710 Survival Stratification in Scleroderma Patients by DeMeester Score

Abstracts was calculated. Relevant clinical data was extracted from our lung transplant database. Descriptive statistics were used. We analyzed time to event using Kaplan-Meier, groups were compared using the log-rank test. Logistic regression was used to adjust for potential confounders. P-values of ⱕ0.05 were considered statistically significant. Results: Fifty-four percent (n⫽184) of patients listed for transplant were male and 46% (n⫽156) were female. Median age at listing was 59.5 years old. Distribution of diagnoses was 45% pulmonary fibrosis, 25% chronic obstructive pulmonary disease, 11% cystic fibrosis, 4% pulmonary arterial hypertension, and 9% other. Median lung allocation score (LAS) at listing was 37.8. Of the 340 patients, 37 (11%) had a PRA ⱖ25%. Likelihood of transplant was lower in patients with PRA ⱖ25% (51% vs. 84%, p⬍0.001). Median time to transplant was longer in patients with PRA ⱖ25% (186 days versus 46 days, p⬍0.001). Death on the waitlist was also significantly higher in the allosensitized group (19% versus 7%, p⬍ 0.01) compared to the non-allosenzited group. Multivariable analysis demonstrated that patients with PRA ⱖ25% were at increased risk of death on the waiting list (OR 5.12; 95% CI: 1.79-14.63, p⫽0.004), after adjusting for LAS and age. Conclusions: In our study, PRA ⱖ25% was associated with a lower likelihood of transplantation, longer time to transplant, and increased risk of dying on the waiting list. Given these findings, further studies evaluating the effects of desensitization are warranted. 708 Percutaneous Coronary Intervention Improves Outcomes in Patients with Coronary Artery Disease Undergoing Lung Transplantation R.R. Bunge,1 H. Seethamraju,2 S. Scheinin,1 J. Estep,3 T. Motomura,1 S. La Francesca,1 W. Fischer,1 A.D. Perulakar,2 M. Loebe,1 B.A. Bruckner.1 1Cardiovascular Surgery & Thoracic Transplant, The Methodist Hospital DeBakey Heart & Vascular Center, Houston, TX; 2 Internal Medicine/Division of Pumonary Transplant, The Methodist Hospital, Houston, TX; 3Internal Medicine/Division of Cardiology, The Methodist Hospital DeBakey Heart & Vascular Center, Houston, TX. Purpose: Patients with end stage lung disease and significant coronary artery disease (CAD) with at least one lesion ⬎50% stenosis are at higher risk for lung tx. Coronary revascularization (CR) for these patients include percutaneous coronary revascularization (PCI) with stents or coronary artery bypass (CABG). The primary objective of this study was to determine the best method of CR with lowest mortality in a large series of patients at a single center. Methods and Materials: Between 2000 and 2010, 298 pts underwent cardiac catheterization and eventually received either a single or double lung transplant. Of the 298 patients, 233 had no dz (78.2%), 16 had mild dz (5.4%, ⬍50% lesions), and 49 with significant dz (16.4%, ⬎50% lesion in one vessel). Results: Pts with no CAD or mild dz went straight to lung transplant. Those with significant dz (n⫽49), either underwent PCI with stenting (n⫽15), surgical CABG (n⫽6), or no intervention (n⫽28). The PCI group included a total of 10 LAD, 4 RCA, 3 OM, and 2 Dx stents (12 bare metal and 7 drug eluting stents). The surgical group included 3 preop CABG and 3 concomitant lung tx⫹CABG. Pts who underwent preop PCI and lung tx, had 30 day, 6 mo, and 1 yr survival of 100%, 93%, and 85% respectively. In the CABG group, 2 patients died within the first 30 days of lung tx/CABG procedure (mortality 67%). Those pts with significant dz and no CR had 30 day, 6 mo, and 1 yr survival of 86%, 64%, and 54%. Further analysis of the non-intervention CAD group revealed 9 abnormal and 19 normal stress tests (myocardial SPECT). The majority of the abnormal tests (⬎90%) demonstrated scar or fixed perfusion defects. Conclusions: In our single center experience, preoperative PCI intervention conferred a significant survival advantage over non-intervention and CABG patients. Although stress testing can be helpful, aggressive CR may be indicated in this high risk population undergoing major lung transplant surgery and has resulted in an algorithm change at our institution. 709 Single Versus Double-Lung Transplantation in Emphysema M. Delgado,1 J.M. Borro,1 D. González,1 R. Fernández,1 S. Campainha,2 J.A. García,1 E. Fieira,1 L. Mendez,1 M. De LaTorre.1

S243 1

Toracic Surgery, University Hospital A Coruña, A Coruña, Spain; Pulmonology, Centro Hospitalar de Gaia/Espinho., Vila Nova de Gaia, Portugal.

2

Purpose: The indication of single or double lung transplantation in patients diagnosed pulmonary emphysema is a topic of current debate. Our aim was to analyze differences in the incidence of perioperative complications, survival and quality of life between single and double lung transplantation. Methods and Materials: From 1999-2010, of 280 transplanted patients, 73 (26%) had a previous diagnosis of pulmonary emphysema. A retrospective analysis was carried out to compare single-lung (group 1) to doublelung (group 2) transplantation. Survival analysis was performed using the Kaplan-Meier method. The impact of type of transplant (single vs doublelung), bacterial and fungal infections, acute and chronic rejection on survival was determined through COX multivariate analysis. Results: 73 patients (62 men) were included (group 1: 40; group 2: 33). Mean age was 54,8⫾7,14 years, with no statistically significant differences between groups. Mean follow-up time was 58 months (range: 4-134 months). Perioperative complications were recorded in 27.6% of patients in group 1 vs 54% in group 2 (p⫽0.032). Excluding perioperative mortality median survival was 65,3 months for group 1 and 59,4 months for group 2 (p⫽ 0,96). No relationship was found among type of transplant and the presence of bacterial or fungal lung infections (p⫽ 0,92) and BOS (p⫽ 0,83). COX regression multivariate analysis revealed that acute rejection had a statistically significant relation to worse survival (p⫽ 0,001; RR⫽3,4). No difference was found between type of transplant and survival (p⫽0,48). Conclusions: Perioperative complications were more frequent in bilateral lung transplantation. BOS and infection were similar in both groups, and we found no differences in overall survival. The results support our group’s decision to consider single-lung transplantation as the treatment of choice in emphysema. Retransplantation of native lung can overcome the problem of BOS with decreased mobidity and mortality (when compared to double-lung retransplantation) and additional techniques can be used to solve the problem of hyperinflation of the native lung. 710 Survival Stratification in Scleroderma Patients by DeMeester Score J.P. Gagermeier,1 P. Patel,2 J. Joseph,2 P.M. Fischiella,3 C.S. Davis,3 C.G. Alex,1 R.B. Love.4 1Pulmonary and Critical Care Medicine, Loyola University Medical Center, Maywood, IL; 2Medicine, Loyola University Medical Center, Maywood, IL; 3General Surgery, Loyola University Medical Center, Maywood, IL; 4Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL. Purpose: Scleroderma often results in progressive gastroesophageal reflux disease (GERD) that may result in lung injury; the DeMeester score is a measure of GERD severity. The concern that GERD, regardless of severity, will shorten survival in all scleroderma patients may result in reluctance to perform lung transplantation. We hypothesized that acceptable one year survival may be seen in scleroderma patients with GERD, and the DeMeester score may stratify patients for consideration for lung transplantation. Methods and Materials: A retrospective analysis of 10 scleroderma patients referred for lung transplantation that underwent esophageal function testing (EFT) from April, 2005 through July, 2011 was conducted. Patients were stratified into groups with DeMeester scores less or greater than 70. Pulmonary function testing and right heart catheterization, obtained at evaluation, and one year survival were compared between the 2 groups. Results: One year survival from the time of EFT was 100% (7/7) in patients with a DeMeester score of less than 70, while survival was 33% (1/3) in patients with a score greater than 70 (Fisher’s exact test; p ⫽ .06). There appears to be a trend of improved median survival in those patients with a DeMeester score less than 70, while mean values of FEV1, FVC and pulmonary artery pressure, respectively, appeared similar in the two groups. The single survivor with a DeMeester score greater than 70 underwent anti-reflux surgery.

S244

The Journal of Heart and Lung Transplantation, Vol 31, No 4S, April 2012

DeMeester Score Stratification in Scleroderma Patients DeMeester Score Group

FVC (L)*

PA pressure* (mm Hg)

Median Survival in Days (Post EFT)

One Year Survival

1.48 ⫾ 0.76

1.84 ⫾ 1.03

32 ⫾ 6

941

100%

1.23 ⫾ 0.29

1.42 ⫾ 0.23

38 ⫾ 21

206

33%

Subjects

Mean DeMeester Score*

FEV1 (L)*

⬍ 70

7

28.2 (24.1)

⬎ 70

3

146 (84.8)

*Data are presented as mean ⫾ SD.

Conclusions: One year survival of 100% was seen in scleroderma patients with a DeMeester score less than 70. Although the study size is limiting, consideration for lung transplantation in specific scleroderma patients despite the presence of GERD may be suggested. 711 Changes in Pulmonary Volumes in Patients Who Underwent Lung Transplantation for Pulmonary Fibrosis A. Bertani,1 P. Vitulo,2 S. Soresi,2 L. DeMonte,1 F. Tuzzolino,1 A. Callari,2 B. Gridelli.1 1Thoracic Surgery and Lung Transplantation, ISMETT-UPMC Italy, Palermo, Italy; 2Pulmonology, ISMETT-UPMC Italy, Palermo, Italy. Purpose: The ideal graft size match for lung transplantation (LTX) in patients with pulmonary fibrosis (IPF) is still unclear. Donor lungs are usually undersized to adapt to a smaller recipient’s chest cavity. We investigated the functional, estimated and CT scan rendered volumes of donors and recipients of LTX. Methods and Materials: Preoperarative estimated total lung capacity (rTLC-pre), estimated functional vital capacity (r-eFVC-pre), actual FVC (rFVC-pre) and CT scan lung volumetry (rCT-pre) were calculated in 96 patients with IPF who were listed for LTX. Estimated post-LTX TLC (eTLC-post), actual post LTX FVC (rFVC-post) and CT scan lung volumetry (rCT-post) were calculated in the recipients of LTX. Estimated TLC (dTLC) and FVC (dFVC) were calculated in 26 lung matched donors of IPF recipients. All the volumes are presented as mean values. Results: Despite a trend towards matching smaller donors with larger recipients, dTLC and rTLC-pre did not differ significantly (5.53 vs. 5.57 liters, p⫽0.42). In the recipients, rCT-pre was significantly smaller than rTLC-pre (3.16 vs 5.53 lt, p⬍0.0001). Also, rFVC-pre was significantly smaller than r-eFVC-pre (1.87 vs. 3.47 lts, p⬍0.001). After the transplant, rCT-post was smaller than eTLC-post (3.02 vs.5.72 lts, p⬍0.001). Also, rCT was significantly smaller than dTLC (3.02 vs 5.57 lts, p⬍0.001), corresponding to a 45.3% volume reduction. rCT-pre and rCT-post did not differ significantly (3.09 vs.3.21 lts, p⫽0.61). rFVC-post increased compared to rFVC-pre by a factor of 18.08%. Conclusions: The analysis of donor and pre/post LTX lung volumes (estimated, actual, and CT scan rendered) suggests that the pulmonary graft tends to adapt to the recipient small chest cavity. Given the acceptable functional results, this result could suggest the possibility of further reducing the donor/recipient volume ratio when matching lung donors to recipients, thus allowing expansion the donor pool. 712 Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplant: First Results of the French Experience, 2007-2011 P. Mordant,1 M. Lafarge,1 Y. Castier,1 L. Brouchet,2 P.E. Falcoz,3 A. Haloun,4 F. Le Pimpec-Barthes,5 G. Lesèche,1 J.-M. Maury,6 M. Reynaud-Gaubert,7 C. Saint-Raymond,8 M. Stern,9 H. Mal.1 1Hôpital Bichat - Claude Bernard, Paris, France; 2CHU, Toulouse, France; 3 CHU, Strasbourg, France; 4CHU, Nantes, France; 5HEGP, Paris, France; 6CHU, Lyon, France; 7CHU, Marseille, France; 8CHU, Grenoble, France; 9Hôpital Foch, Suresnes, France. Purpose: Some candidates to lung transplantation (LTx) worsened dramatically their lung function and necessitate respiratory support in intensive care unit (ICU). In this context, extracorporeal membrane oxygenation (ECMO) has been used as a bridge to LTx, according to the French high emergency lung allocation system. The goal of this study is to analyze the outcome of these patients.

Methods and Materials: A retrospective national study has included every patient supported by ECMO as a bridge to LTx in France from April 2007 to July 2011. Thirty-six patients were identified in 9 centres. Recipients’ diagnosis was cystic fibrosis (CF) in 20 cases (56%), pulmonary fibrosis (PF) in 11 cases (30%), and another diagnosis in 5 cases (14%). Results: Thirty patients (83%) underwent single (n⫽5, 17%) or double (n⫽25, 83%) LTx. Seventeen patients (47% of the assisted, 56% of the transplanted population) left the hospital alive, and 2 (5% of the assisted, 7% of the transplanted population) were still hospitalized at the end of the follow up. After ECMO initiation, 2-year survival rates were 50% for the overall population, 71% for CF, 21% for PF, and 20% for other diagnoses (p⬍.001). After LTx, 2-year survival rates were 60% for the overall population, 71% for CF, 42% for PF, and 33% for other diagnoses (p⫽.114). Conclusions: In the French experience, ECMO as a bridge to LTx is associated with prolonged survival in a majority of patients. 713 CT Scores Are Predictive of Survival in CF Patients Awaiting Lung Transplantation M. Loeve,1,2 W.C.J. Hop,3 M. de Bruijne,2,4 P.Th.W. van Hal,5 P. Robinson,6 M.L. Aitken,7 J.D. Dodd,8 H.A.W.M. Tiddens.1,2 1Pediatric Pulmonology, Erasmuc MC Sophia Children’s Hospital, Rotterdam, Zuid Holland, Netherlands; 2Radiology, Erasmus MC, Rotterdam, Zuid Holland, Netherlands; 3Biostatistics, Erasmus MC, Rotterdam, Zuid Holland, Netherlands; 4Medical Informatics, Erasmus MC, Rotterdam, Zuid Holland, Netherlands; 5Respiratory Medicine, Erasmus MC, Rotterdam, Zuid Holland, Netherlands; 6Pediatric Pulmonology, Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia; 7Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA; 8 Radiology, Sint Vincent’s Hospital, Dublin, Ireland. Purpose: Up to a third of cystic fibrosis (CF) patients awaiting lung transplantation (LTX) die while waiting. Inclusion of computed tomography (CT) scores may improve survival prediction models such as the lung allocation score (LAS). This study investigated the association between CT and survival in CF patients screened for LTX. Methods and Materials: Clinical data and chest CTs of 411 CF patients screened for LTX between 1990 and 2005 were collected from 17 centers. CTs were scored with the Severe Advanced Lung Disease (SALD) 4-category scoring system, including the components ‘infection/inflammation’ (INF), air trapping/hypoperfusion (AT), normal/hyperperfusion (NOR) and bulla/cysts (BUL). The volume of each component was computed using semi-automated software. Survival analysis included Kaplan-Meier curves, and Cox-regression models. Results: 366 (186 males) out of 411 patients entered the waiting list (median age 23, range 5-58 years). Subsequently, 67/366(18%) died while waiting, 263/366(72%) underwent LTX, and 36/366(10%) were awaiting LTX at the census date. INF and LAS were significantly associated with waiting list mortality in univariate analyses. The multivariate Cox model including INF and LAS grouped in tertiles and comparing tertiles 2 and 3 to tertile 1, showed waiting list mortality hazard ratios of 1.62 (95%CI 0.78-3.36, p⫽0.19), and 2.65 (1.35-5.20, p⫽0.005) for INF and 1.42 (0.63-3.24, p⫽0.40), and 2.32 (1.17-4.60, p⫽0.016) for LAS, respectively. These results indicated that INF and LAS had significant, independent predictive value for survival. Conclusions: CT score INF correlates with survival, and adds to the predictive value of LAS. 714 Fluid Balance and Immediate Post Operative Outcomes Following Lung Transplant L. Munshi,1 L.G. Singer,3 M. Cypel,2 S. Keshavjee,2 M. Binnie,3 N.D. Ferguson.1 1Critical Care, Toronto General Hospital, University of Toronto, Toronto, ON, Canada; 2Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada; 3Respirology, Toronto General Hospital, University of Toronto, Toronto, ON, Canada. Purpose: Primary graft dysfunction is the leading cause of immediate mortality following lung transplant. It is characterized by a state of pro-