88 Acute Rejection after Lung Transplantation Is Associated with Daily Changes in Air Pollution

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

Kaplan-Meier survival estimates to 1-year for the 3 groups can be seen in Figure 1 and demonstrate no discernible difference (p ⫽ 0.36).

Results: During this time, 1027 lung transplants were performed, of which 529 underwent pretransplant catheterization. Of these, 174 (32.9%) had mild or moderate CAD, while 355 (67.1%) had no CAD. In the CAD population, age was greater (median: 61 vs. 55 years, p⬍0.001), while male sex (75.3% vs. 47.9%, p 0.001) and white ethnicity (91.4% vs. 84.2%, p 0.029) were more prevalent. Preoperatively, no difference in the prevalence of arrhythmia, CHF, peripheral vascular disease, or diabetes was found. Postoperatively, there was no significant difference in hospital stay, rate of readmission or MI, arrhythmia, CVA, PCI or CABG between recipients with or without CAD. Postoperative survival was comparable between the two groups out to 5 years. Conclusions: Patients with preoperative mild or moderate CAD do not experience increased cardiovascular morbidity or mortality after lung transplant. 87

Conclusions: Our older lung transplant recipients did not suffer worse early mortality when compared to our younger patients. A preference towards single lung transplantation in the older group may prove beneficial for minimizing perioperative complications. Longer follow-up is necessary to determine the late consequences of this policy, but our data support the use of lung transplantation in this select, older population. 86 Preoperative Mild or Moderate Coronary Artery Disease (CAD) Does Not Affect Long-Term Outcomes of Lung Transplantation G. Zanotti,1 M.G. Hartwig,1 A. Castleberry,1 J.T. Martin,1 Z.A. Hashmi,1 M. Horvath,2 S.S. Lin,1 R.D. Davis.1 1Surgery, Duke University Medical Center, Durham, NC; 2Duke Health Technology Solutions, Duke University, Durham. Purpose: The impact of non-revascularized preoperative mild or moderate CAD on long-term outcomes following lung transplantation is unknown. We compared post-transplant cardiovascular morbidity and overall survival among recipients with or without pretransplant CAD. None of these recipients underwent revascularization during lung transplantation. Methods and Materials: This was a retrospective review of our center’s lung transplant database from May 1996 to October 2011. Preoperative coronary angiogram is routinely performed in recipients older than age 50. All patients with pretransplant coronary angiograms were included for analysis. Outcome measures after transplant were: myocardial infarction (MI), new onset arrhythmia, cerebrovascular accident (CVA), cardiac revascularization, and death, with follow-up time at 1, 3 and 5 years.

Coronary Revascularization in Lung Transplant Recipients with Concomitant Coronary Artery Disease J.T. Martin, M.G. Hartwig, Z.A. Hashmi, A.W. Castleberry, G. Zanotti, L.K. Shaw, J.B. Williams, S.S. Lin, S.L. Reddy, R.D. Davis. Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC. Purpose: Coronary artery revascularization with bypass grafting was performed at the time of implantation in a select group of recipients. The purpose of this study is to review late outcomes in these patients and to identify optimal strategies for revascularization. Methods and Materials: We reviewed the records of patients who underwent lung transplantation at our institution between January 1992 and December 2010. Surgical approach and transplant selection were based upon recipient age, underlying diagnosis, and adherence to standard principles of coronary revascularization. Patients older than 40 routinely underwent coronary artery catheterization. Results: Of 1012 transplants performed during the study period, 725 underwent pre-transplant catheterization. Of these, 52 were identified as having significant coronary artery disease (CAD) not amenable to percutaneous coronary intervention (PCI) and underwent concomitant CABG with lung transplantation (CABG group). 40 patients underwent PCI prior to lung transplantation (PCI group). The remaining 635 did not require revascularization and served as control. The mean age for the CABG group was 59.8 years (range 38-77). Forty-two (81%) received bilateral transplants, and 10 (19%) received single allografts. Five patients in the CABG group (9.6%) required additional coronary interventions during the follow-up period, compared with 4 (10%) in the PCI group and 15 (2.4%) in the control group (p⫽ 0.001). The 1-year and 5-year survival rates were 80% and 48% in the CABG group, 85% and 61% in the PCI group, and 85% and 57% for the control group.

Conclusions: In a select group of patients it is possible to offer coronary revascularization in the setting of lung transplantation with reasonable outcomes. 88 Acute Rejection after Lung Transplantation Is Associated with Daily Changes in Air Pollution S.E. Verleden1, H. Scheers,2 T.S. Nawrot,2 F. Fierens,2 R. Vos,1 R. Geenens,1 J. Yserbyt,1 S. Wauters,1 J. Somers,1 D. Ruttens,1

Abstracts A. Van Eylen,1 E.K. Verbeken,1 B. Nemery,2 D.E. Van Raemdonck,1 G.M. Verleden,1 B.M. Vanaudenaerde.1 1Lung Transplant Unit, KULeuven and UZ Gasthuisberg, Leuven, Belgium; 2Department of Public Health, KULeuven and UHasselt, Leuven, Belgium.

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Cardiac Function

Measurement Purpose: Epidemiological studies demonstrated that particulate air pollution (PM) can trigger adverse health effects. We demonstrated that chronic exposure to air pollution is associated with increased risk of chronic rejection and mortality after lung transplantation (LTx). In the present study, we investigated whether short-term elevations in PM10 increased the risk of acute rejection after LTx.

LV Power (J/Minute) RV Power ( J/Minute) Ejection Fraction 2D Echo (%)

Baseline in donor (n⫽6)

1hr post-bypass

7.4⫹/⫺1.1 1.1 ⫹/⫺0.4 54⫹/⫺4

5.9⫹/⫺1.9 (80%) 0.8⫹/⫺0.4 (73%) 58⫹/⫺3 (107%)

Conclusions: 1. Cold storage fails to protect the DCD heart. 2. Cold crystalloid microperfusion provides protection and resuscitation for the DCD heart with resulting post bypass cardiac function approaching donor baseline levels pre DCD. 3. Cold crystalloid microperfusion shows promise for improved preservation of DCD and marginal donors in clinical transplantation. 90

Methods and Materials: 1275 transbronchial/endobronchial biopsies of 416 LTx patients were included in this study, between 2001 and 2011. A and B grade rejection was scored as well as bronchoalveolar lavage differential and total cell count. Each sample was matched with its corresponding PM10 concentration in terms of time (date of sampling) and the patient’s residence. Results: A difference of 10 ␮g/m3 in PM10 3 days before the diagnosis of acute rejection was associated with an OR of 1.13 (95%CI 1.04-1.22; p⫽0.0042). This effect was predominantly associated with inflammation in the airway submucosa, where an increase of 10 ␮g/m3 was associated with an OR of 1.15 (95%CI 1.04-1.27; p⫽0.0044) and not with perivascular inflammation (OR⫽1.05, 95%CI 0.95-1.15; p⫽0.32). Variations in PM10 at lag day3 correlated with neutrophils (p⫽0.013), lymphocytes (p⫽0.0031) and total cell count (p⫽0.024) in BAL. Azithromycin was protective against the PM10 effect. Conclusions: The risk for acute rejection after lung transplantation increased with temporal changes in particulate air pollution, moreover BAL neutrophilia and lymphocytosis were also associated. Whether this PM10associated inflammation in the airways really represents acute rejection (classical B-grade) remains to be further investigated. Interestingly, azithromycin therapy was protective against the PM effect. 89 Continuous Crystalloid Microperfusion Provides Excellent Preservation for Transplantation of Donation after Cardiocirculatory Death Hearts F.L. Rosenfeldt, R.F. Salamonsen, R. Ou, D.S. Esmore, J. Byrne. Cardiothoracic Surgery, Alfred Hospital, Melbourne, VIC, Australia. Purpose: We previously showed that donation after cardiocirculatory death (DCD) canine hearts can be resuscitated if perfused with warm blood but not if stored in ice (Repse S et al. J Heart Lung Transplant 2010;29: 747-55). We subsequently developed a simplified system of cold crystalloid microperfusion and showed that microperfusion was superior to conventional cold storage for DCD heart preservation as evaluated on an in-vitro rig (ISHLT 2011 Meeting). We have now extended this work to orthotopic transplantation. Methods and Materials: Anaesthetised greyhounds underwent DCD by withdrawal of ventilation. After 30 min of stand-off, hearts were given cardioplegia, explanted and allocated to 4 hr of either perfusion (n⫽6) or ice storage (n⫽3). Perfusion hearts received cold crystalloid gravity-feed microperfusion (20mL/min, 7mmHg, 9.0C) with oxygenated electrolytenutrient solution. Hearts were then transplanted into recipient greyhounds. Results: All perfused animals came off bypass with good left and right ventricular function. All cold-stored hearts failed to support the circulation off bypass.

Additional Intraoperative Blood Cardioplegia To Improve Donor Heart Ischemic Tolerance – A Single Center Prospective Cohort Study F.M. Wagner,1 T. Deuse,1 P. Marcsek,1 H. Treede,1 M. Kubik,1 A. Jaeckle,2 H. Reichenspurner.1 1Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany; 2Cardiology, University Heart Center Hamburg, Hamburg, Germany. Purpose: To analyze the effectiveness of intraop. blood cardioplegia for clinical heart transplantation. Methods and Materials: Between 1/2002 and 11/2010 n⫽155 orthotopic heart transplants were performed at our center. In Gr.1 (n⫽40; 01/2002 – 12/2005) donor hearts were preserved with standard filtrated cold UW single flush perfusion (1000ml). In Gr.2 (n⫽69; 01/2006 – 02/09) after initial UW preservation additional Buckberg cold blood cardioplegia was administered every 20 min. during implantation with 3 min “hot shot” immediately prior to reperfusion. In Gr.3 (n⫽46; 03/2009 – 11/2011) preservation was as in Gr.2 but blood cardioplegia was leucocyte depleted by 40 ␮ inline filtration. Primary end point was incidence of primary graft failure (PGF), secondary endpoints influence of donor/recipient risk factors, ischemic time and survival. Results: Mean donor age was 33,9 ⫾ 12,7 in Gr.1, 37,9⫾13 in Gr.2 and 39,3⫾13 in Gr.3 (p⬍0,05 vs. Gr.1). Mean total ischemic time tended to be longer in Gr.3 (259⫾35min; range 185-385) but did not differ statistically from Gr.1 (210⫾48min) and Gr.2 (227⫾46Min). Incidence of PGF was 7,5%(3/40) in Gr.1, 1,5%(1/69) and 0%(0/46) in Gr.2 and Gr.3, respectively (p⬍0,05 vs. Gr.1). Occurrence of PGF did not correlate with ischemic time, donor age or size match; 3 of 4 PGF were female donors. Recipient risk profile (age, Re-op, VAD, urgency status) did not differ between groups. 30 day / 1 year survival was 85% / 75% in Gr.1, 94,2% / 88,4% in Gr.2 and 91,3 / 87% in Gr.3. Conclusions: Additional blood cardioplegia during implantation significantly reduced the risk of primary graft failure despite increased donor rik profile particularily if given via a leucocyte depleting filter. Safe extension of ischemic times seems feasible up to six hours. 91 Equivalent Long Term Survival of Heart Transplant Patients Receiving Resuscitated Donor Hearts S.R. Hosmane, M. Devbhandari, S. Williams, R. Venkateswaran, N. Yonan. Transplant Department, University Hospital of South Manchester, Manchester, United Kingdom. Purpose: Resuscitated donor hearts have been used to expand the donor pool in recent years. Concerns remain over the short and long term outcome of these organs due to the potential ischemic damage. Methods and Materials: Between 1996 and 2011, 263 adult heart transplantations were performed in our institution. 241 patients received hearts from donors without cardiac arrest (group 1) while 22 patients received resuscitated donor hearts (group 2). The decision to use the resuscitated heart was at the discretion of the transplanting surgeon. Their outcomes