/default-source/standards-guidelines/2024\_consensusdocument\_perioperativeuseofecls\_intraoperativeconsiderations.pdf ](https://www.ishlt.org/docs/default-source/standards-guidelines/2024_consensusdocument_perioperativeuseofecls_intraoperativeconsiderations.pdf) [↩](#cite-ref-2-1 "Back to text") 3. 3. [ American Society of Echocardiography. Guidelines for transesophageal echocardiography to assist surgical decision-making (2020). ](https://www.asecho.org/wp-content/uploads/2023/03/PIIS0894731720301334.pdf) [↩](#cite-ref-3-1 "Back to text") 4. 4. [ ISHLT Working Group. Primary lung graft dysfunction, Part I: Definition and grading (2017). ](https://www.ishlt.org/docs/default-source/standards-guidelines/2017_consensusdocument_ishlt_plgdpart1.pdf?sfvrsn=cc0ca4dc_7) [↩](#cite-ref-4-1 "Back to text") 5. 5. [ ISHLT Working Group. Primary lung graft dysfunction, Part IV: Prevention and treatment (2017). ](https://www.ishlt.org/docs/default-source/standards-guidelines/2017_consensusdocument_ishlt_plgdpart4.pdf?sfvrsn=9bc85220_7) [↩](#cite-ref-5-1 "Back to text") 6. 6. [ pmc.ncbi.nlm.nih.gov/articles/PMC3733407 ](https://pmc.ncbi.nlm.nih.gov/articles/PMC3733407/) [↩](#cite-ref-6-1 "Back to text") 7. 7. [ ISHLT consensus statement on perioperative ECLS in lung transplantation, Part II: Intraoperative considerations (2024). ](https://www.ishlt.org/docs/default-source/standards-guidelines/2024_consensusdocument_perioperativeuseofecls_intraoperativeconsiderations.pdf?sfvrsn=d968c647_1) 8. 8. [ ISHLT consensus statement on perioperative ECLS in lung transplantation, Part III: Postoperative considerations (2025). ](https://www.ishlt.org/docs/default-source/standards-guidelines/2025_consensusdocument_perioperativeuseofecls_postoperativeconsiderations.pdf?sfvrsn=8923878d_1) Keep going Build momentum in Anesthesiology with focused, exam‑style practice -------------------------------------------------------------------- - Airway, ventilation, and crisis drills - High‑yield anesthesia pharmacology made practical - Track weak topics and improve faster [ Start practicing ](https://mdster.com/user/dashboard) [ Explore Anesthesiology ](https://mdster.com/speciality/anesthesiology) [ View pricing ](https://mdster.com/pricing) [ Explore features ](https://mdster.com/features) No credit card required. Full access to all features\*. No commitment. Cancel anytime. \*AI SOE Examiner is limited to 10 cases monthly for Advanced & Bundle subscribers. 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