Role of chest surgeon in lung transplantation

1. Role of chest surgeon in lung transplantation Dr Alper Toker Istanbul Medical school Department of chest surgery

3. THE REGISTRY OF THE INTERNATIONAL SOCIETY FOR HEART AND LUNG TRANSPLANTATION: TWENTY-FIFTH ANNUAL REPORT ISHLT 2008 J Heart Lung Transplant 2008;27: 937-983

4. REGISTRY DATABASE:Number of Transplants Reported ISHLT 2008 J Heart Lung Transplant 2008;27: 937-983

5. NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE 2196 2168 1924 1789 1788 1615 1574 1481 1461 1457 1375 1366 1229 1087 923 707 418 189 83 45 15 14 NOTE: This figure includes only the lung transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as representing changes in the number of lung transplants performed worldwide. ISHLT 2008 J Heart Lung Transplant 2008;27: 937-983

6. AVERAGE CENTER VOLUMELung Transplants: January 1, 2000 - June 30, 2007 ISHLT 2008 J Heart Lung Transplant 2008;27: 937-983

7. ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival (Transplants: January 1994 - June 2006) P < 0.0001 ISHLT 2008 J Heart Lung Transplant 2008;27: 937-983

8. Questions of the chest surgeon • Is the patient an ideal candidate? • Which transplantation ? • Donor organ ? • Technical details • Strategy in posttransplant complications

9. Candidate • Could transplantation NOW be an overtreatment for the patient ? • Patient is in very bad condition and it is impossible for him to tolerate such an operation. • Cardiac problems and comorbidity • Total pleurectomy (for pneumothorax) • Lobectomy, surgery for emphysema • Open lung biopsy • Chest wall deformity

10. Pathophysiology of brain death IC pathology Hemorrhage Trauma Tumor Increased ICP Cushing’s Reflex Endogenous cathecholamin storm Cathecholamin storm Hipertension Increased after load Miyocardial ischemia Papillary muscle disfunction Mitral insufficiency Pulmonary edema Destruction of vasomotor centers Decreased SVR Decreased perfusion pressure Distal organ ischemia

11. Donor • Age 65 years • PO2 = 3 x FiO2 (mmHg), normal PCO2 • Normal CXR • Smoking < 30 p/y • No sepsis • No malignancy • Size (predicted and aktüel TLC) • Virology tests • No history for lung disease • Normal bronchoscopy

12. Donor • Same results in donors at age 65 (55) . Bhorade et al JHLT 2000. • Donor age + prolonged ischemia: Poor results. Meyer et al Chest 2000 • Abnormal CXR is not a reason to reject automatically. Fisher et al J HLTx 2001 • Mucopurulan sputum is not reason to reject the lung automatically. F Whiting et al Am Surg 2003

13. Donor Selection • Organisms in BAL shown to carry poorer early and medium term results. Whiting et al Am Surg 2003. • Smoking History of > 20 pack years not a contraindication. Aigner et al Chest SurgClin N Am 2003 • Large Number of lungs rejected are found to have been acceptable for Tx on the basis of their physiology, microbiology and histology. Ware et al Lancet 2002

14. NonHeart Beating Donors (NHB) • Nonheart beating donors “Ex vivo perfusion” • Ex vivo evaluation. • Ex vivo lung repair • Ex vivo reconditioning.

15. Lung size matching • Use donor predicted TLC • Use recipient actual and predicted PLC • Adjust for sex mismatch • Emphysema: DTLC larger than PRTLC and at least 10% less than RATLC(BB) • Fibrotics: DTLC larger than RATLC and smaller than RPTLC • Avoid oversizing BSLT and HLT

16. Strategies for lung preservation

17. Attempts to improve preservation • Donor cooling. (CPB) • Varying degrees of ventilation and oxygenation. • The use of different preservation solutions. • The use of different temperatures for lung storage and transportation. • Ex vivo evaluation • Ex vivo lung repair

18. Injury during lung preservation • Lysosomal enzymes • Proteolytic enzymes • Endothelial cell injury • Cellular swelling • Free radical injury • Energy spending

19. Lung Inflation at time of Harvest • Antigrade and retrograde lung perfusion • Extracellular vs Intracellular perfusate • Temperature at transport • Controlled re-perfusion • Inhaled Nitric oxide • Bypass and ECMO (baro-trauma) • Non heart beating lung donors

20. Perfadex versus Eurocollins • 4 historical comparative, non-randomized studies • • superior early graft function in Perfadex group • • better (NS) early survival in Perfadex group • Müller C et al. Transplantation 1999;68:1139-43 Strüber M et al. Eur J Cardiothorac Surg 2001;19:190-194Fischer S et al. J Thorac Cardiovasc Surg 2001;121:594-596Aziz et al. Ann Thorac Surg 2003;75:990-5

21. Transplantation in Istanbul Medical School November 2004

31. Conclusion • Superior preservation techniques have improved early graft dysfunction. • Lung ischaemic time is now accepted at up to 8 hours.

32. Controlled Conditions during reperfusion • Controlled reperfusion: low PA pressure during first 10 min, slowly releasing PA clamp or reperfusion on CBP Bhabra MS et al. Ann Thorac Surg1998;65:187-192 • Controlled ventilation. de Perrot M et al. Effect of ventilation induced lung injury on reperfusion injury. J Thorac Cardiovasc Surg2002 • The use of Nitric oxide inhalation at re-perfusion. Bhabra et al Ann Thoracic Surgery 1997

37. INDICATIONS for LTx • SLTx: • IPF, PF, Emphysema (all types), sarcoidosis, re-transplantation • BSLTx: • CF, Bronchiectasis, Emphysema, Pulmonary hypertension. Septic lung disease • HLTx: • Eisenmenger syndrome, dual organ dysfunction, pulmonary hypertension

38. ADULT LUNG TRANSPLANTATION: Indications for Single Lung Transplants (Transplants: January 1995 - June 2007) *Other includes: Sarcoidosis: 2.1% Bronchiectasis: 0.4% Congenital Heart Disease: 0.2% LAM: 0.7% OB (non-ReTx): 0.5% Miscellaneous: 5.8% ISHLT 2008 J Heart Lung Transplant 2008;27: 937-983

39. ADULT LUNG TRANSPLANTATION: Indications for Bilateral/Double Lung Transplants (Transplants: January 1995 - June 2007) *Other includes: Sarcoidosis: 3.0% Bronchiectasis: 4.8% Congenital Heart Disease: 1.3% LAM: 1.2% OB (non-ReTx): 1.1% Miscellaneous: 6.6% ISHLT 2008 J Heart Lung Transplant 2008;27: 937-983

40. Bilateral sequential lung transplantation

41. Cannulation

43. Operative mortality • Mortality within 1 – 30 days Greft failure : % 23.4 Infection : % 16 Bleeding : % 3.7 Acute rejection : % 4.1 Other intra tx : % 4.6 Others : % 48.2

44. Ischemia reperfusion injury Primary graft dysfunction (PGD) • Major reason for Early posttransplant mortality • UNOS/İSHLT PGD % 10.2 • Mortality % 42 • No PGD then mortality %6 Risk factors • Ischemic time over 330 min • PaO2/FiO2 posttransplant 6th hour • Inotropic need of recipient • Donor PaO2/FiO2 rate • Donor age

45. Posttransplant problems • Exclude • Bleeding • Bleeding from lymphatics • Anastomosis problems • Pulmonary artery- atrium • Suspect • Primary Greft failure • Acute – hiperacute rejection • Don’t risk • Infection • Airleak • Be ready for • GIS problems • Hematologic problems • No pressure ventilation ECMO – novalung • Renal failure • Hepatic failure • Cardiac failure

46. Bronchial complications • Dehiscence rare, first case only! • Main problem is bronchial stenosis which is around 3-5% Possible causes : Ischaemia, telescoping, type of anastomosis, infection, etc Treatment: Bronchial dilatation, Bronchial stents, Argon laser. Cryo was disappointing

47. Controversies and Developments • Use of Marginal Donors • Choice of procedure • SLT versus BSL for emphysema • Heart/Lung versus BSLT for CF • HLT v BLT v SLT for PPH • SLT versus BLT in young IPF • The use of NHB lung donors • Lobar Transplantation

48. NON HEART BEATING LUNG DONATION

49. Non Heart Beating Donation Steen et al Lancet 2001; 357(9259): 825-9 18 hrs 1 week

50. NHB Lung Donation ( 2003) • Stig Steen, Lund, Sweden • Single case, • Uncontrolled Donation, • Perfusion Assessment • Robert Love, Madison, Wisconsin, USA • 5 Patients • All Controlled • Conventional Flush Perfusion