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Prognostic Factors in Lung Transplantation After Hematopoietic Stem Cell Transplantation
S158
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
4( 02) Prognostic Factors in Lung Transplantation After Hematopoietic Stem Cell Transplantation T.F. Chen-Yoshikawa ,1 S. Sugimoto,2 T. Shiraishi,3 M. Minami,4 Y. Matsuda,5 M. Chida,6 S. Maeda,6 A. Aoyama,1 Y. Okada,5 M. Okumura,4 A. Iwasaki,3 S. Miyoshi,2 T. Oto,7 H. Date.1 1Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan; 2General Thoracic Surgery, Okayama University Hospital, Okayama, Japan; 3Thoracic Surgery, Fukuoka University Hospital, Fukuoka, Japan; 4General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan; 5Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan; 6General Thoracic Surgery, Graduate School of Medicine, Dokkyo Medical University, Mibu, Japan; 7Organ Transplant Center, Okayama UniversityHospital, Okayama, Japan. Purpose: Lung transplantation is the final life-saving option for patients with pulmonary complications after hematopoietic stem cell transplantation (HSCT). Patients undergoing HSCT for hematologic diseases are thought to be high-risk candidates for lung transplantation; therefore, few lung transplants are performed for these patients. This study aimed to describe the characteristics and outcomes of lung transplantation in patients with pulmonary complications after HSCT. Methods: We retrospectively investigated 62 patients who underwent lung transplantation after HSCT. Results: Seventeen patients underwent cadaveric lung transplantation, whereas 45 underwent living-donor lobar lung transplantation (LDLLT). In the LDLLT group, 18 patients underwent LDLLT after HSCT in which one of the donors had also served as a donor for HSCT. Seven patients underwent single LDLLT for which the donor was the same as the one from whom stem cells were obtained for HSCT. Preoperative hypercapnia was observed in 52 patients (84%). Thirteen patients (21%) required mechanical ventilation. Fifty-five patients underwent HSCT for hematologic malignancies, and four (7%) relapsed after lung transplantation. Immunosuppression tapering was intentionally conducted in six of seven patients undergoing single LDLLT from the same donor as for HSCT, with successful discontinuation of immunosuppression after lung transplantation in two patients. The 5-year survival rate was 64.2%. Survival curves according to surgical procedures were shown in Figure 1. In a multivariable analysis, patients younger than 45 years and those with the same donor for both procedures exhibited significantly better survival (p = 0.012 and 0.041, respectively). Conclusion: Lung transplantation for pulmonary complications after HSCT was performed safely and yielded better survival, especially in younger recipients for whom both lung transplantation and HSCT involved the same donor.
4( 03) Lung Volumes Pre and Post Transplant: The Frustrum Model S. Park , W. Ring, M.A. Wait. Thoracic & Cardiovascular Surgery, UT Southwestern Medical Center, Dallas, TX. Purpose: To validate the frustum model for lung volumes in patients with interstitial lung disease (ILD) undergoing lung transplantation, and to test
whether lung size by frustum model is associated with cumulative survival advantage and need for diaphragm plication following lung transplant. Methods: This retrospective observational study consisted of 180 patients seen in the University of Texas Southwestern-affiliated hospitals during the period from May 2010 to May 2016. Patients receiving bilateral or single lung transplant for ILD with available pre and post-operative CT scans were included. Bilateral lung transplants were performed through thoracosternotomy and single lung transplants through a unilateral thoracotomy. Cardiopulmonary bypass was used in 48% of patients. The frustum equation for a truncated cone [V = was used to calculate total lung volume with pre and post-operative CT and XR chest PA closest to surgery time. Lung height was defined as the distance from the first rib to the diaphragm on XR chest. Radius 1 and 2 were obtained with same landmarks on CT scan. Patients were stratified by post/pre transplant lung volume ratio > 1 or ratio ≤ 1. Multivariate logistic regression analysis and Cox proportional hazards regression models were used for statistical analysis of diaphragm plication and overall survival. Results: Of the total 180 patients included, 39 (22%) had lung volume ratio ≤ 1 and 141 (78%) had ratio > 1. To validate the frustum model, a Pearson Correlation Coefficient was used to assess correlation between plethysmography TLC and frustum volume (n = 251, r= .85, p < .01). Multivariate analysis for diaphragm plication included lung ratio, BMI, and smoking status. Lung volume ratio was a significant predictor of diaphragm plication (ratio > 1 OR 7.19, p < .05). Multivariable Cox regression model for survival included lung ratio, diabetes, dyslipidemia, reintubation, and post-operative pneumonia. The only significant predictors were lung ratio (ratio ≤ 1HR 1.79, p < .05) and reintubation (HR 3.43, p< .01). Conclusion: The frustum model is a valid method for evaluating lung volumes in transplantation. The study suggests that lung volume confirms previous observations of a survival advantage to larger donor size in ILD. However, larger lung size may require diaphragm plication. 4( 04) Impact of Acute Respiratory Syncytial Virus Infection on the Lung Function of Lung Transplant Recipients: What Happens? H. Lafoeste ,1 C. Picard,1 L. Beaumont,1 E. Farfour,2 S. De Miranda,1 B. Douvry,1 A. Hamid,1 N. Carlier,1 D. Grenet,1 F. Parquin,3 E. Sage,3 A. Roux.1 1Respiratory Medicine, Foch Hospital, Suresnes, France; 2Microbiology Department, Foch Hospital, Suresnes, France; 3Thoracic Surgery, Foch Hospital, Suresnes, France. Purpose: Acute respiratory virus infections have been associated with lung function decline at the time of infection in lung transplant recipients (LTR). An increased risk of acute cellular rejection (ACR) and chronic lung allograft dysfunction (CLAD) has also been reported following viral infection. We report on the lung function at time of infection and 6 months after respiratory syncytial virus (RSV) infection in a single center. Methods: retrospective analysis of the charts of all consecutive patients with at least one positive PCR for RSV on a respiratory sample in 439 LTR followed between 01/01/2013 and 01/02/2016. At the time of infection, decliners, defined as patients with a drop of FEV1 > 10% from baseline, were compared to non-decliners using univariate non-parametric test analysis. At 6 months, the occurrence of ACR, anti-HLA donor specific antibodies (DSA) and the incidence/evolution of bronchiolitis obliterans syndrome (BOS) were assessed. Results: RSV infection occurred in 42 patients (9.7% of LTR; incidence 3.95/100 patient-years) at a median time post LT of 760 days [25; 75 th percentile = 272; 1432]. Thirty (71%) were acute decliners and 12 (29%) were non-decliners. Decliners had more frequently a past history of similar episode (acute viral infection with drop in lung function), than the non-decliners (respectively 16/30, vs 2/12; p= 0.036) and tended to have more frequently pre-existing BOS stage 1 or more (8/30, vs 0/12; p= 0.08). The diagnosis, the immunosuppression, co infection with bacteria or other viruses, concomitant ACR did not differ statistically between the two groups. At 6 months, ACR occurred in one patient in each group (p= 0.48), and de novo or aggravating BOS 0p or more occurred equally in both groups (10/30, vs 4/12; p= 0.99). 7/30 (23%) of the decliners had de novo or increasing DSA (vs 1 in nondecliners; p= 0.4), and 2 of them experienced humoral rejection in the following 6 months.
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
4( 02) Prognostic Factors in Lung Transplantation After Hematopoietic Stem Cell Transplantation T.F. Chen-Yoshikawa ,1 S. Sugimoto,2 T. Shiraishi,3 M. Minami,4 Y. Matsuda,5 M. Chida,6 S. Maeda,6 A. Aoyama,1 Y. Okada,5 M. Okumura,4 A. Iwasaki,3 S. Miyoshi,2 T. Oto,7 H. Date.1 1Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan; 2General Thoracic Surgery, Okayama University Hospital, Okayama, Japan; 3Thoracic Surgery, Fukuoka University Hospital, Fukuoka, Japan; 4General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan; 5Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan; 6General Thoracic Surgery, Graduate School of Medicine, Dokkyo Medical University, Mibu, Japan; 7Organ Transplant Center, Okayama UniversityHospital, Okayama, Japan. Purpose: Lung transplantation is the final life-saving option for patients with pulmonary complications after hematopoietic stem cell transplantation (HSCT). Patients undergoing HSCT for hematologic diseases are thought to be high-risk candidates for lung transplantation; therefore, few lung transplants are performed for these patients. This study aimed to describe the characteristics and outcomes of lung transplantation in patients with pulmonary complications after HSCT. Methods: We retrospectively investigated 62 patients who underwent lung transplantation after HSCT. Results: Seventeen patients underwent cadaveric lung transplantation, whereas 45 underwent living-donor lobar lung transplantation (LDLLT). In the LDLLT group, 18 patients underwent LDLLT after HSCT in which one of the donors had also served as a donor for HSCT. Seven patients underwent single LDLLT for which the donor was the same as the one from whom stem cells were obtained for HSCT. Preoperative hypercapnia was observed in 52 patients (84%). Thirteen patients (21%) required mechanical ventilation. Fifty-five patients underwent HSCT for hematologic malignancies, and four (7%) relapsed after lung transplantation. Immunosuppression tapering was intentionally conducted in six of seven patients undergoing single LDLLT from the same donor as for HSCT, with successful discontinuation of immunosuppression after lung transplantation in two patients. The 5-year survival rate was 64.2%. Survival curves according to surgical procedures were shown in Figure 1. In a multivariable analysis, patients younger than 45 years and those with the same donor for both procedures exhibited significantly better survival (p = 0.012 and 0.041, respectively). Conclusion: Lung transplantation for pulmonary complications after HSCT was performed safely and yielded better survival, especially in younger recipients for whom both lung transplantation and HSCT involved the same donor.
4( 03) Lung Volumes Pre and Post Transplant: The Frustrum Model S. Park , W. Ring, M.A. Wait. Thoracic & Cardiovascular Surgery, UT Southwestern Medical Center, Dallas, TX. Purpose: To validate the frustum model for lung volumes in patients with interstitial lung disease (ILD) undergoing lung transplantation, and to test
whether lung size by frustum model is associated with cumulative survival advantage and need for diaphragm plication following lung transplant. Methods: This retrospective observational study consisted of 180 patients seen in the University of Texas Southwestern-affiliated hospitals during the period from May 2010 to May 2016. Patients receiving bilateral or single lung transplant for ILD with available pre and post-operative CT scans were included. Bilateral lung transplants were performed through thoracosternotomy and single lung transplants through a unilateral thoracotomy. Cardiopulmonary bypass was used in 48% of patients. The frustum equation for a truncated cone [V = was used to calculate total lung volume with pre and post-operative CT and XR chest PA closest to surgery time. Lung height was defined as the distance from the first rib to the diaphragm on XR chest. Radius 1 and 2 were obtained with same landmarks on CT scan. Patients were stratified by post/pre transplant lung volume ratio > 1 or ratio ≤ 1. Multivariate logistic regression analysis and Cox proportional hazards regression models were used for statistical analysis of diaphragm plication and overall survival. Results: Of the total 180 patients included, 39 (22%) had lung volume ratio ≤ 1 and 141 (78%) had ratio > 1. To validate the frustum model, a Pearson Correlation Coefficient was used to assess correlation between plethysmography TLC and frustum volume (n = 251, r= .85, p < .01). Multivariate analysis for diaphragm plication included lung ratio, BMI, and smoking status. Lung volume ratio was a significant predictor of diaphragm plication (ratio > 1 OR 7.19, p < .05). Multivariable Cox regression model for survival included lung ratio, diabetes, dyslipidemia, reintubation, and post-operative pneumonia. The only significant predictors were lung ratio (ratio ≤ 1HR 1.79, p < .05) and reintubation (HR 3.43, p< .01). Conclusion: The frustum model is a valid method for evaluating lung volumes in transplantation. The study suggests that lung volume confirms previous observations of a survival advantage to larger donor size in ILD. However, larger lung size may require diaphragm plication. 4( 04) Impact of Acute Respiratory Syncytial Virus Infection on the Lung Function of Lung Transplant Recipients: What Happens? H. Lafoeste ,1 C. Picard,1 L. Beaumont,1 E. Farfour,2 S. De Miranda,1 B. Douvry,1 A. Hamid,1 N. Carlier,1 D. Grenet,1 F. Parquin,3 E. Sage,3 A. Roux.1 1Respiratory Medicine, Foch Hospital, Suresnes, France; 2Microbiology Department, Foch Hospital, Suresnes, France; 3Thoracic Surgery, Foch Hospital, Suresnes, France. Purpose: Acute respiratory virus infections have been associated with lung function decline at the time of infection in lung transplant recipients (LTR). An increased risk of acute cellular rejection (ACR) and chronic lung allograft dysfunction (CLAD) has also been reported following viral infection. We report on the lung function at time of infection and 6 months after respiratory syncytial virus (RSV) infection in a single center. Methods: retrospective analysis of the charts of all consecutive patients with at least one positive PCR for RSV on a respiratory sample in 439 LTR followed between 01/01/2013 and 01/02/2016. At the time of infection, decliners, defined as patients with a drop of FEV1 > 10% from baseline, were compared to non-decliners using univariate non-parametric test analysis. At 6 months, the occurrence of ACR, anti-HLA donor specific antibodies (DSA) and the incidence/evolution of bronchiolitis obliterans syndrome (BOS) were assessed. Results: RSV infection occurred in 42 patients (9.7% of LTR; incidence 3.95/100 patient-years) at a median time post LT of 760 days [25; 75 th percentile = 272; 1432]. Thirty (71%) were acute decliners and 12 (29%) were non-decliners. Decliners had more frequently a past history of similar episode (acute viral infection with drop in lung function), than the non-decliners (respectively 16/30, vs 2/12; p= 0.036) and tended to have more frequently pre-existing BOS stage 1 or more (8/30, vs 0/12; p= 0.08). The diagnosis, the immunosuppression, co infection with bacteria or other viruses, concomitant ACR did not differ statistically between the two groups. At 6 months, ACR occurred in one patient in each group (p= 0.48), and de novo or aggravating BOS 0p or more occurred equally in both groups (10/30, vs 4/12; p= 0.99). 7/30 (23%) of the decliners had de novo or increasing DSA (vs 1 in nondecliners; p= 0.4), and 2 of them experienced humoral rejection in the following 6 months.