- Email: [email protected]
89 Early Outcomes of Bilateral Sequential Single Lung Transplantation after Ex-Vivo Lung Evaluation and Reconditioning
S38
The Journal of Heart and Lung Transplantation, Vol 30, No 4S, April 2011
88 Clinical Ex Vivo Lung Perfusion – Pushing the Limits C. Aigner,1 A. Slama,1 K. Hötzenecker,1 B. Urbanek,2 W. Schmid,2 A. Scheed,1 G. Lang,1 S. Keshavjee,3 W. Klepetko.1 1Dept. of Thoracic Surgery, Medical University of Vienna, Vienna, Austria; 2Dept. of Anaesthesiology, Medical University of Vienna, Vienna, Austria; 3Dept. of Thoracic Surgery, Toronto General Hospital, Toronto, Canada. Purpose: Ex vivo lung perfusion (EVLP) has been proven to provide the opportunity to evaluate and optimise unacceptable donor lungs prior to transplantation. We report on the initial clinical results of a prospective study of lung transplantation after ex vivo perfusion. Methods and Materials: All donors lungs who are deemed unacceptable by our standard criteria and meet the inclusion criteria of our prospective non-randomized clinical study are evaluated with ex vivo lung perfusion using acellular Steen Solution for two to four hours. Lungs showing a ⌬PO2 of at least 350 mmHg between arterial and venous solution with stable or improving functional parameters are accepted for transplantation. Results: From 3/2010 – 10/2010 10 lungs were evaluated ex vivo. Mean donor age was 45 years (range 16-58). Mean donor PaO2 at FiO2 1,0/PEEP 5 was 206⫾50 mmHg. 4 lungs, all with trauma history did not improve and were not used. 6 lungs improved to a ⌬PO2 of more than 350 mmHg. Mean PaO2 in those lungs was 468⫾34 mmHg after EVLP. These lungs were transplanted with a mean total ischemic time of 570 minutes. Mean recipient age was 42 years (range 18-66) Diagnoses were fibrosis (n⫽2), COPD (n⫽2), CF (n⫽1), SPH (n⫽1). 5 recipients had a PGD score 0 at 24 hours posttransplant. The patient with secondary pulmonary hypertension was left on a planned prolonged ECMO postoperatively for hemodynamic reasons showing good lung function. Median intubation time was 2 days. 30 day mortality was 0%. Conclusions: Ex lung perfusion is a safe and effective method to evaluate and optimise nonacceptable donor lungs. In the setting of an already very liberal use of marginal donor organs we were able to transplant 6 additional lungs which would not have been used otherwise with excellent short term results. 89 Early Outcomes of Bilateral Sequential Single Lung Transplantation after Ex-Vivo Lung Evaluation and Reconditioning B. Zych,1 A.F. Popov,1 M. Carby,2 A.R. Simon,1 K.C. Redmond.1 1 Department of Cardiothoracic Transplantation & Mechanical Support, Royal Brompton & Harefield Hospital, London, Harefield, United Kingdom; 2Respiratory Medicine, Royal Brompton & Harefield Hospital, London, Harefield, United Kingdom. Purpose: Ex-vivo lung perfusion (EVLP) is a novel approach for extended evaluation and/or reconditioning of donor lungs not meeting standard ISHLT criteria for transplantation (tx). This is a prospective evaluation of 11 consecutive EVLP runs performed between January 2009 and September 2010 at a single institution. Methods and Materials: Lungs offered and rejected for routine tx were evaluated and procured normally if they met the inclusion criteria for EVLP. Thus obtained grafts were implanted in the EVLP circuit and reperfused according to the institutional protocol using acellular supplemented STEEN Solution™ up to a target flow rate of 40% of the donor’s calculated flow at a cardiac index of 3.0 l/min/m2 with a LA pressure ⬍5mmHg and PA pressure ⬍15mmHg. After re-warming to 37°C, grafts were ventilated with a 6-8ml/kg(donor weight) tidal volume with a respiratory rate of 7-8/minute, an IE ratio of 1:2 and PEEP of 5-10cmH20. Hemodynamic and respiratory data was monitored continuously and the graft was underwent hourly clinical assessments. Results: Donor data: n⫽11, age 44.81⫾8.82 years, cause of death: intracranial hemorrhage - 10(91%), stroke - 1(9%), history of smoking 7(64%), average pack year 19.57⫾8.59 years, mechanical ventilation time 98.36⫾91.60 hours, CXR: abnormal - 10(91%), normal - 1(9%). EVLP: Mean duration 146.04⫾31.06 minutes. Arterial PaO2 before termination of the circuit improved significantly compared to the last pre-retrieval value: 55.95⫾9.46 vs 40.4⫾14.92 kPa (p⬍0.05). After ex-vivo evaluation and reconditioning, 5 (45%) pairs of lungs were successfully transplanted. Recipient data: Age 41.8⫾15.69 years, underlying disease: cystic fibrosis
- 2(40%), emphysema - 3(60%). Median ITU stay was 7 (range 3–72) days, median follow-up 91 (range 67–269) days, with a 30 day survival rate of 100%. There was one late death (day 203) due to pneumonia. Conclusions: EVLP facilitates assessment and reconditioning of borderline lungs with a conversion rate to tx of 45% and excellent short-term survival. 90 Clinical Lung Transplantation after Ex Vivo Evaluation of Uncontrolled Non Heart-Beating Donors Lungs: Initial Experience F.J. Moradiellos,1 J.M. Naranjo,1 M. Córdoba,1 C. Salas,2 D. Gómez,1 J.L. Campo-Cañaveral,1 S. Crowley,1 M. Valle,3 A. Varela de Ugarte.1 1 Thoracic Surgery Department, Puerta de Hierro University Hospital, Madrid, Spain; 2Pathology Department, Puerta de Hierro University Hospital, Madrid, Spain; 3Pneumology Department, Puerta de Hierro University Hospital, Madrid, Spain. Purpose: To describe the first series of Ex Vivo evaluations of human lungs from Maastricht type I non heart-beating donors and clinical transplantations with these organs. Methods and Materials: Eight potential male donors entered the non heart-beating protocol after sudden cardiac arrest in the street and unsuccessful resuscitation. Bipulmonary blocks were topically cooled and flushed with antegrade and retrograde cold Perfadex. A normothermic Ex Vivo evaluation was initiated, perfusing the lungs with a flow 40% of the estimated cardiac output and protectively ventilating after reaching 32°C. Oxygenation tests were performed hourly. Three criteria were to be met for acceptance: ⌬pO2(difference between atrium and pulmonary artery pO2) over 400mmHg, stable or improving evaluation data and surgeon approval of lung appearance and procedure. Results: Ex Vivo evaluation was correctly perfomed in all cases. Average perfusion time was 273min. Four blocks did not pass the evaluation because of low oxygenation and declining compliance. Bronchiolitis, diffuse emphysema and bone marrow emboli were found in the pre-Ex Vivo pathology analyses of rejected lungs. Four blocks passed the evaluation after an average time of perfusion of 270min. The mean ⌬pO2 was 461mmHg and the mean compliance was 87.2mlL/cmH2O with a tendency to increase in each evaluation. Acceptable blocks were cold preserved until implantation. Four bilateral lung transplantations were performed (3 emphysema, 1 bronchiectasis) with a total “out of the body” time of 15h19m and 17h35m for first and second lung. There were no cases of grade 3 PGD (31.6% PGD⫽0; 10.5% PGD⫽1) Two patients died of non-Ex Vivo related causes after 92 and 122 days. Two patients are alive and well after 204 and 333 days, with no signs of BOS. Conclusions: Ex vivo evaluation of uncontrolled non-heart beating donorlungs enables us to ensure an optimal function under physiological conditions before clinical implantation and promises a more widespread use of this kind of donors in the future. 91 Reconditioning of Lungs from Non-Heart-Beating Donors with Normothermic Ex Vivo Lung Perfusion D. Nakajima, T. Yamada, F. Chen, J. Sakamoto, A. Ohsumi, T. Fujinaga, T. Shoji, H. Sakai, T. Bando, H. Date. Thoracic Surgery and Organ Preservation Technology, Graduate School of Medicine, Kyoto University, Kyoto, Japan. Purpose: To resolve the shortage of donor lungs, the use of non-heartbeating donors (NHBD) has come into practice. An ideal method of preservation that can improve the quality of NHBD lungs has been investigated. Normothermic ex vivo lung perfusion (EVLP) enables organ viability assessment before transplantation. In this study, we investigated whether NHBD lungs can be resuscitated after warm ischemia by normothermic EVLP. Methods and Materials: Four hours after cardiac arrest, the beagles were allocated into 2 groups (n⫽6 each): static cold storage (SCS) or normothermic EVLP using STEEN solution for 3.5 h. The physiological lung functions were evaluated during normothermic EVLP. In both groups, left lungs were then transplanted and reperfused for 4 h to investigate posttransplant lung functions.
The Journal of Heart and Lung Transplantation, Vol 30, No 4S, April 2011
88 Clinical Ex Vivo Lung Perfusion – Pushing the Limits C. Aigner,1 A. Slama,1 K. Hötzenecker,1 B. Urbanek,2 W. Schmid,2 A. Scheed,1 G. Lang,1 S. Keshavjee,3 W. Klepetko.1 1Dept. of Thoracic Surgery, Medical University of Vienna, Vienna, Austria; 2Dept. of Anaesthesiology, Medical University of Vienna, Vienna, Austria; 3Dept. of Thoracic Surgery, Toronto General Hospital, Toronto, Canada. Purpose: Ex vivo lung perfusion (EVLP) has been proven to provide the opportunity to evaluate and optimise unacceptable donor lungs prior to transplantation. We report on the initial clinical results of a prospective study of lung transplantation after ex vivo perfusion. Methods and Materials: All donors lungs who are deemed unacceptable by our standard criteria and meet the inclusion criteria of our prospective non-randomized clinical study are evaluated with ex vivo lung perfusion using acellular Steen Solution for two to four hours. Lungs showing a ⌬PO2 of at least 350 mmHg between arterial and venous solution with stable or improving functional parameters are accepted for transplantation. Results: From 3/2010 – 10/2010 10 lungs were evaluated ex vivo. Mean donor age was 45 years (range 16-58). Mean donor PaO2 at FiO2 1,0/PEEP 5 was 206⫾50 mmHg. 4 lungs, all with trauma history did not improve and were not used. 6 lungs improved to a ⌬PO2 of more than 350 mmHg. Mean PaO2 in those lungs was 468⫾34 mmHg after EVLP. These lungs were transplanted with a mean total ischemic time of 570 minutes. Mean recipient age was 42 years (range 18-66) Diagnoses were fibrosis (n⫽2), COPD (n⫽2), CF (n⫽1), SPH (n⫽1). 5 recipients had a PGD score 0 at 24 hours posttransplant. The patient with secondary pulmonary hypertension was left on a planned prolonged ECMO postoperatively for hemodynamic reasons showing good lung function. Median intubation time was 2 days. 30 day mortality was 0%. Conclusions: Ex lung perfusion is a safe and effective method to evaluate and optimise nonacceptable donor lungs. In the setting of an already very liberal use of marginal donor organs we were able to transplant 6 additional lungs which would not have been used otherwise with excellent short term results. 89 Early Outcomes of Bilateral Sequential Single Lung Transplantation after Ex-Vivo Lung Evaluation and Reconditioning B. Zych,1 A.F. Popov,1 M. Carby,2 A.R. Simon,1 K.C. Redmond.1 1 Department of Cardiothoracic Transplantation & Mechanical Support, Royal Brompton & Harefield Hospital, London, Harefield, United Kingdom; 2Respiratory Medicine, Royal Brompton & Harefield Hospital, London, Harefield, United Kingdom. Purpose: Ex-vivo lung perfusion (EVLP) is a novel approach for extended evaluation and/or reconditioning of donor lungs not meeting standard ISHLT criteria for transplantation (tx). This is a prospective evaluation of 11 consecutive EVLP runs performed between January 2009 and September 2010 at a single institution. Methods and Materials: Lungs offered and rejected for routine tx were evaluated and procured normally if they met the inclusion criteria for EVLP. Thus obtained grafts were implanted in the EVLP circuit and reperfused according to the institutional protocol using acellular supplemented STEEN Solution™ up to a target flow rate of 40% of the donor’s calculated flow at a cardiac index of 3.0 l/min/m2 with a LA pressure ⬍5mmHg and PA pressure ⬍15mmHg. After re-warming to 37°C, grafts were ventilated with a 6-8ml/kg(donor weight) tidal volume with a respiratory rate of 7-8/minute, an IE ratio of 1:2 and PEEP of 5-10cmH20. Hemodynamic and respiratory data was monitored continuously and the graft was underwent hourly clinical assessments. Results: Donor data: n⫽11, age 44.81⫾8.82 years, cause of death: intracranial hemorrhage - 10(91%), stroke - 1(9%), history of smoking 7(64%), average pack year 19.57⫾8.59 years, mechanical ventilation time 98.36⫾91.60 hours, CXR: abnormal - 10(91%), normal - 1(9%). EVLP: Mean duration 146.04⫾31.06 minutes. Arterial PaO2 before termination of the circuit improved significantly compared to the last pre-retrieval value: 55.95⫾9.46 vs 40.4⫾14.92 kPa (p⬍0.05). After ex-vivo evaluation and reconditioning, 5 (45%) pairs of lungs were successfully transplanted. Recipient data: Age 41.8⫾15.69 years, underlying disease: cystic fibrosis
- 2(40%), emphysema - 3(60%). Median ITU stay was 7 (range 3–72) days, median follow-up 91 (range 67–269) days, with a 30 day survival rate of 100%. There was one late death (day 203) due to pneumonia. Conclusions: EVLP facilitates assessment and reconditioning of borderline lungs with a conversion rate to tx of 45% and excellent short-term survival. 90 Clinical Lung Transplantation after Ex Vivo Evaluation of Uncontrolled Non Heart-Beating Donors Lungs: Initial Experience F.J. Moradiellos,1 J.M. Naranjo,1 M. Córdoba,1 C. Salas,2 D. Gómez,1 J.L. Campo-Cañaveral,1 S. Crowley,1 M. Valle,3 A. Varela de Ugarte.1 1 Thoracic Surgery Department, Puerta de Hierro University Hospital, Madrid, Spain; 2Pathology Department, Puerta de Hierro University Hospital, Madrid, Spain; 3Pneumology Department, Puerta de Hierro University Hospital, Madrid, Spain. Purpose: To describe the first series of Ex Vivo evaluations of human lungs from Maastricht type I non heart-beating donors and clinical transplantations with these organs. Methods and Materials: Eight potential male donors entered the non heart-beating protocol after sudden cardiac arrest in the street and unsuccessful resuscitation. Bipulmonary blocks were topically cooled and flushed with antegrade and retrograde cold Perfadex. A normothermic Ex Vivo evaluation was initiated, perfusing the lungs with a flow 40% of the estimated cardiac output and protectively ventilating after reaching 32°C. Oxygenation tests were performed hourly. Three criteria were to be met for acceptance: ⌬pO2(difference between atrium and pulmonary artery pO2) over 400mmHg, stable or improving evaluation data and surgeon approval of lung appearance and procedure. Results: Ex Vivo evaluation was correctly perfomed in all cases. Average perfusion time was 273min. Four blocks did not pass the evaluation because of low oxygenation and declining compliance. Bronchiolitis, diffuse emphysema and bone marrow emboli were found in the pre-Ex Vivo pathology analyses of rejected lungs. Four blocks passed the evaluation after an average time of perfusion of 270min. The mean ⌬pO2 was 461mmHg and the mean compliance was 87.2mlL/cmH2O with a tendency to increase in each evaluation. Acceptable blocks were cold preserved until implantation. Four bilateral lung transplantations were performed (3 emphysema, 1 bronchiectasis) with a total “out of the body” time of 15h19m and 17h35m for first and second lung. There were no cases of grade 3 PGD (31.6% PGD⫽0; 10.5% PGD⫽1) Two patients died of non-Ex Vivo related causes after 92 and 122 days. Two patients are alive and well after 204 and 333 days, with no signs of BOS. Conclusions: Ex vivo evaluation of uncontrolled non-heart beating donorlungs enables us to ensure an optimal function under physiological conditions before clinical implantation and promises a more widespread use of this kind of donors in the future. 91 Reconditioning of Lungs from Non-Heart-Beating Donors with Normothermic Ex Vivo Lung Perfusion D. Nakajima, T. Yamada, F. Chen, J. Sakamoto, A. Ohsumi, T. Fujinaga, T. Shoji, H. Sakai, T. Bando, H. Date. Thoracic Surgery and Organ Preservation Technology, Graduate School of Medicine, Kyoto University, Kyoto, Japan. Purpose: To resolve the shortage of donor lungs, the use of non-heartbeating donors (NHBD) has come into practice. An ideal method of preservation that can improve the quality of NHBD lungs has been investigated. Normothermic ex vivo lung perfusion (EVLP) enables organ viability assessment before transplantation. In this study, we investigated whether NHBD lungs can be resuscitated after warm ischemia by normothermic EVLP. Methods and Materials: Four hours after cardiac arrest, the beagles were allocated into 2 groups (n⫽6 each): static cold storage (SCS) or normothermic EVLP using STEEN solution for 3.5 h. The physiological lung functions were evaluated during normothermic EVLP. In both groups, left lungs were then transplanted and reperfused for 4 h to investigate posttransplant lung functions.