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Overview of Lung Transplantation

Overview of Lung Transplantation. Luca Paoletti, MD Assistant Professor of Medicine Medical University of South Carolina. Objectives. D efine indications for lung transplantation R eview guidelines for recipient selection for lung transplantation

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Overview of Lung Transplantation

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  1. Overview of Lung Transplantation Luca Paoletti, MD Assistant Professor of Medicine Medical University of South Carolina

  2. Objectives • Define indications for lung transplantation • Review guidelines for recipient selection for lung transplantation • Review surgical approaches for transplantation • Describe survival outcomes following transplantation

  3. Transplantation CF IPF

  4. History of Lung Transplantation • 1963- First Transplant • 1963-1981 over 40 attempted • 1983- First long term successful lung transplant • 1990- First living donor transplant • Early 2000’s - Double lung transplant more common

  5. NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE 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 2012 J Heart Lung Transplant.  2012 Oct; 31(10): 1045-1095

  6. LUNG TRANSPLANTS Transplant Recipient Age by Year of Transplant(Transplants: January 1, 1987 – June 30, 2011) ISHLT 2012 J Heart Lung Transplant.  2012 Oct; 31(10): 1045-1095

  7. AGE DISTRIBUTION OF ADULT LUNG TRANSPLANT RECIPIENTS (1/1985-6/2011) ISHLT 2012 J Heart Lung Transplant.  2012 Oct; 31(10): 1045-1095

  8. DONOR AGE DISTRIBUTION FOR LUNG TRANSPLANTS (1/1985-6/2011) ISHLT 2012 J Heart Lung Transplant.  2012 Oct; 31(10): 1045-1095

  9. When to consider transplant • Untreatable, advanced stage lung disease • No other significant medical disease • Limited life expectancy • Poor quality of life • Support system • Mustparticipate in rehab J Heart Lung Transplant 2006. 25, 745-755

  10. Absolute Contraindications • Extrapulmonic disease • HIV infection • Malignancy within prior 2 years • Hepatitis B antigen positivity • Hepatitis C biopsy proven liver disease • Severe Musculoskeletal disease • Substance addiction in prior 6 months • Absence of reliable support system • Untreatable psychosocial problems • Non-compliance J Heart Lung Transplant 2006. 25, 745-755

  11. Relative Contraindications • Age > 65 • Critical or unstable medical condition • Systemic or multisystem extrapulmonic disease • Pan resistant organisms • Symptomatic osteoporosis • Mechanical ventilation • BMI <17 or >30 J Heart Lung Transplant 2006. 25, 745-755

  12. Role of Rehab Pre-op • Dyspnea = inactivity = muscle weakness = difficulty with ADLs • Rehab = improvement in functional capacity • Rehab = comfort with staff pre and post • Rehab = group therapy • Rehab = assessment of patient and their support

  13. Role of Rehab post op • Continued muscle strengthening • Continued endurance training • Improvement in PFTs • Improvement in 6MWT • Prepares for home program

  14. ADULT LUNG TRANSPLANTSIndications(Transplants: January 1995 - June 2011) ISHLT 2012 J Heart Lung Transplant.  2012 Oct; 31(10): 1045-1095

  15. ADULT LUNG TRANSPLANTSMajor Indications By Year (Number) ISHLT 2012 J Heart Lung Transplant.  2012 Oct; 31(10): 1045-1095

  16. J Heart Lung Transplant 2006. 25, 745-755

  17. COPD Referral to transplant center: • BODE index of 5 Transplantation: • BODE index 7 – 10 or at least 1 of the following: • PaCO2 > 50mmHg • Pulmonary hypertension or corpulmonale despite O2 therapy • FEV1 < 20% predicted and: • DLCO of less than 20% or homogenous emphysema on CT J Heart Lung Transplant 2006;25:745–55.

  18. BODE score

  19. Idiopathic Pulmonary Fibrosis Referral • Histologic or radiographic evidence of UIP irrespective of vital capacity • Histologic evidence of fibrotic NSIP Transplantation • DLCO < 39% predicted • 10% or greater decrease in FVC during 6 months of follow-up • A decrease in pulse oximetry below 88% during a 6-MWT • Honeycombing on HRCT • Reassess every 3 months J Heart Lung Transplant 2006;25:745–55.

  20. Cystic Fibrosis Referral • FEV1 < 30% predicted or a rapid decline in FEV1 • Young, female patients refer early • Exacerbation of pulmonary disease requiring ICU • Increasing frequency of exacerbations requiring antibiotics • Recurrent hemoptysis not controlled by embolization Transplantation • Oxygen-dependent respiratory failure • Hypercapnia • Pulmonary hypertension J Heart Lung Transplant 2006;25:745–55.

  21. Pulmonary Arterial Hypertension • Symptomatic progressive disease despite vasodilator treatment • WHO III-IV • Right atrial pressure > 15mmHg • Low or declining 6 minute walk test

  22. Pre-transplant Evaluation • PFTs • 6 minute walk test • EKG • Echocardiogram • Cardiac cath • HRCT • Chemistries • LFTs • Serologies- CMV, HIV, Hepatitis, EBV • V/Q scan • Dexa scan • GERD

  23. Ideal Donor Selection • Donor Age < 55 • Smoking History < 20 pk/yrs • No history of significant lung disease • PaO2/FIO2 > 300 on PEEP of 5 cm H2O • CXR clear • BAL: No organisms on gram stain • Normal endobronchial examination • Absence of chest trauma • ABO matched • Size matched

  24. Good vs. Bad

  25. Bad

  26. Donor Selection Provisional Yes • Donor Net Alert • UNOS website • Potential donor evaluation Absolutes • Blood type • Donor height • Serology • HIV • Hepatitis • Mucus • X-ray (pneumonia) • Antigens • Relative • PaO2 = • Bronchoscopy • Location • Smoking history • Laboratory values

  27. Donor Ventilator Management • Conventional Mechanical Ventilation • Volume Control • Tidal Volume 8-10cc/kg OF ideal body weight • Rate to achieve PCO2 35-45 • PEEP of 5-8

  28. Donor Ventilator Management • Prevent aspiration: • Inflate ETT cuff to 25 cm H20 • Head of bed > 30 degrees • Airway Clearance • Bag ventilation and suction • Therapeutic Bronchoscopy

  29. Donor Selection:

  30. Getting the Lungs

  31. Lung Transplant Surgery

  32. Sternotomy

  33. Clamshell Incision

  34. Thoracotomy

  35. Cardiopulmonary Bypass

  36. Anastomosis

  37. Donor Lung

  38. MUSC Team

  39. OR

  40. Possibly the futureEx Vivo Lung Perfusion

  41. Costs • Varies from center to center • Median cost in 2007: $140,000 • Mean LOS -18 days Remember… • Annual infusion therapy for A1AT/Pulm HTN is over $100,000

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