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LUNG TRANSPLANTATION CURRENT STATUS

LUNG TRANSPLANTATION CURRENT STATUS. Iskander Al-Githmi, MD, FRCSC-GS , FRCSC -Ts , FRCSC-CDs, FACS, FCCP. Division of Cardiothoracic Surgery. King Abdulaziz University Hospital. NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE.

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LUNG TRANSPLANTATION CURRENT STATUS

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  1. LUNG TRANSPLANTATION CURRENT STATUS Iskander Al-Githmi, MD, FRCSC-GS, FRCSC -Ts , FRCSC-CDs, FACS, FCCP Division of Cardiothoracic Surgery King Abdulaziz University Hospital

  2. 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 2009

  3. AVERAGE CENTER VOLUMELung Transplants: January 1, 2000 - June 30, 2008 ISHLT 2009

  4. Lung Transplantation in KSA • 4 transplants at KFH – Jeddah 1991 - 1994 • 1996 ,first single lung transplant at KFSH & RC (Riyadh ) • First bilateral lung transplant at KFSH & RC (Riyadh ) 1998 • 2001 , the lung transplant unit was established at KFSH & RC ( Jeddah) • Dec. 23,2001, the first successful bilateral lung transplant in the Middle East was performed at KFSH & RC (Jeddah)

  5. KFSH&RC – Jeddah Lung Transplantation Program • Patients with end-stage lung diseases, N=13 • Indications: • Pulmonary fibrosis (n=8) • Bronchiectasis (n=2) • Pulmonary HTN (n=1) • COPD (n=1) • LAM (n=1)

  6. Types of transplantation: • Single lung (n=10) • Bilateral lung (n=3) Results: 10/13 survived Mortality 3/13 (n=1 liver failure, n=1 stroke, n=1 T.B.) 1 year survival 95 %

  7. Lung transplantation in KSA • KFSH & RC ( Jeddah ) is the only active hospital performing lung transplantation in the Middle East • IPF is the commonest indication followed by Broncheictasis • 95% 1 year survival

  8. AGE DISTRIBUTION OF LUNG TRANSPLANT RECIPIENTS(1/1985-6/2008) ISHLT 2009

  9. DONOR AGE DISTRIBUTION FOR LUNG TRANSPLANTS (1/1985-6/2008) ISHLT 2009

  10. LUNG TRANSPLANTS:Transplant Recipient Age by Year of TransplantTransplants: January 1, 1987 – June 30, 2008 ISHLT 2009

  11. Lung transplantation evaluation process • Cardiothoracic Transplant Surgeon • Transplant Pulmonologist • Transplant Coordinator • Transplant Anesthiologist • Infectious Disease • Nutritionist • Social services • Psychologist • Physiotherapist

  12. Recipient Selective Criteria: • End-stage pulmonary disease with life expectancy < 2 yrs. • Absence of severe extra pulmonary diseases. • Strong motivation towards the idea of lung transplantation. • Severe functional limitation, but potential for rehabilitation. • Excellent psychosocial support. • No current smoking or substances abuse

  13. Indications: • Obstructive air way disease (29%) - COPD - Alpha 1 antitrypsin deficiency • Idiopathic pulmonary fibrosis (19%) • Septic pulmonary disease (16%) - Bronchiectasis - cystic fibrosis • Primary pulmonary hypertension (11%)

  14. Other Varieties (11%) e.g. - sarcoidosis - lymphangioliomyomatosis (LAM) - eosinophilic granuloma

  15. Contra-indications: • Age > 65 years • Active smoking • Poor compliance with the treatment • Severe active infections (HIV, Hepatitis B & C)

  16. Con’t. • Active malignancy within the past two years. • Drugs or alcohol abuse. • Dysfunction of major other organs - renal dysfunction - untreatable CAD or LV dysfunction - liver dysfunction • Ventilator dependence - high mortality • BMI < 16 and BMI > 30 • Severe osteoporosis

  17. Donor Selection Criteria (Standard): • Age < 55 years • ABO blood group compatibility • No significant lung diseases • Absence of chest trauma • Smoking Hx < 20 pack years • Clear CXR • PaO2 > 300mm Hg on F102 1.0 and PEEP 5 cm for 5 min. • Bronchoscopy – clear • Sputum gram stain- Absence of organisms

  18. Donor-Recipient Matching Issues • ABO blood group is the most antigen system • Panel reactive antibodies • Size matching Undesized: persistent pneumothorax and increase work of breathing. Oversized: atelectasis and distortion of anatomy

  19. Donor Supply • Increasinggap between demand and supply • Newer strategies A. Marginal donors Do not fill these criteria:- 1- Age < 55 yrs 2- Clear Chest X-ray 3- No smoking history ` 4- Sputum gram stain negative 5- Normal gas exchange

  20. Donor Supply • Living lobar transplantation • Harvesting left lower lobe from one healthy donor & right lower lobe from another( 25% of TLC for each) • Pioneered by University of southern California (Vaughn Starns). • Impressive result in both children & adults • Associated with Significant morbidity but no fatalities reported

  21. Donor Supply • Non -heart beating donor (NHBD) • A donor whose death is defined by irreversible cessation of circulatory and respiratory functions (UDDA) • Period of time between a systole and retrieval is controversial , recommendation is 2-5min • NHBD contributes < 1% of the numbers of transplants in USA • In Holland 50% of cadaveric transplants are from NHBD

  22. Non-heart beating donor

  23. Donor Supply • Xenotransplantation Initial enthusiasm – unlimited donor supply • Hardening factors 1. Severe immune response 2. Apparent incompatibilities between the coagulation systems of the two species European resp.journal 2003;supp

  24. Donor Supply Reconditioning Lung Donor

  25. Toronto Xvivo Lung Perfusion System

  26. Shaf Keshavjee, MD,FRCSCDirector of Lung Transplant ProgramUniversity of Toronto

  27. Lung transplantation • Single or double lung • Wait time -Blood Type -Size • Severity of illness -Life expectancy while on the waiting list -Outcome post transplant • Surgical time (6-8 hours) • Hospital stay (14-21 days) • Follow up ( life long, frequent office visits)

  28. ADULT LUNG TRANSPLANTATION: Indications for Single Lung Transplants (Transplants: January 1995 - June 2008) *Other includes: Sarcoidosis: 2.1% Bronchiectasis: 0.4% Congenital Heart Disease: 0.2% LAM: 0.8% OB (non-ReTx): 0.5% Miscellaneous: 6.3% ISHLT 2009

  29. ADULT LUNG TRANSPLANTATION: Indications for Bilateral/Double Lung Transplants (Transplants: January 1995 - June 2008) *Other includes: Sarcoidosis: 2.9% Bronchiectasis: 4.5% Congenital Heart Disease: 1.1% LAM: 1.2% OB (non-ReTx): 1.1% Miscellaneous: 7.7% ISHLT 2009

  30. ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival (Transplants: January 1994 - June 2007) ISHLT 2009

  31. ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival by Procedure Type and Era(Transplants: January 1990 – June 2007) Diagnosis: Idiopathic Pulmonary Fibrosis, Single Lung ISHLT 2009

  32. ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival by Procedure Type and Era(Transplants: January 1990 – June 2007) Diagnosis: Idiopathic Pulmonary Fibrosis, Double Lung ISHLT 2009

  33. ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival By Diagnosis(Transplants: January 1990 – June 2007) Survival comparisons Alpha-1 vs. CF: p < 0.0001 Alpha-1 vs. COPD: p < 0.0001 Alpha-1 vs. IPF: p < 0.0001 Alpha-1 vs.Sarcoidosis: p = 0.0380 CF vs. COPD: p < 0.0001 CF vs. IPF: p < 0.0001 CF vs. IPAH: p < 0.0001 CF vs. Sarcoidosis: p < 0.0001 IPAH vs. IPF: p = 0.0046 COPD vs. IPF: p < 0.0001 ISHLT 2009

  34. ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival by Gender(Transplants: January 1990 – June 2007) ISHLT 2009

  35. ADULT LUNG TRANSPLANTATIONKaplan-Meier Survival by Age Group(Transplants: January 1990 – June 2007) ISHLT 2009

  36. Eur J Cardiothorac Surg 2006;30:846-851

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