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Long Term Outcome after Bronchial Artery Revascularization in Double Lung Transplantation – A More Than Fifteen Year Follow-Up Study
Abstracts (78%⫾21% of predicted), respectively. Patient life of quality is under assessment and results will be compared to all contemporary LTx. Conclusions: ECMO used as a bridge to LTx results in acceptable early and late survival in selected patients with end stage pulmonary disease. 596 Long Term Outcome after Bronchial Artery Revascularization in Double Lung Transplantation – A More Than Fifteen Year Follow-Up Study M. Perch,1 M.A. Nørgaard,2 C.J. Møller,3 J. Carlsen,1 M. Iversen,1 G. Pettersson.4 1Department of Cardiology, Unit of Lung Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; 2Department of Thoracic Surgery, Aalborg University Hospital, Aalborg, Denmark; 3Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; 4Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH. Purpose: In lung transplantation the systemic arterial blood supply is not routinely restored. When lung transplantation was started in Copenhagen 1992 en bloc double lung transplantation (DLTx) with bronchial artery revascularization (BAR) was the preferred procedure. The initial follow-up showed a possible survival benefit. We now report long term outcome of DLTx with BAR. Methods and Materials: From June 1992 to July 1997 a total of 62 patients underwent en bloc DLTx with BAR at the National Danish Center for Lung Transplantation. The majority of recipients had emphysema or alfa-1-antitrypsin deficiency. In 58 patients the surgical result of BAR was evaluated using a cinematographic mammarybronchial arteriography at approximately one month after the transplantation. Longest follow up was 19 years. No patient was lost to follow up. Survival was analyzed for all en bloc DLTx patients with BAR and for the groups with successful BAR versus unsuccessful BAR using a Kaplan-Meier plot with log rank test. Three patients were censored at the time of re-transplantation. Results: BAR success was classified as successful or unsuccessful: 51 had a successful BAR and 7 were unsuccessful. The median survival time for all en bloc DLTx with BAR patients was 7.8 years (CI 6.88.9). Median survival time for the group with successful BAR was 9 years (CI 5.7-12.4) versus 2.7 years (CI 1.9-3.4) with unsuccessful BAR (p¼0.616).
Conclusions: This study suggests the possibility that en bloc DLTx with BAR can offer a long term survival benefit. 597 Prebypass Hemodynamic Instability in Patients with Severe Pulmonary Hypertension Undergoing Double Lung Transplantation P. Shah, H. Ricky, M. Jose, B. Christian, S. Kathirvel. Anesthesiology and Thoracic Transplantation, University of Pittsburgh, Pittsburgh, PA.
S219 Purpose: Severe Pulmonary hypertension (PHTN) is defined as the mean pulmonary artery pressure (mPAP) greater than 40 mmHg at rest. Lung transplantation is often the common treatment pathway for end-stage pulmonary hypertension. Anesthetic management of lung transplantation in a patient with severe PHTN can be challenging. The intraoperative period during the induction, initial one lung ventilation, and clamping of the pulmonary artery is particular dangerous as vasodilation, myocardial depression, initiation of positive pressure ventilation, acute increase in RV afterload can lead to systemic hypotension and acute RV failure leading to cardiac arrest. Our aim is review patients with severe PHT undergoing their first double lung transplantation over the last 10 year period. Methods and Materials: We investigated the role of the severity of PHT in predicting the need for mechanical support (VA-ECMO, or CPB) prior to first lung pneumonectomy. We retrospectively reviewed 88 cases of sequential double lung transplants, between 2007 and September 2009, who had a mean pulmonary pressure greater (mPA) 40 mmHg on their preoperative right heart catheterization. Results: Our results show a clear dose response relationship between mPA and need for MCS: for patients with mPA between 40-49 (45/59 patient done under support, with 19/45 needing support unplanned), 50-60 (21/22 with support, 9/21 unplanned), 60-70 (8/9, and 1/8 unplanned), and 470 (1/1, 0/1 unplanned). Moreover, examining all 88 patients, patients needing support 75/88 vs 13/88 done without support, the average mean PA was 50 vs 45, PVR (7.7 vs 4.6), and 6 minute walk distance (161 vs 221 meters). In conclusion, we show that mean pulmonary artery pressure shows a dose response relationship with need for MCS. Conclusions: The incidence of hemodynamic instability requiring resuscitation and emergency institution of cardiopulmonary bypass or extracorporeal life support is very high (26%) in severe PHT and future studies should focus on the prediction and management. 598 Bridge to Lung Transplantation with Veno-Venous Extracorporeal Membrane Oxygenation for End-Stage Lung Disease: A Single Center Experience C.F. Evans,1 Z.N. Kon,1 B.P. Wehman,1 M. Gibber,1 A.T. Iacono,2 J.P. Garcia,1 B.P. Griffith.1 1Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD; 2Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland Medical Center, Baltimore, MD. Purpose: Veno-venous extracorporeal membrane oxygenation (ECMO) has been reported as a successful treatment strategy for patients with refractory, albeit reversible lung disease. Its use as a bridge to transplantation (BTT) for patients with irreversible lung disease is less well described. We report our institutional experience with ECMO as a bridge to transplant. Methods and Materials: All patients with end stage lung disease who were placed on VV ECMO as BTT between 2009 and 2012 were identified. Underlying disease, indication for ECMO support, time from intubation to cannulation for ECMO, duration of support and outcomes were analyzed. Results: During that time period, 28 patients were placed on ECMO as BTT. Underlying disease included restrictive lung disease (n¼22), obstructive lung disease (n¼5) and pulmonary hypertension (n¼1). The median interval from intubation to initiation of ECMO was four days (range 0-15 days). The median duration of support was 12 days (range 1-155 days). Thirteen patients received lung transplants and fifteen patients died. Of the thirteen patients who were successfully BTT, seven patients survived to discharge, three remain in the hospital and three died. Conclusions: The prognosis of patients with end stage lung disease is poor. Despite longer support times than previously reported series, our experience demonstrates the efficacy of ECMO as a bridge to transplant.
Conclusions: This study suggests the possibility that en bloc DLTx with BAR can offer a long term survival benefit. 597 Prebypass Hemodynamic Instability in Patients with Severe Pulmonary Hypertension Undergoing Double Lung Transplantation P. Shah, H. Ricky, M. Jose, B. Christian, S. Kathirvel. Anesthesiology and Thoracic Transplantation, University of Pittsburgh, Pittsburgh, PA.
S219 Purpose: Severe Pulmonary hypertension (PHTN) is defined as the mean pulmonary artery pressure (mPAP) greater than 40 mmHg at rest. Lung transplantation is often the common treatment pathway for end-stage pulmonary hypertension. Anesthetic management of lung transplantation in a patient with severe PHTN can be challenging. The intraoperative period during the induction, initial one lung ventilation, and clamping of the pulmonary artery is particular dangerous as vasodilation, myocardial depression, initiation of positive pressure ventilation, acute increase in RV afterload can lead to systemic hypotension and acute RV failure leading to cardiac arrest. Our aim is review patients with severe PHT undergoing their first double lung transplantation over the last 10 year period. Methods and Materials: We investigated the role of the severity of PHT in predicting the need for mechanical support (VA-ECMO, or CPB) prior to first lung pneumonectomy. We retrospectively reviewed 88 cases of sequential double lung transplants, between 2007 and September 2009, who had a mean pulmonary pressure greater (mPA) 40 mmHg on their preoperative right heart catheterization. Results: Our results show a clear dose response relationship between mPA and need for MCS: for patients with mPA between 40-49 (45/59 patient done under support, with 19/45 needing support unplanned), 50-60 (21/22 with support, 9/21 unplanned), 60-70 (8/9, and 1/8 unplanned), and 470 (1/1, 0/1 unplanned). Moreover, examining all 88 patients, patients needing support 75/88 vs 13/88 done without support, the average mean PA was 50 vs 45, PVR (7.7 vs 4.6), and 6 minute walk distance (161 vs 221 meters). In conclusion, we show that mean pulmonary artery pressure shows a dose response relationship with need for MCS. Conclusions: The incidence of hemodynamic instability requiring resuscitation and emergency institution of cardiopulmonary bypass or extracorporeal life support is very high (26%) in severe PHT and future studies should focus on the prediction and management. 598 Bridge to Lung Transplantation with Veno-Venous Extracorporeal Membrane Oxygenation for End-Stage Lung Disease: A Single Center Experience C.F. Evans,1 Z.N. Kon,1 B.P. Wehman,1 M. Gibber,1 A.T. Iacono,2 J.P. Garcia,1 B.P. Griffith.1 1Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD; 2Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland Medical Center, Baltimore, MD. Purpose: Veno-venous extracorporeal membrane oxygenation (ECMO) has been reported as a successful treatment strategy for patients with refractory, albeit reversible lung disease. Its use as a bridge to transplantation (BTT) for patients with irreversible lung disease is less well described. We report our institutional experience with ECMO as a bridge to transplant. Methods and Materials: All patients with end stage lung disease who were placed on VV ECMO as BTT between 2009 and 2012 were identified. Underlying disease, indication for ECMO support, time from intubation to cannulation for ECMO, duration of support and outcomes were analyzed. Results: During that time period, 28 patients were placed on ECMO as BTT. Underlying disease included restrictive lung disease (n¼22), obstructive lung disease (n¼5) and pulmonary hypertension (n¼1). The median interval from intubation to initiation of ECMO was four days (range 0-15 days). The median duration of support was 12 days (range 1-155 days). Thirteen patients received lung transplants and fifteen patients died. Of the thirteen patients who were successfully BTT, seven patients survived to discharge, three remain in the hospital and three died. Conclusions: The prognosis of patients with end stage lung disease is poor. Despite longer support times than previously reported series, our experience demonstrates the efficacy of ECMO as a bridge to transplant.