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Do Long Term Outcomes Justify Third Time Redo Lung Transplantation?
S330
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
823 The Effect of the Elective Intra-Operative Use of Mechanical Circulatory Support on the Development of Primary Graft Dysfunction Following Bilateral Lung Transplantation F. Sertic, D. Diagne, L. Chavez, M. Molina, T. Richards, A. Habertheuer, M. Porteous, R. Gallop, M. Oyster, L. Kalman, E. Cantu, J. Christie, M.M. Crespo, C. Bermudez and J. Diamond. University of Pennsylvania, Philadelphia, PA.
transplantation were 67.3 %, 50.0 %, and 31.5 %, respectively. There is no significant difference on survival outcome when compared to the patient group required ECMO post-transplant due to the other causes. Univariate and multivariate analysis indicated that when the patient was placed on ECMO within 48 hours after transplantation, the patient was more likely to prevent in-house mortality regardless of patients’ preoperative conditions or duration of ECMO support. Conclusion: Earlier recognition of PGD and initiation of ECMO may be beneficial in this population.
Purpose: Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplant. Studies have identified the intraoperative use of cardiopulmonary bypass (CPB) as a risk factor for PGD. There has been an increase in the use of extracorporeal membrane oxygenation (ECMO) for intraoperative support over the last decade. We sought to further evaluate the differential risk of PGD across various extracorporeal life support (ECLS) modalities. Methods: Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplant. Studies have identified the intraoperative use of cardiopulmonary bypass (CPB) as a risk factor for PGD. There has been an increase in the use of extracorporeal membrane oxygenation (ECMO) for intraoperative support over the last decade. We sought to further evaluate the differential risk of PGD across various extracorporeal life support (ECLS) modalities. Results: A model including age, race, body mass index, diagnosis and pulmonary artery pressure was developed to predict ECLS use. Our analysis included 238 patients who underwent BLT (figure 1). 49 patients who received elective intra-operative ECMO after 2015 were matched with 49 patients who received intraoperative CPB before 2015. There was no difference in the development of severe PGD (p=0.4) or any PGD (p=0.6) between the two groups. Seventy patients who underwent BLT with no ECLS after 2015 were matched with 70 patients who underwent BLT before 2015 with CPB support. There was no difference in the development of severe PGD (p=0.2) or any PGD (p=0.3) between the two groups. Exclusion of patients bridged to transplant with ECMO didn’t alter the results. Conclusion: In a single center study of BLT recipients, there was no difference in the development of PGD across different ECLS modes. Future analysis will compare the impact of ECMO vs. CPB on biomarkers associated with lung and endothelial injury.
824 Extracorporeal Membrane Oxygenation for Primary Graft Dysfunction after Lung Transplantation T. Harano,1 J. D’Cunha,1 M.R. Morrell,2 J.D. Luketich,1 and P. Sanchez.1 1Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; and the 2Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. Purpose: Primary graft dysfunction (PGD) is the leading course of early death after lung transplantation. Extracorporeal membrane oxygenation (ECMO) was used as the last resort for PGD. The aim of this study is to explore the outcome and predictor for in-house mortality in post-lung transplant patients who required ECMO for PGD. Methods: Between January 2006 and December 2015, 1049 cases of lung transplantation were performed at our center. Ninety-six patients (9.15 %) required ECMO support after lung transplantation. And 52 patients (4.96 %) required ECMO support for PGD. We retrospectively collected patient demographics and survival outcome of these patients. Results: The mean age was 61.9 years § 14.9 years. The mean lung allocation score was 49.5 § 18.3. Seven patients (13.5 %) required veno-arterial ECMO due to concomitant hemodynamical instability. The patients were on ECMO for 5.00 § 10.6 days. Forty-four patients (84.6 %) were successfully decannulated. There were 23 in-house mortalities. The 90-day, 1-year and 5-year survival of patients who required ECMO after lung
825 Do Long Term Outcomes Justify Third Time Redo Lung Transplantation? W. Ragalie, P. Downey, D. Ross, E. Depasquale and A. Ardehali. UCLA, Los Angeles, CA. Purpose: Graft failure remains a significant obstacle to long-term survival in lung transplantation (LT), however, the reported outcomes of reoperative LT are inferior to primary LT, and there is controversy of how best to manage a scarcity of donor allografts for candidates likely to derive maximum benefit. The outcomes of third-time LT have not been described in detail. Methods: Review of UNOS database was performed. 3rd time recipients of LT were identified and compared to first-time and second-time LT recipients. Survival was estimated with Kaplan Meier method and compared
Abstracts using log-rank test. Influence of 2nd and 3rd LT was performed using univariate and multivariate analyses. Results: 28 recipients of 3rd LT were compared to 1,252 2nd LT and 32,703 primary recipients. Patients of 3rd LT were younger (38.1 § 16.0 years vs 44.4 § 16.8 for 2nd LT, 52.6 § 14.6 for primary LT), and have shorter wait list times (37.0 days [95% CI 9.0-67.5] vs 45.5 days [13.0-57.5] for 2nd LT and 112.0 [30.0- 329.0] for primary LT. Median survival was 60 months for primary LT, 32 months for 2nd LT, and 19 months for 3rd LT (log-rank p<0.001 for 1st vs 2nd and 3rd, p=0.065 for 2nd vs 3rd LT). Univariate and multivariate analyses demonstrated each reoperative LT as risk for death, and 3rd LT patients had higher rates of non-cardiovascular causes of death compared to 2nd and primary LT (81.8% vs 64.7% vs 73.5%, p<0.001. Conclusion: Reoperative LT has significantly lower long-term survival compared to primary LT, and survival after 3rd LT appears to be worse than 2rd LT. Further work is needed to define which candidates are likely to benefit most from reoperative LT.
826 Predicting Long Term Survival in Lung Transplant: Analysis of United Network for Organ Sharing (UNOS) Database J. Sethi,1 G.A. Garrido Rosa,2 K. Patel,2 and N. Sharma.2 1Pulmonary and Critical Care Medicine, University of South Florida, Tampa, FL; and the 2 Advanced Lung Diseases & Lung Transplantation, University of South Florida, Tampa, FL. Purpose: With the ISHLT registry the trends in mortality and morbidity are well described. However, there is significant heterogeneity in patient population undergoing transplant influencing the overall data. We aim to identify recipient related factors predicting long term survival in patient undergoing lung transplant and assess survival in setting of favorable factors. Methods: We retrospectively reviewed the UNOS dataset for adult patients undergoing lung transplant between 1990 and 2017. Pertinent baseline characteristics, demographics, clinical parameters, and outcomes was performed. Primary end-point was patient survival time. Post-transplant survival was assessed using Kaplan-Meier and log rank tests. SPSS (version 24) was used for statistical testing. Results: A total of 35483 patients with a underwent lung transplant during the review period. Median age was 56 years (range 18-81), with 55.7 % being male. Most common underlying conditions were COPD (n=9884; 28%), IPF (n=9594; 27.1%) and cystic fibrosis (n=4164; 11.2%). Overall median survival was 5.47 years (5.36- 5.58; CI=95%). Comparison of Kaplan-Meier curves showed better median survival with Age ≤65 yrs (5.6yrs vs 4.24yrs; p<0.00), first-time transplants (5.59yrs vs 2.85yrs, p<0.00), better pre-transplant performance status i.e. Karnofsky performance status >60 (6.26yrs vs 5.25yrs; p<0.00). Patients with normal BMI of 18-25 fared better than other groups [5.8yrs vs 5.37yrs (25-29.9) vs 5.10yrs (30-34.9) vs 4.42yrs (>35) vs 5.19yr (<18), p <0.000]. Additionally, mechanical and extracorporeal support at the time of listing was
S331 associated with worse outcomes 3.46yrs vs 5.49yrs, P<0.000). History of diabetes, dialysis and serum albumin level had no statistical impact on long term survival. In presence of above favorable factors median survival improves 7.95 years (7.53-8.37; CI=95%). Conclusion: Lung transplant survival is significantly influenced by recipient age, BMI, Functional status, need for mechanical ventilation or ECMO and history of previous transplants. Better patient selection can help improve long term outcomes from lung transplant. 827 A Real-Life Evaluation of Criteria for Listing for Lung Transplant: A Single-Center, Five-Year Experience L. Morlacchi,1 S. Henchi,1 V. Rossetti,1 A. Palleschi,2 D. Tosi,2 S. Aliberti,1 G. Sotgiu,3 P. Tarsia,1 and L. Rosso.2 1Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Centre, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano; Universita degli Studi di Milano, Milano, Italy; 2Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano; Universita degli Studi di Milano, Milano, Italy; and the 3Clinical Epidemiology and Medical Statistics Unit; Department of Medical, Surgical and Experimental, Universita degli Studi di Sassari, Sassari, Italy. Purpose: Lung transplant (LuTx) is nowadays considered a valuable option for end-stage lung disease, and an appropriate selection of candidates is essential to improve survival. Currently available listing criteria for LuTx are mainly based on experts opinions. The aim of this study is to evaluate physicians’ adherence to inclusion and exclusion criteria for LuTx. Methods: This was a retrospective observational study on consecutive adult patients referred to our clinics for primary LuTx for any indication from January 2012 to May 2017. Prevalence of disease-related contraindications and listing criteria as stated in ISHLT (Orens 2006, Weill 2014) and SEPAR consensus was evaluated. Population was divided into three groups, based on the bundle of listing criteria: a) diffuse parenchymal lung diseases, DPLD; b) cystic fibrosis (CF) and non-CF bronchiectasis; c) COPD. Comparisons between listed individuals and those who were not considered amenable to LuTx were performed for the general population and individual groups. Multivariate logistic regression was used to analyse the association between variables and inclusion in WL Survival was modelled using the Kaplan-Meier product limit estimator with statistical differences between survival curves assessed using the mantel-Cox log-rank test. Results: 305 patients (59% males, median (IQR) age 52 (36-60) years) were enrolled: 54% belonged to Group A, 31% to Group B, and 15% to Group C. For Group A, no specific criteria were significantly more frequent in listed patients. Conversely, criteria associated with an increased probability of being included in WL were: respiratory failure [OR 7.0 (95%CI: 1.4-34.3; P= 0.02)] for Group B and BODE >7 [OR 12.0 (95%CI: 1.3-111.3; P= 0.03)] for Group C. Ineligible individuals (no criteria and/or contraindications) and transplanted patients showed a better survival than those on WL but not yet transplanted, both for the whole cohort and for different groups Conclusion: Placement on active WL seems to be mainly based on multidisciplinary clinical decisions more than on the strict application of listing criteria with an improved survival both in patients not eligible for LuTx and for those transplanted. Currently available listing criteria for DPLD did not prove a suitable tool for candidate selection, owing to high clinical heterogeneity of these diseases.
828 Frailty is Highly Prevalent in Lung Transplant Candidates and Varies by Frailty Tool A. O’Boye, K. Leitner, M. Kelly, J. Wright, J. Lee, R. Tomic and S. Bhorade. Northwestern Memorial Hospital, Chicago, IL. Purpose: Lung transplantation is a lifesaving therapy in patients with advanced lung disease. However, frail lung transplant candidates are more likely to be delisted or die on the waitlist. There is a need to objectively identify frailty and assess potential reversible risk factors in potential lung transplant candidates.
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
823 The Effect of the Elective Intra-Operative Use of Mechanical Circulatory Support on the Development of Primary Graft Dysfunction Following Bilateral Lung Transplantation F. Sertic, D. Diagne, L. Chavez, M. Molina, T. Richards, A. Habertheuer, M. Porteous, R. Gallop, M. Oyster, L. Kalman, E. Cantu, J. Christie, M.M. Crespo, C. Bermudez and J. Diamond. University of Pennsylvania, Philadelphia, PA.
transplantation were 67.3 %, 50.0 %, and 31.5 %, respectively. There is no significant difference on survival outcome when compared to the patient group required ECMO post-transplant due to the other causes. Univariate and multivariate analysis indicated that when the patient was placed on ECMO within 48 hours after transplantation, the patient was more likely to prevent in-house mortality regardless of patients’ preoperative conditions or duration of ECMO support. Conclusion: Earlier recognition of PGD and initiation of ECMO may be beneficial in this population.
Purpose: Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplant. Studies have identified the intraoperative use of cardiopulmonary bypass (CPB) as a risk factor for PGD. There has been an increase in the use of extracorporeal membrane oxygenation (ECMO) for intraoperative support over the last decade. We sought to further evaluate the differential risk of PGD across various extracorporeal life support (ECLS) modalities. Methods: Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplant. Studies have identified the intraoperative use of cardiopulmonary bypass (CPB) as a risk factor for PGD. There has been an increase in the use of extracorporeal membrane oxygenation (ECMO) for intraoperative support over the last decade. We sought to further evaluate the differential risk of PGD across various extracorporeal life support (ECLS) modalities. Results: A model including age, race, body mass index, diagnosis and pulmonary artery pressure was developed to predict ECLS use. Our analysis included 238 patients who underwent BLT (figure 1). 49 patients who received elective intra-operative ECMO after 2015 were matched with 49 patients who received intraoperative CPB before 2015. There was no difference in the development of severe PGD (p=0.4) or any PGD (p=0.6) between the two groups. Seventy patients who underwent BLT with no ECLS after 2015 were matched with 70 patients who underwent BLT before 2015 with CPB support. There was no difference in the development of severe PGD (p=0.2) or any PGD (p=0.3) between the two groups. Exclusion of patients bridged to transplant with ECMO didn’t alter the results. Conclusion: In a single center study of BLT recipients, there was no difference in the development of PGD across different ECLS modes. Future analysis will compare the impact of ECMO vs. CPB on biomarkers associated with lung and endothelial injury.
824 Extracorporeal Membrane Oxygenation for Primary Graft Dysfunction after Lung Transplantation T. Harano,1 J. D’Cunha,1 M.R. Morrell,2 J.D. Luketich,1 and P. Sanchez.1 1Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; and the 2Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. Purpose: Primary graft dysfunction (PGD) is the leading course of early death after lung transplantation. Extracorporeal membrane oxygenation (ECMO) was used as the last resort for PGD. The aim of this study is to explore the outcome and predictor for in-house mortality in post-lung transplant patients who required ECMO for PGD. Methods: Between January 2006 and December 2015, 1049 cases of lung transplantation were performed at our center. Ninety-six patients (9.15 %) required ECMO support after lung transplantation. And 52 patients (4.96 %) required ECMO support for PGD. We retrospectively collected patient demographics and survival outcome of these patients. Results: The mean age was 61.9 years § 14.9 years. The mean lung allocation score was 49.5 § 18.3. Seven patients (13.5 %) required veno-arterial ECMO due to concomitant hemodynamical instability. The patients were on ECMO for 5.00 § 10.6 days. Forty-four patients (84.6 %) were successfully decannulated. There were 23 in-house mortalities. The 90-day, 1-year and 5-year survival of patients who required ECMO after lung
825 Do Long Term Outcomes Justify Third Time Redo Lung Transplantation? W. Ragalie, P. Downey, D. Ross, E. Depasquale and A. Ardehali. UCLA, Los Angeles, CA. Purpose: Graft failure remains a significant obstacle to long-term survival in lung transplantation (LT), however, the reported outcomes of reoperative LT are inferior to primary LT, and there is controversy of how best to manage a scarcity of donor allografts for candidates likely to derive maximum benefit. The outcomes of third-time LT have not been described in detail. Methods: Review of UNOS database was performed. 3rd time recipients of LT were identified and compared to first-time and second-time LT recipients. Survival was estimated with Kaplan Meier method and compared
Abstracts using log-rank test. Influence of 2nd and 3rd LT was performed using univariate and multivariate analyses. Results: 28 recipients of 3rd LT were compared to 1,252 2nd LT and 32,703 primary recipients. Patients of 3rd LT were younger (38.1 § 16.0 years vs 44.4 § 16.8 for 2nd LT, 52.6 § 14.6 for primary LT), and have shorter wait list times (37.0 days [95% CI 9.0-67.5] vs 45.5 days [13.0-57.5] for 2nd LT and 112.0 [30.0- 329.0] for primary LT. Median survival was 60 months for primary LT, 32 months for 2nd LT, and 19 months for 3rd LT (log-rank p<0.001 for 1st vs 2nd and 3rd, p=0.065 for 2nd vs 3rd LT). Univariate and multivariate analyses demonstrated each reoperative LT as risk for death, and 3rd LT patients had higher rates of non-cardiovascular causes of death compared to 2nd and primary LT (81.8% vs 64.7% vs 73.5%, p<0.001. Conclusion: Reoperative LT has significantly lower long-term survival compared to primary LT, and survival after 3rd LT appears to be worse than 2rd LT. Further work is needed to define which candidates are likely to benefit most from reoperative LT.
826 Predicting Long Term Survival in Lung Transplant: Analysis of United Network for Organ Sharing (UNOS) Database J. Sethi,1 G.A. Garrido Rosa,2 K. Patel,2 and N. Sharma.2 1Pulmonary and Critical Care Medicine, University of South Florida, Tampa, FL; and the 2 Advanced Lung Diseases & Lung Transplantation, University of South Florida, Tampa, FL. Purpose: With the ISHLT registry the trends in mortality and morbidity are well described. However, there is significant heterogeneity in patient population undergoing transplant influencing the overall data. We aim to identify recipient related factors predicting long term survival in patient undergoing lung transplant and assess survival in setting of favorable factors. Methods: We retrospectively reviewed the UNOS dataset for adult patients undergoing lung transplant between 1990 and 2017. Pertinent baseline characteristics, demographics, clinical parameters, and outcomes was performed. Primary end-point was patient survival time. Post-transplant survival was assessed using Kaplan-Meier and log rank tests. SPSS (version 24) was used for statistical testing. Results: A total of 35483 patients with a underwent lung transplant during the review period. Median age was 56 years (range 18-81), with 55.7 % being male. Most common underlying conditions were COPD (n=9884; 28%), IPF (n=9594; 27.1%) and cystic fibrosis (n=4164; 11.2%). Overall median survival was 5.47 years (5.36- 5.58; CI=95%). Comparison of Kaplan-Meier curves showed better median survival with Age ≤65 yrs (5.6yrs vs 4.24yrs; p<0.00), first-time transplants (5.59yrs vs 2.85yrs, p<0.00), better pre-transplant performance status i.e. Karnofsky performance status >60 (6.26yrs vs 5.25yrs; p<0.00). Patients with normal BMI of 18-25 fared better than other groups [5.8yrs vs 5.37yrs (25-29.9) vs 5.10yrs (30-34.9) vs 4.42yrs (>35) vs 5.19yr (<18), p <0.000]. Additionally, mechanical and extracorporeal support at the time of listing was
S331 associated with worse outcomes 3.46yrs vs 5.49yrs, P<0.000). History of diabetes, dialysis and serum albumin level had no statistical impact on long term survival. In presence of above favorable factors median survival improves 7.95 years (7.53-8.37; CI=95%). Conclusion: Lung transplant survival is significantly influenced by recipient age, BMI, Functional status, need for mechanical ventilation or ECMO and history of previous transplants. Better patient selection can help improve long term outcomes from lung transplant. 827 A Real-Life Evaluation of Criteria for Listing for Lung Transplant: A Single-Center, Five-Year Experience L. Morlacchi,1 S. Henchi,1 V. Rossetti,1 A. Palleschi,2 D. Tosi,2 S. Aliberti,1 G. Sotgiu,3 P. Tarsia,1 and L. Rosso.2 1Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Centre, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano; Universita degli Studi di Milano, Milano, Italy; 2Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano; Universita degli Studi di Milano, Milano, Italy; and the 3Clinical Epidemiology and Medical Statistics Unit; Department of Medical, Surgical and Experimental, Universita degli Studi di Sassari, Sassari, Italy. Purpose: Lung transplant (LuTx) is nowadays considered a valuable option for end-stage lung disease, and an appropriate selection of candidates is essential to improve survival. Currently available listing criteria for LuTx are mainly based on experts opinions. The aim of this study is to evaluate physicians’ adherence to inclusion and exclusion criteria for LuTx. Methods: This was a retrospective observational study on consecutive adult patients referred to our clinics for primary LuTx for any indication from January 2012 to May 2017. Prevalence of disease-related contraindications and listing criteria as stated in ISHLT (Orens 2006, Weill 2014) and SEPAR consensus was evaluated. Population was divided into three groups, based on the bundle of listing criteria: a) diffuse parenchymal lung diseases, DPLD; b) cystic fibrosis (CF) and non-CF bronchiectasis; c) COPD. Comparisons between listed individuals and those who were not considered amenable to LuTx were performed for the general population and individual groups. Multivariate logistic regression was used to analyse the association between variables and inclusion in WL Survival was modelled using the Kaplan-Meier product limit estimator with statistical differences between survival curves assessed using the mantel-Cox log-rank test. Results: 305 patients (59% males, median (IQR) age 52 (36-60) years) were enrolled: 54% belonged to Group A, 31% to Group B, and 15% to Group C. For Group A, no specific criteria were significantly more frequent in listed patients. Conversely, criteria associated with an increased probability of being included in WL were: respiratory failure [OR 7.0 (95%CI: 1.4-34.3; P= 0.02)] for Group B and BODE >7 [OR 12.0 (95%CI: 1.3-111.3; P= 0.03)] for Group C. Ineligible individuals (no criteria and/or contraindications) and transplanted patients showed a better survival than those on WL but not yet transplanted, both for the whole cohort and for different groups Conclusion: Placement on active WL seems to be mainly based on multidisciplinary clinical decisions more than on the strict application of listing criteria with an improved survival both in patients not eligible for LuTx and for those transplanted. Currently available listing criteria for DPLD did not prove a suitable tool for candidate selection, owing to high clinical heterogeneity of these diseases.
828 Frailty is Highly Prevalent in Lung Transplant Candidates and Varies by Frailty Tool A. O’Boye, K. Leitner, M. Kelly, J. Wright, J. Lee, R. Tomic and S. Bhorade. Northwestern Memorial Hospital, Chicago, IL. Purpose: Lung transplantation is a lifesaving therapy in patients with advanced lung disease. However, frail lung transplant candidates are more likely to be delisted or die on the waitlist. There is a need to objectively identify frailty and assess potential reversible risk factors in potential lung transplant candidates.