Is Lobar Size Reduction a Safe and Value Procedure Compared to Standard Lung Transplantation? A Cohort Study with Propensity Score

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The Journal of Heart and Lung Transplantation, Vol 39, No 4S, April 2020

Results: A total of 52 (11%) patients had a WD within 90 days. The median time to WD was 44 days for the overall cohort. There was no association between WD and pulse dose steroids on bivariate analysis (11% pulse vs 10% no pulse; p=.885). On Kaplan Meier analysis, there was no difference in time to WD between the pulse and no pulse dose cohorts (p=.868). On multivariable analysis, none of the following were predictors of WD: pulse dose steroids, age, albumin, HgbA1c, intra-operative transfusion, or CPB; although CPB trended toward significance (HR 1.85, p=.059). No dose-response effect was observed. Conclusion: Pulse dose steroids are used in the treatment of confirmed or suspected acute rejection. Contrary to our hypothesis, steroid pulses are not associated with increased rates of WD following lung transplantation.

(968) Non-Home Discharge is Not Associated with Mortality Following Bilateral Lung Transplant C. Heid,1 M. Khoury,2 R. Vela,1 K. Maaraoui,3 C. Liu,3 J. Pruszynski,1 W.S. Ring,1 M. Wait,1 L.C. Huffman,1 and M. Peltz.1 1Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX; 2Surgery, University of Texas Southwestern Medical Center, Dallas, TX; and the 3University of Texas Southwestern Medical Center, Dallas, TX. Purpose: Non-home discharge (NHD) has been associated with adverse outcomes and mortality in other surgical disease processes. The aim of this study is to assess the association of NHD and mortality after bilateral lung transplant. We hypothesized NHD was associated with increased mortality after bilateral lung transplantation. Methods: Our institutional Society of Thoracic Surgeons Database was queried for bilateral lung transplants performed between 2012-2018. The primary endpoint was mortality. Secondary endpoints included a composite of stroke/TIA, prolonged ventilation, pneumonia and renal failure. The chi square and Kruskal-Wallis tests were used to compare the distributions of variables by discharge location. Kaplan-Meier plot and log rank test were used to compare survival between groups. A multivariable Cox model assessed the effect of NHD and covariates on survival. Results: A total of 376 patients were included in the analysis; of which 125 (34%) required NHD. On bivariate analysis, the following were associated with NHD: age (median 56 vs 61 years, p=.001), cardiopulmonary bypass use (39% vs 57%, p=.001), operative time (median 5.8 hours vs 6 hours, p=0.049), time in initial intensive care unit stay (117 hours vs 235 hours, p<.001), and the composite of post-surgical complications (89% vs 97%, p=.020). On multivariate analysis, none of the covariates were associated with long-term survival. On Kaplan-Meier and log rank analysis, there was no association between NHD and survival (p=.504). The cumulative hazard analysis showed a trend toward higher rates of early, but not late mortality for the NHD cohort. Conclusion: NHD occurred in 34% of bilateral lung transplants. There was no association between NHD and mortality.

(969) Is Frailty Associated with Sarcopenia and Dynapenia in Lung Transplant Candidates? S. Mathur,1 M. Ferreira,1 N. Maia,1 C. Martin,1 N. Chowdhury,2 A. Islam,2 and L.G. Singer.2 1Dept of Physical Therapy, University of Toronto, Toronto, ON, Canada; and the 2Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada. Purpose: Physical frailty is a predictor of pre- and early post-transplant outcomes in lung transplant patients, and may be driven by the presence of sarcopenia (loss of muscle mass), dynapenia (decline in muscle contractile function) and/or mobility limitations. The purpose of this study was to examine the association between physical frailty (Fried Frailty Index; FFI) and measures of sarcopenia, dynapenia and mobility in lung transplant candidates. As a secondary aim, we examined the relationships between sarcopenia and dynapenia. Methods: 49 lung transplant candidates from the Frailty and Sarcopenia in Organ Transplantation (FROST) cohort study were included. Frailty was evaluated using the FFI. Dynapenia was assessed by quadriceps muscle strength and power using computerized dynamometry. Sarcopenia was evaluated using B-mode ultrasound to obtain quadriceps (rectus femoris) cross-sectional area (CSA) and muscle quality (echogenicity). Mobility was measured using the Short Physical Performance Battery (SPPB). Bivariate associations were examined using Spearman’s rho. Results: The sample included 24 patients with ILD, 18 with COPD, and 7 with other diagnoses (53% females; age 59.6§13yrs, FEV1 1.14§0.66L, BMI 25.3§4.0 kg/m2). Based on the FFI, 22% were frail, 71% were prefrail, and 6% were not frail. There was an association between FFI and the SPPB score (r= -0.41, p=0.003); specifically, with the chair stands component of the SPPB (r=0.30, p=0.035). No significant correlations were found between FFI and sarcopenia or dynapenia measures. Quadriceps muscle strength and power were associated with muscle CSA (r=0.44 and 0.47, respectively; p< 0.002) and echogenicity (r= -0.38 and -0.58, respectively; p< 0.008). Conclusion: Mobility limitations appear to overlap with the frailty phenotype in lung transplant candidates, however the presence of sarcopenia and dynapenia may be distinct from frailty.

Summary of measures Median [25th - 75th percentile] Fried Frailty Index (/5) SPPB Score (/12) Gait speed (m/sec) Chair stands time (sec) Quadriceps peak torque (Nm) Quadriceps power (Watts) Rectus femoris CSA (cm2) Rectus femoris echogenicity (arbitrary units)

2 [2.0 - 2.2] 12 [11-12] 1.0 [0.9-1.2] 9.2 [7.5-11.4] 90.7 [72.1-132.3] 206 [167-297] 6.7 [5.7-8.6] 58 [50 - 67]

(970) Is Lobar Size Reduction a Safe and Value Procedure Compared to Standard Lung Transplantation? A Cohort Study with Propensity Score M. Schiavon,1 P. Mendogni,2 E. Faccioli,1 S. Pieropan,2 F. Braccioni,3 G. Lorenzoni,1 D. Gregori,1 A. Mazzucco,2 G.M. Comacchio,1 L. Rosso,2 M. Mammana,1 A. Dell'Amore,1 M. Nosotti,2 and F. Rea.1 1Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padova, Italy; 2Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milano, Italy; and the 3Azienda Ospedaliera di Padova, Padova, Italy. Purpose: Lung transplantation (LT) usually requires an optimal donor/ recipient size matching to guarantee satisfactory results. In patients of small dimensions or with reduced thoracic cage the waiting time to receive a standard organ may be greater than their life expectancy. Lobar reduction is an important surgical option for these subjects but it is so far underutilized. In addition, lobar transplantation is suspected of high perioperative complications being technically demanding. This bicentric cohort study

Abstracts analyzed the impact of lobar lung transplantation on 1-year survival. Secondary end-point were common early and long-terms outcomes. Methods: A retrospective study was performed on 619 consecutive LT between January 2006 and December 2018 (559 standard LT, group I and 60 lobar reduction, group II). A propensity score weighting approach was employed to account for potential confounding factors. The effect of the intervention on the post-operative outcomes of interest was assessed using a weighted regression approach. Results: The propensity score was estimated on 571 patients (522 in group I and 49 in group II). Group I presented a higher percentage of single LT (29% vs 4%, p<0.001) and a lower donor/recipient height ratio (1.02 vs 1.08, p<0.001). One-year survival for group I and II were 72 and 73%, respectively. Considering early outcomes, group II presented a higher percentage of severe PGD (2-3) at 72 hours (52 vs 35%, p=0.022) and longer ICU stay (9 vs 6 days, p=0.014) compared to group I. No other differences in terms of morbidity, mortality, mechanical ventilation and hospital stay were observed. At long-terms, the two groups presented comparable 5-year survival (51 vs 57%) and pulmonary function (best post-operative percentage FEV1, 84 vs 78%). At the regression analysis, lobar lung transplantation was associated with severe PGD at 72 hours (p=0.01) and worse long-term pulmonary function (p=0.04). Conclusion: In our cohort, lobar transplantation did not affect 1-year survival. Although a higher rate of severe PGD at 72 hours and a slightly reduced respiratory function were observed in the lobar transplantation group, these factors did not affect the morbidity and long-term survival. Lobar transplantation could be positively considered to increase the donors’ pool especially for recipients with small chest cavity. (971) Impact of Donor Age on IPF Patient Survival in Lung Transplantation S. Dutta, A. Kashem, G. Sunagawa, S. Brann, E. Leotta, N. Shigemura and Y. Toyoda Lewis Katz School of Medicine, Philadelphia, PA. Purpose: Due to the high mortality of idiopathic pulmonary fibrosis (IPF) patients on the waiting list, potential older donors are considered frequently for lung transplantation. We investigated the survival outcome of IPF patients receiving lungs from donors aged <50 and ≥50 years. Methods: We retrospectively studied IPF transplant recipients that underwent either a single or double lung transplant at our center (Mar-2012 to Jun-2019) and divided patients into two groups (donors age <50 vs. ≥50 years old). We previously reported on a smaller group of patients, and now are updating with a larger cohort. Demographic variables, lung allocation score (LAS), length of stay (LOS), cardiopulmonary bypass (CPB), induction types and surgical procedures were compared for significance (p<0.05) using STATA Inc. Survival was compared by log-rank test using a Kaplan-Meier curve and p-values <0.05 were significant. Results: Patients (n=388) were separated into two groups based on donor age: 8-49 years old (n=322) vs. 50-65 years old (n=66). Demographic data showed no significant differences between groups for recipients’ age (p=0.49), sex (p=0.64), height (p=0.90), BMI (p=0.10), and donors’ sex (p=0.20). Clinical parameters such as LAS (p=0.46), LOS (p=0.34), CPB on vs off (p=0.40), Campath vs. Simulect induction (p=0.40), and antero-apical,

S387 clamshell, median sternotomy surgical approaches (p=0.59) were not significantly different between groups. Log-rank test for equality of survivor functions demonstrated no significant difference between cohorts (p=0.65; KM curve). Survival probability at 30 days, 3, 6, 12 months, 2, and 3 years was 98%, 96%, 92%, 87%, 76%, and 69% for <50 donor age group vs. 98%, 97%, 92%, 90%, 74%, and 74% for ≥50 donor age group respectively. Conclusion: In idiopathic pulmonary fibrosis patients, survival outcomes after lung transplantation using donors below 50 years old were similar to using donors ≥50-65 years old. Utilizing suitable older donor lungs has the potential to increase the donor pool for IPF patients.

(972) WITHDRAWN (973) First Series of Combined Heart & Lung Transplantation from India V. Rahulan,1 P. Yadav,2 A. Jindal,1 A. Narayanan,1 G. Balasubramani,3 P. Dutta,1 and S. Attawar.1 1Pulmonary and Sleep Medicine, Heart and Lung Transplant Unit, Gleneagles Global Health City, Chennai, Tamil Nadu, India; 2Pulmonary and Sleep Medicine, Heart and Lung Transplant Unit, Gleneagles Global Health City, Bangalore, India; and the 3Heart and Lung Transplant Unit, Gleneagles Global Health City, Chennai, Tamil Nadu, India. Purpose: This study analyses the data of patients undergoing Combined heart and lung transplant(CHLTx) with primary pulmonary hypertension (PPH),advanced lung diseases with right ventricular failure and uncorrected congenital heart diseases which are not uncommon in India unlike the developed countries. Methods: Single centre retrospective study of patients who underwent thoracic organ transplantation from April 2017 to October 2019. Results: 107 patients underwent CHLTX,double lung and single lung transplantation. 17 patients underwent CHLTx . Primary etiology was congenital heart disease in 6 (35.3 %), PPH in 6(35.3 %), followed by Group III PH, in 5 (29.4 %) {ILD with severe PH in 4 (30%) and bronchiectasis with severe PH in 1 (7%)}. Post operatively primary graft dysfunction (PGD) was observed in 5 (29.4 %) patients. 2 (11.76 %) had Grade 3 and 3 (17.64 %) had Grade 2 PGD. Post-op ECMO was used in 4 (23.5%) cases. 30 day mortality was observed at n = 3 (17.64 %). 4 (23.5 %) had gram negative sepsis of which 3 (17.64%) expired. Conclusion: For CHLTx in Eisenmenger syndrome with no clear guidelines about the timing,often patient’s symptoms and degree of cyanosis are the deciding factors. With well developed congenital cardiac surgery services in developed countries, patients requiring CHLTx for Eisenmenger are rare. However, in India it’s not uncommon. The criteria to decide between double lung transplantation vs CHTLX in the other two groups were made with ECHO and right heart catheterisation results. In cases where the results were ambiguous, Cardiac MRI was used to decide between CHTLX vs only lung transplantation. Patients with Right ventricular EF < 25% on Cardiac MRI were advised to undergo CHLTx. Our early experience in CHLTx proves encouraging for patients with end stage cardiopulmonary disorders in India. Cardiac MRI plays a vital role in deciding between CHLTx vs only lung transplantation. Further follow up of the patients is required to establish long term outcomes and complications following combined heart lung transplant. (974) Meld Scoring System to Predict Outcomes in Patients Who Undergo VV ECMO Implantation C. Kurihara, and A. Bharat Northwestern University Feinberg School of Medicine, Chicago, IL. Purpose: Veno-venous Extracorporeal membrane oxygenation (VV ECMO) is gaining popularity in the management of severe acute respiratory distress syndrome (ARDS) and bridge patients to lung recovery or transplantation. Several risk factors have been reported to predict prognosis of patients with lung failure. The Model for End-Stage Liver Disease (MELD) system provides a score based on a patient’s international normalized ratio (INR) and creatinine