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Lung Transplant

Lung Transplant. Dave Sweet. CASE.

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Lung Transplant

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  1. Lung Transplant Dave Sweet

  2. CASE • You are currently the fellow working at VGH and as you come in Monday morning the charge nurse tells you that there are several transplants going on today including a lung transplant and that we are holding a bed. You have several resident working with you that are very excited and they start firing questions off….

  3. CASE • What diseases are currently we doing lung transplants for? • Alpha1-antitrypsin • CF • COPD • IPF (UIP and occ NSIP) • IPAH (including Eisenmengers) • Sarcoidosis

  4. CASE • What are the general goals for determining the appropriateness of a lung transplant in a individual patient?

  5. General Principles • Need to consider the natural history and prognosis of primary disease and weigh against projected survival post transplant. • Ultimate goal= • Obtain max mileage from native lung, conferring a greater overall survival time with new lung. • Avoiding death on the waiting list.

  6. General Principles • Consider quality of life while on waiting list compared to quality of life with new lung. • Traditionally, looked at the median 2-year posttransplant survival rate and compared this to projected survival with underlying condition. • When former=longer….patients are transplant candidates.

  7. General Principles • 2 year survival rate is not arbitrary number. Two reasons why used. • Average waiting time is around 2 yrs. • Based on disease the first month mortality varies greatly. …..but then the mortality decreases relatively linearly. This will compensate for this.

  8. CASE • Do the survival rates for different diseases vary post transplant? What is the generally quoted first month mortality?

  9. CASE First month mortality quoted as 7% to 24%

  10. CASE • Which diseases are thought to have the greatest survival advantages? Which diseases are questionable?

  11. Survival advantage? • Use of time-dependent, nonproportional hazard models, equity points, and crossover points. • Survival benefit demonstrated with: • CF • IPF • IPAH Critical Care Aspects of Lung Transplantation. Journal of Intensive Care Med 19(2); 2004

  12. Survival advantage? • However, also raised questions about any survival benefit for px with • COPD • Eisenmener syndrome But in addition to survival, quality of life also needs to be taken into consideration. ie) COPD px changes in quality-adjusted life-years may be sufficient to justify transplantation.

  13. Survival advantage?

  14. CASE • What are the indications for lung transplantation for these various diseases based on the ATS 1998 consensus statement?

  15. Indications • COPD • FEV1< 25% (without reversibility) • And/or PaCO2 >55 and/or elevated PAP with progressive deterioration • Preference to those px with: • elevated PaCO2 with progressive deterioration • require long term oxygen therapy. Nathan et al. Lung Transplantation: Disease-Specific Considerations for referral. Chest 2005;127:1006-1016

  16. Indications • Interesting……the level of subjective dyspnea my be a better predictor of mortality than FEV1. • ie) grade IV dyspnea= stopping to take a breath during 100 yrd walk. - median survival of 3 yrs, which is comparable to 3 yr posttransplant survival rate (61%) • In contrast, FEV1<35% pred had a median survival of 5 yrs.

  17. Indications • Currently several other models being investigated which incorporate a number of diff parameters such as the BODE index. • Body weight, Obstruction, Dyspnea level, Exercise tolerance. • Score out of 10. • 7-10=80% mort at 52 months (transplant cand) • <7= 5 yr mort of <50% (not transplant cand)

  18. Indications • IPF: • Divided now into UIP and NSIP • UIP=When diagnosed should be referred!!! • Traditionally, break points at FVC of 60-70% and DLCO of 50-60% are indicative for poor outcome. Very inconsistent.

  19. Indications • Other models look at DLCO and HRCT scan to help predict mortality (May see in future!) • Also, one of the most sensitive markers may be desaturation to less than 89% during a 6 min walk. • If able to maintain sats may be able to defer transplant referral.

  20. Indications • NSIP: • True NSIP have much better prognosis and majority will not need transplant. • Subgroup which may require include: 1) DLCO <35% and/or a dec in DLCO of >15% have shown to have mortality similar to UIP with median survival of 2 yrs.

  21. Indications • CF: • FEV1 <30% or • Rapid progressive resp deterioration with FEV1 >30% (inc hosp, rapid fall in FEV1, massive hemoptysis, inc cachexia) • Room air PaCO2 >50 or PaO2 <55. • Woman whose condition is deteriorating rapidly.

  22. Indications • IPAH: • Medical management has improved greatly. • 1990= 10.5% of all lung transplants. • 2001=3.6% of all lung transplants. • Should exhaust all medical management before consider transplant.

  23. Indications • NYHA class III or IV after 3 months of IV epoprostenol have 2 yr survival of 46% and should be considered for transplant. • NYHA class I and II= 93% and not candidate.

  24. Indications • Sarcoidosis (common disease, rare transplant) • In 1998 guideline no official recommendation. • Need to have stage IV. Advanced fibrotic changes, honey-combing, hilar retraction, bullae, cysts, and emphysema. • Also reasonable when FVC<50% and/or FEV1 <40%.

  25. CASE • After you clearly describe the answers to the above questions your staff speaks up and asks you if you are familiar with the Lung Allocation Score (LAS). • What is the LAS? Why was it designed?

  26. LAS • In Canada we determine how organs or allocated by: • Size of patient • ABO matching (Not HLA matching) • Time on the list. Kozower et al. The impact of the lung allocation score on short-term transplant outcomes: A multicenter study. J thorac Cardiovasc Surg 2008;135:166-77

  27. LAS In the US: • Organ procurement and transplantation network (OPTN) began allocating lungs in 1990 based on size, blood type and amount of time candidate had spent on waiting list. • 1995, minor change when 3 months credit given to IPF px to offset their inc mortality. (Not done in Canada) • To better list px according to medical urgency and expected benefit the LAS was developed.

  28. LAS • Developed by multivariate modeling and approved by OPTN in 2004. Implemented in May 2005. • Three main objectives are: • Reduce deaths on transplant list • Inc transplant benefit for lung recipients • Ensure efficient and equitable allocation of organs

  29. LAS • Gives a score between 1-100. • Weighted combination of predicted risk of death during the following year on the waiting list and the predicted likelyhood of survival during the first year after transplant.

  30. CASE • Is there any evidence that it is working?

  31. First year of implementation compared to previous year. • 170 in each group. • Dec in waiting times (680 to 445 days). • Dec death on waiting list (74 to 51…30%) • Determined that there was a switch with inc in IPF px and dec in COPD and CF. • Inc in primary graft dysfunction (14.1 to 22.9%). • Inc in ICU stay (5.7 to 7.8 days). • Hosp mort and 1 yr survival were similar.

  32. Concluded that the LAS is doing what it was designed to do. • Reason why inc in PGD is likely due to higher number of retransplants and IPF which both are established risk factors for PGD. • When controlled for Dx, the rates of PGD were no longer different. • This also explains the inc in ICU stay, mech vent. • Most important…..no change in mortality.

  33. Donor criteria? Less than 20% of organ donors possess lungs suitable for transplantation

  34. Age <40 years (heart-lung), <50 years (lung) • Smoking history less than 20 pack-years • Arterial partial oxygen pressure of 140 mm Hg on a fraction of inspired oxygen (FIO2) of 40% or 300 mm Hg on an FIO2 of 100% • Normal chest x-ray Sputum free of bacteria, fungi, or significant numbers of white blood cells on Gram and fungal staining • Bronchoscopy showing absence of purulent secretions or signs of aspiration • Absence of thoracic trauma • Human immunodeficiency virus negative

  35. CASE • You learn that the patient is a 58 yo male with severe COPD. Other PMHx includes a NSTEMI 8 yrs prev, HTN, hypercholesterolemia. Pre-op ECHO results show good biventricular fxn with PAS=33 mmHg via TRJ. Pre-op cath results show clean coronaries and right heart cath confirms the right sided pressures. Preop PFT show a PEV1 of 25% and moderate to severe airtrapping. They are doing a single right lung transplant and no plan for bypass.

  36. CASE • 8) How is the choice for a single vs a double lung transplant made? In what situations is a double lung preferred?

  37. Single vs Double? • Based on numerous factors such as: • Disease • Age • Comorbidities • Institutional biases • Organ availability • Emergency of procedure

  38. Single vs Double? • Majority done in Canada are single lung transplants. • First isolated single lungs were done for pulmonary fibrosis and this continues to be the norm. • COPD originally thought not possible to receive single lung transplants. • First done in 1989 by Mal and colleagues Critical Care Aspects of Lung Transplantation. Journal of Intensive Care Med 19(2); 2004

  39. Single vs Double? • Currently a standard throughout the country. • Specifically, in COPD if px is of shorter stature and older do better. • Pulmonary HTN= single or double but if choose single expect to have more difficulty in first few days. Many centers mandate only bilateral. • Bilateral transplants are mandatory for px with CF and bronchiectasis. Critical Care Aspects of Lung Transplantation. Journal of Intensive Care Med 19(2); 2004

  40. Single vs Double? • Bilateral lung transplants for mycetomas or other chronic fungal or mycobacterial infections • Many larger centers are now favoring bilateral transplants. Specifically the Duke University Medical Center. Critical Care Aspects of Lung Transplantation. Journal of Intensive Care Med 19(2); 2004

  41. Single vs Double? • Feel do not exclude other patient in many cases. • If single lung is “marginal” for transplant, taking both will provide adequate function. • Early post-op management is easier with bilateral

  42. Single vs Double? • Additionally, in 225 px who survive 6 months. • Single lung transplant (as compared to bilateral) was a significant risk for BOS in multivariate Cox model (HR=2.08, p=0.001) • ? If immunologic advantages of bilateral ? Hadjiliadis D et. al. Chest 2002;122:1168-1175.

  43. Single vs Double? • A recent review of the United Network of Organ Sharing lung transplant database of 2260 transplants for emphysema compared single vs double lung transplants. • No difference in 30 day mortality but long term survival data favored bilateral lung transplants for individuals <60 yrs of age. • Bilat were older and more women. ? How to interpret? Meyer et al. J heart Lung Transplant 2001;20:935-941.

  44. Case • 9) In what situations will a lung transplant be done on bypass? Why if done on bypass is it relevant to post-op management?

  45. Bypass? • Most adult transplants can be done without CPB. A number of specific situations will necessitate CPB. • Primary or secondary pulmonary htn are most safely done on bypass. • Px with CF likely have such voluminous purulent secretions that independent ventilation is impossible. • During bilateral transplant early graft dysfxn of the first transplanted lung (reperfusion) preventing single lung vent. • If native lung is unable to sustain patient with single lung ventilation.

  46. Bypass? • Why relevant to post-op care? 1) If get significant PGD it is unlikely the patient can be supported on single lung ventilation. 2) Bypass is a significant risk factor for PGD!! Most recent large study by Dalibon, which reviewed 140 LT, confirmed that CPB was associated with longer MV, more pulm edema, more transfusions and inc early mortality!! Dalibon et. al. J Cardiothorac Vasc Anesth 2006;20:668-672.

  47. CASE • You hear that the case is finishing up. There was minimal surgical difficulty the lung was implanted using continuous 3/0 polypropylene sutures for the bronchial anastomosis (end-end-technique), continuous 4/0 polypropylene sutures for the pulmonary vein to left atrial anastomosis, and continuous 5/0 polypropylene sutures for the pulmonary arterial anastomosis.

  48. CASE • Unfortunately you hear that they need to do the case on bypass as they were unable to do the transplant on single lung ventilation. The overall ischemia time was 6 hours and 8 minutes for the lung. The post-transplant bronch looked pristine and the TEE looked good. The patient is brought to ICU post-op stable on AC and FIO2 of 100% and quickly weaned to 80%. CVP=12 CI=3.5, PA=40/18. (If the nurse said the PAWP=16…what would you say??)

  49. CASE • 10) Generally what ventilator settings would you like post transplant px to be on? What about this patient? What is your general plan to wean the ventilator?

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