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325 5 Years Experience with Lung Donation after Cardiac Death
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The Journal of Heart and Lung Transplantation, Vol 31, No 4S, April 2012
more strict criteria in terms of graft evaluation in order to improve our outcomes with uncontrolled NHBD. 325 5 Years Experience with Lung Donation after Cardiac Death M. Cypel, A. Pierre, K. Yasufuku, M. DePerrot, V. Leist, L.G. Singer, T.K. Waddell, S. Keshavjee. University of Toronto, Toronto, ON, Canada. Purpose: To review our experience after 5 years of lung transplantation (LTx) using lung donation after cardiac death (DCD). Methods and Materials: Outcomes DCD LTx were compared with contemporaneous recipients receiving lungs from brain death donors(BDD). Incidence of severe primary graft dysfunction(PGD), ICU and hospital length of stay(LOS), 30 day mortality, and overall survival were analyzed. Results: During the study period, 448 LTx were performed; 408 from BDD and 40 from DCD donors. The proportion of DCD donors among cadaveric donors and the proportion lung transplants using DCD donors are shown in Figure 1. Recipient diagnosis was similar in both groups (BDD vs. DCD): Emphysema (26% vs. 30%), pulmonary fibrosis (33% vs. 32%), cystic fibrosis (20% vs. 23%), and others (22% vs. 14%). Median donor P/F was 422 mmHg in BDD group and 360 mmHg in DCD group (p⫽0.004). Median recipient P/F at ICU arrival was 350 mmHg in BDD vs. 301 mmHg in DCD (p⫽0.06). Incidence of severe primary graft dysfunction after LTx requiring ECMO support was 2.7% in BDD and 7.5% in DCD (p⫽0.14). Median ICU stay was 4 days in BDD and 5 days in DCD. Median hospital LOS was 23 days in both groups (p⬎0.05). 30 day, 1 year and 3 year proportional survival were 95.7%, 84%, and 70% in BDD and 95%, 85%, and 64% in DCD respectively (P⬎0.05 for all comparisons). Within the DCD group, 18 lungs underwent ex vivo lung perfusion (EVLP). Lungs undergoing EVLP had decreased incidence of PGD 3 at 72h after LTx: 0 vs 22% (p⫽0.04). Conclusions: Lung transplantation using DCD donors currently accounts for 15-20% of our LTx activities. The use of controlled DCD lungs is associated with similar clinical outcomes as LTx using BDD donors. EVLP led to decreased incidence of severe PGD in the DCD population.
326 A Randomized Trial of Nebulized Albuterol To Enhance Resolution of Pulmonary Edema in 506 Brain Dead Organ Donors L.B. Ware,1 M. Landeck,2 T. Koyama,1 E. Johnson,2 G.R. Bernard,1 J.W. Lee,3 M.A. Matthay.3 1Vanderbilt University, Nashville, TN; 2 California Transplant Donor Network, Oakland, CA; 3University of California, San Francisco, CA. Purpose: Donor lung utilization rates are persistently lower than other solid organs primarily due to donor lung dysfunction. Since pulmonary edema is common in organ donors and can impair oxygenation, we hypothesized that a treatment that enhances the resolution of pulmonary edema by stimulating the rate of alveolar fluid clearance would improve donor oxygenation and increase donor lung utilization. Methods and Materials: We conducted a randomized, blinded, placebocontrolled trial of nebulized albuterol (5 mg every 4 h) vs. placebo during the period of active donor management in 506 brain dead organ donors who were managed by the California Transplant Donor Network. The primary outcome was change in oxygenation (A-a O2 difference, PaO2/ FiO2) from enrollment to organ procurement. Secondary outcomes included change in static compliance of the respiratory system and donor lung utilization.
Results: 260 donors were randomized to albuterol and 246 to placebo. The groups were well matched for age, gender, ethnicity, smoking, and cause of brain death. The change in A-a O2 difference and PaO2/FiO2 did not differ from enrollment to organ procurement between the two treatments (p ⫽ 0.58/ 0.54). There was no difference in the change in the static compliance between the two groups (p ⫽ 0.34). Donor lung utilization was not different between the two groups (29% for albuterol vs. 31% for placebo, p ⫽ 0.55). Donors in the albuterol group vs. placebo group were more likely to have the study drug dose reduced due to tachycardia (14% vs. 1%, p ⬍ 0.001) and to have the study drug held due to tachycardia (8% vs. 0%, p ⬍ 0.001). Other than sinus tachycardia, no tachyarrhythmias were observed in either group. Conclusions: Treatment with high dose inhaled albuterol during donor management did not lead to improved donor oxygenation or increased donor lung utilization compared to placebo but did result in more tachycardia. Based on these findings, high dose nebulized albuterol should not be used in organ donors to enhance the resolution of pulmonary edema. 327 Good Lungs for Bad Recipients and Bad Lungs for Good Recipients – Follow Up on Eurotransplant Rescue Offers W. Sommer,1 C. Kuehn,1 I. Tudorache,1 M. Avsar,1 J. Salman,1 J. Gottlieb,2 A. Haverich,1 G. Warnecke.1 1Cardiothoracic Surgery, Hannover Medical School, Hannover, Germany; 2Respiratory Medicine, Hannover Medical School, Hannover, Germany. Purpose: Marginal donor lungs are increasingly used for transplantation. Still unclear is, whether this enlargement of the donor pool has negative impact on outcome. Eurotransplant offers donor lungs that have been declined by three centres as a rescue offer. We follow up on these transplants and compare them to those following regular allocation. Methods and Materials: An analysis of all organ offers and the corresponding recipients in our centre between January 2010 and August 2011 was performed. Results: A total of 184 lung transplantations were performed, 112 regular donor lungs were regularly accepted for intended recipients, whereas a total of 72 rescue lung offers, were accepted for recipients selected by our centre. Donor characteristics differed between these two groups. Mean age of the marginal organ donors was significantly higher than that of regular donors (42.51⫾14.63 vs. 37.29⫾14.59 yrs, p⬎0.01), the donor mechanical ventilation time was longer (5.72⫾4.82 days vs. 5.05⫾4.01 days) and donor oxygenation (PaO2/FiO2) ratio was lower (388.33⫾110.34 vs. 425.42⫾97.20 mmHg; p⬎0.01). Recipients of marginal organs were older than selected recipients (50.61 vs. 42.16 yrs; p⬎0.001), needed a shorter time of mechanical ventilation (19.50⫾306.61 vs. 68.50⫾718.84 hours mean; p⬎0.01) as well as shorter ICU (2.0⫾14.54 vs. 5.0⫾23.69 days) and hospital stays (24.00⫾23.39 vs. 47.00⫾43.62 days; p⬎0.0001). The 90day survival was better in recipients receiving marginal as compared to regular lung offers (95 vs. 90.2%). The preoperative state of health of the two recipient cohorts differed, indicated by the regular allocation group consisting of 66.1% “High Urgency”-listed patients, whereas rescue offers were used only for 11.1% “High Urgency”-listed recipients. Conclusions: Marginal donor lungs can safely be used for transplantation. Our data supports our practice to accept marginal donor lungs for stable recipients. We conclude that a further increase of marginal donor organs should be attempted. 328 Retention of IL-10ⴙ Neutrophils May Be Essential To Limit Lung Graft Ischemia-Reperfusion Injury M. Ibrahim,1 G. Macri,1 H.J. Huang,3 S. Yamamoto,2 D. Kreisel,2 A.E. Gelman.2 1Thoracic Surgery, University of Rome La Sapienza, Rome, Lazio, Italy; 2Surgery, Washington University in Saint Louis, Saint Louis, MO; 3Medicine, Washington University in Saint Louis, Saint Louis, MO. Purpose: Neutrophils are primarily thought to exacerbate lung graft ischemia-reperfusion injury (IRI). Recent observations suggest that IL-10⫹ neutrophils have regulatory properties. Using a mouse orthotopic lung
The Journal of Heart and Lung Transplantation, Vol 31, No 4S, April 2012
more strict criteria in terms of graft evaluation in order to improve our outcomes with uncontrolled NHBD. 325 5 Years Experience with Lung Donation after Cardiac Death M. Cypel, A. Pierre, K. Yasufuku, M. DePerrot, V. Leist, L.G. Singer, T.K. Waddell, S. Keshavjee. University of Toronto, Toronto, ON, Canada. Purpose: To review our experience after 5 years of lung transplantation (LTx) using lung donation after cardiac death (DCD). Methods and Materials: Outcomes DCD LTx were compared with contemporaneous recipients receiving lungs from brain death donors(BDD). Incidence of severe primary graft dysfunction(PGD), ICU and hospital length of stay(LOS), 30 day mortality, and overall survival were analyzed. Results: During the study period, 448 LTx were performed; 408 from BDD and 40 from DCD donors. The proportion of DCD donors among cadaveric donors and the proportion lung transplants using DCD donors are shown in Figure 1. Recipient diagnosis was similar in both groups (BDD vs. DCD): Emphysema (26% vs. 30%), pulmonary fibrosis (33% vs. 32%), cystic fibrosis (20% vs. 23%), and others (22% vs. 14%). Median donor P/F was 422 mmHg in BDD group and 360 mmHg in DCD group (p⫽0.004). Median recipient P/F at ICU arrival was 350 mmHg in BDD vs. 301 mmHg in DCD (p⫽0.06). Incidence of severe primary graft dysfunction after LTx requiring ECMO support was 2.7% in BDD and 7.5% in DCD (p⫽0.14). Median ICU stay was 4 days in BDD and 5 days in DCD. Median hospital LOS was 23 days in both groups (p⬎0.05). 30 day, 1 year and 3 year proportional survival were 95.7%, 84%, and 70% in BDD and 95%, 85%, and 64% in DCD respectively (P⬎0.05 for all comparisons). Within the DCD group, 18 lungs underwent ex vivo lung perfusion (EVLP). Lungs undergoing EVLP had decreased incidence of PGD 3 at 72h after LTx: 0 vs 22% (p⫽0.04). Conclusions: Lung transplantation using DCD donors currently accounts for 15-20% of our LTx activities. The use of controlled DCD lungs is associated with similar clinical outcomes as LTx using BDD donors. EVLP led to decreased incidence of severe PGD in the DCD population.
326 A Randomized Trial of Nebulized Albuterol To Enhance Resolution of Pulmonary Edema in 506 Brain Dead Organ Donors L.B. Ware,1 M. Landeck,2 T. Koyama,1 E. Johnson,2 G.R. Bernard,1 J.W. Lee,3 M.A. Matthay.3 1Vanderbilt University, Nashville, TN; 2 California Transplant Donor Network, Oakland, CA; 3University of California, San Francisco, CA. Purpose: Donor lung utilization rates are persistently lower than other solid organs primarily due to donor lung dysfunction. Since pulmonary edema is common in organ donors and can impair oxygenation, we hypothesized that a treatment that enhances the resolution of pulmonary edema by stimulating the rate of alveolar fluid clearance would improve donor oxygenation and increase donor lung utilization. Methods and Materials: We conducted a randomized, blinded, placebocontrolled trial of nebulized albuterol (5 mg every 4 h) vs. placebo during the period of active donor management in 506 brain dead organ donors who were managed by the California Transplant Donor Network. The primary outcome was change in oxygenation (A-a O2 difference, PaO2/ FiO2) from enrollment to organ procurement. Secondary outcomes included change in static compliance of the respiratory system and donor lung utilization.
Results: 260 donors were randomized to albuterol and 246 to placebo. The groups were well matched for age, gender, ethnicity, smoking, and cause of brain death. The change in A-a O2 difference and PaO2/FiO2 did not differ from enrollment to organ procurement between the two treatments (p ⫽ 0.58/ 0.54). There was no difference in the change in the static compliance between the two groups (p ⫽ 0.34). Donor lung utilization was not different between the two groups (29% for albuterol vs. 31% for placebo, p ⫽ 0.55). Donors in the albuterol group vs. placebo group were more likely to have the study drug dose reduced due to tachycardia (14% vs. 1%, p ⬍ 0.001) and to have the study drug held due to tachycardia (8% vs. 0%, p ⬍ 0.001). Other than sinus tachycardia, no tachyarrhythmias were observed in either group. Conclusions: Treatment with high dose inhaled albuterol during donor management did not lead to improved donor oxygenation or increased donor lung utilization compared to placebo but did result in more tachycardia. Based on these findings, high dose nebulized albuterol should not be used in organ donors to enhance the resolution of pulmonary edema. 327 Good Lungs for Bad Recipients and Bad Lungs for Good Recipients – Follow Up on Eurotransplant Rescue Offers W. Sommer,1 C. Kuehn,1 I. Tudorache,1 M. Avsar,1 J. Salman,1 J. Gottlieb,2 A. Haverich,1 G. Warnecke.1 1Cardiothoracic Surgery, Hannover Medical School, Hannover, Germany; 2Respiratory Medicine, Hannover Medical School, Hannover, Germany. Purpose: Marginal donor lungs are increasingly used for transplantation. Still unclear is, whether this enlargement of the donor pool has negative impact on outcome. Eurotransplant offers donor lungs that have been declined by three centres as a rescue offer. We follow up on these transplants and compare them to those following regular allocation. Methods and Materials: An analysis of all organ offers and the corresponding recipients in our centre between January 2010 and August 2011 was performed. Results: A total of 184 lung transplantations were performed, 112 regular donor lungs were regularly accepted for intended recipients, whereas a total of 72 rescue lung offers, were accepted for recipients selected by our centre. Donor characteristics differed between these two groups. Mean age of the marginal organ donors was significantly higher than that of regular donors (42.51⫾14.63 vs. 37.29⫾14.59 yrs, p⬎0.01), the donor mechanical ventilation time was longer (5.72⫾4.82 days vs. 5.05⫾4.01 days) and donor oxygenation (PaO2/FiO2) ratio was lower (388.33⫾110.34 vs. 425.42⫾97.20 mmHg; p⬎0.01). Recipients of marginal organs were older than selected recipients (50.61 vs. 42.16 yrs; p⬎0.001), needed a shorter time of mechanical ventilation (19.50⫾306.61 vs. 68.50⫾718.84 hours mean; p⬎0.01) as well as shorter ICU (2.0⫾14.54 vs. 5.0⫾23.69 days) and hospital stays (24.00⫾23.39 vs. 47.00⫾43.62 days; p⬎0.0001). The 90day survival was better in recipients receiving marginal as compared to regular lung offers (95 vs. 90.2%). The preoperative state of health of the two recipient cohorts differed, indicated by the regular allocation group consisting of 66.1% “High Urgency”-listed patients, whereas rescue offers were used only for 11.1% “High Urgency”-listed recipients. Conclusions: Marginal donor lungs can safely be used for transplantation. Our data supports our practice to accept marginal donor lungs for stable recipients. We conclude that a further increase of marginal donor organs should be attempted. 328 Retention of IL-10ⴙ Neutrophils May Be Essential To Limit Lung Graft Ischemia-Reperfusion Injury M. Ibrahim,1 G. Macri,1 H.J. Huang,3 S. Yamamoto,2 D. Kreisel,2 A.E. Gelman.2 1Thoracic Surgery, University of Rome La Sapienza, Rome, Lazio, Italy; 2Surgery, Washington University in Saint Louis, Saint Louis, MO; 3Medicine, Washington University in Saint Louis, Saint Louis, MO. Purpose: Neutrophils are primarily thought to exacerbate lung graft ischemia-reperfusion injury (IRI). Recent observations suggest that IL-10⫹ neutrophils have regulatory properties. Using a mouse orthotopic lung