Prolonged non-invasive ventilatory support prior to pulmonary transplantation does not affect postoperative outcome

The Journal of Heart and Lung Transplantation Volume 22, Number 1S

Abstracts

Methods: Collection of BC in stable out-patients after LTx undergoing surveillance bronchoscopy (with BAL and transbronchial biopsy) was performed. BC collection and eNO measurement were done the day before bronchoscopy. Rejection and infection were excluded by BAL and biopsy. LTB4 and 8-Iso concentrations were measured using EIA. eNO was measured according to ATS/ERS guidelines, flowrate was 120ml/sec. Results: 39 measurements of 20 patients (10 female) with a mean (⫾SD) age at LTx of 43⫾15 years were evaluated. BAL versus BC Measure- Median LTB4 LTB4 ments time after BAL BC LTx (months) (pg/ml) (pg/ml) Early after LTx 30 Late after LTx 9

5 (1–12) 16 (13–25)

8-Iso BAL 8-Iso BC (pg/ml) (pg/ml)

73 ⫾ 58 72 ⫾ 83* 11 ⫾ 6 49 ⫾ 49 23 ⫾ 29* 3 ⫾ 1

eNO (ppb)

11 ⫾ 10** 5 ⫾ 4 6 ⫾ 3** 3 ⫾ 3

*p ⫽ 0.02, **p ⫽ 0.04.

Conclusions: Stable patients less than one year after LTx showed significantly higher LTB4 and 8-Isoprostane values in BC compared to stable patients later after LTx. In contrast, eNO was low in both groups and did not differ. LTB4 and 8-Isoprostane levels were similar in BC and BAL.

354 REDUCED SIZE LUNG TRANSPLANTATION - FOLLOW UP ON 27 PATIENTS G. Warnecke,1 J. Niedermeyer,2 B. Gohrbandt,1 S. Fischer,1 B. Lindenberg,1 A.R. Simon,1 A. Haverich,1 M. Strueber,1 1T&CV Surgery, Hannover Medical School, Hannover, Germany; 2Respiratory Medicine, Hannover Medical School, Hannover, Germany Background: Patients of small size on the waiting list for lung transplantation have the disadvantage of a prolonged waiting time. High urgent lung transplantation is required more often in this population due to terminal progression of end stage lung disease. Thus, a method of graft size reduction was developed. We analysed the postoperative course of 27 patients with reduced size lung transplantation and compared it to 206 consecutive recipients of size-matched lung grafts. Methods: In 27 recipients of high urgent lung transplants a combination of ex situ and in situ lung volume reduction with donor lung lobectomy and/or wedge resection was used to tailor an oversized graft in order to accept donor lungs without regard to size mismatch. Diagnoses included 15 recipients with cystic fibrosis, 9 with fibrosis, one with bronchiectasis and two retransplantations for bronchiolitis obliterans. All 27 recipients were treated on the intensive care unit for imminent (n⫽21) or actual (n⫽6) mechanical ventilation preoperatively. All grafts were preserved by LPD flush perfusion. Size reduction techniques included ex situ and in situ wedge resection by pericardiumreinforced stapling (n⫽13), lobar transplantation (after donor lobectomy, n⫽8) or a combination of both techniques (n⫽6). Results: In the reduced size group one early graft failure occurred resulting in a 30 day survival of 96% compared to 87% in the control group (P⬍0.01). Within 90 days three additional recipients were lost to fungal infection and sepsis in the reduced size group. A 85% survival was comparable to 82% survival in the control group. The remaining 23 patients were all discharged home. Bronchial complications comprised one stenosis and 3 dehiscences in 54 anastomoses. Conclusion: Techniques of reduced size lung transplantation may permit acceptance of oversize donor grafts. Clinical outcome is very good considering the poor patient status of our study group. Application of this approach helps to reduce the scarcity of small pulmonary grafts.

S189

355 LUNG TRANSPLANTATION IN PATIENTS WITH PULMONARY SARCOIDOSIS N. Milman, M. Iversen, J. Carlsen, Danish Lung Transplant Group, The Heart Centre, Department of Medicine B, Division of Lung Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark Background: January 1992 to April 2002, a total of 277 lung transplantations (LTx) have been performed at this Centre. Aim: Describe the course of LTx in patients (4 men, 2 women) with pulmonary sarcoidosis and without extrathoracic sarcoidosis. Pretransplantation data: Patients were NYHA class III-IV. Chest X-ray showed stage III-IV pulmonary sarcoidosis. Following figures denote median (range). Age at debut of sarcoidosis: 30 years (17-44). Duration of sarcoidosis until LTx: 20 years (10-29). Pulmonary function pre-LTx: FEV1 0.75 L (0.6-3.4), FVC 1.9 L (1.3-4.0), FEV1/FVC 46% (32-85), DLCO 49% (20-79) of predicted value. Arterial blood gases at room air: PaO2 9.8 kPa (6.6-11.6), PaCO2 7.0 kPa (4.9-8.0). Pulmonary artery mean pressure (PAMP) 28 mm Hg (25-35). Pulmonary vascular resistance (PVR) 3.1 Wood Units (2.8-5.9). Transthoracic echocardiography: Left ventricular ejection fraction 63% (41-67). Results: All patients had single lung transplantation (SLTx) at a median age of 48 years (41-55). Immunosuppressive tresatment consisted of induction with antithymocyte immunoglobulin or daclizumab and maintenance with cyclosporine, azathioprine or mycophenolate mofetil, and prednisolone. Perioperative course was uncomplicated. Acute rejection episodes (A2-4) were median 2.5 (0-4). Maximum pulmonary function tests at 2-6 months after transplantation: FEV1 2.1 L (1.4-3.6), FVC 3.0 L (1.7-4.5). Recurrence of sarcoidosis in the transplanted lung occurred in 2 patients after 3 and 6 months, and was not associated with deterioration in lung function. A 47-year-old woman deceased 22 months after transplantation due to chronic rejection with graft failure. Follow up on the remaining 5 patients was 3-106 months. The other 46-year-old woman developed BOS 48 months after transplantation. Conclusion: Lung transplantation in sarcoidosis patients apparently does not differ with respect to morbidity or mortality compared with patients having other lung diseases. Recurrence of sarcoidosis in the transplanted lung occur in at least 30% of the patients, but seldom has clinical implications.

356 PROLONGED NON-INVASIVE VENTILATORY SUPPORT PRIOR TO PULMONARY TRANSPLANTATION DOES NOT AFFECT POSTOPERATIVE OUTCOME H. Castle, P.M. Hopkins, L. Sharples, J. Wallwork, Transplant Unit, Papworth Hospital, Papworth Everard, Cambs, United Kingdom Introduction: With donor organ shortage, potential lung transplant (LT) recipients face prolonged time on the waiting list. Non-invasive ventilation (NIV) is increasingly utilised as patients progress to symptomatic type II respiratory failure. Whilst mechanical ventilation remains a strong relative contraindication to transplantation previous studies suggest patients on NIV may achieve a satisfactory outcome. Our aim was to further analyse the effect of prolonged NIV of at least 3 months duration pre-transplant on long-term outcome. Methods: Retrospective review of clinical records at Papworth Hospital from January 1990 to June 2002. Results: 17 of 460 LT recipients (9 HLT, 2 SLT, 6 DLT) of mean age 42.9⫾13.3 years required NIV pre-transplant. There was no significant

S190

Abstracts

difference in body mass index pre-transplant or six-minute walk test between the NIV group versus the control (non-NIV) group. Median stay in the intensive care unit and hospital was 2 days (range 1-56) and 25 (range 1-147) for the NIV group versus 2 days (range 1-70) and 29 (range 1-130) for the control group (p⫽0.27, 0.99 respectively). Median survival using Kaplan Meier survival analysis was 1322 days (3.6 years) in the NIV group and 1463 days (4.0 years) in the control group (p⫽0.96). There were no significant differences between the two groups in the rates of acute rejection or pulmonary infection in the first 12 months post-transplant. In terms of lung function, those on NIV had significantly lower percent-predicted FEV1 and FVC pre-operatively (17.7% vs 39.3% and 40.9% vs 52.5% respectively). FEV1 continued to remain lower in the NIV group at three months post-transplant (62.9% vs 72.1%) and at 12 months (75.9% vs 84.5%) but this did not achieve statistical significance. There were no significant differences in FVC post transplant. Conclusion: Provided standard nutritional and functional targets are achieved pre-transplant, prolonged use of NIV support does not impede obtaining a satisfactory outcome post-transplant.

357 CARDIOPULMONARY BYPASS DOES NOT INCREASE THE MORBIDITY ASSOCIATED WITH LUNG TRANSPLANTATION FOR CHRONIC OBSTRUCTIVE AIRWAY DISEASE P.C. Jansz, J.I. Ferguson, K.K. Dhital, J. Dunning, J. Wallwork, S.R. Large, Transplant Unit, Papworth Hospital, Cambridge, Cambs, United Kingdom Background: The use of cardiopulmonary bypass in lung transplantation is often cited as increasing post-operative morbidity. Series that support this hypothesis have included patients from different disease groups in their analysis, thereby introducing a potential source of bias. The use of cardiopulmonary bypass based on the surgeon’s preference, adds further controversy to this issue. Method: We have reviewed 125 consecutive patients that underwent single or double lung transplantation for chronic obstructive pulmonary disease in our institution over the past ten years. 62 were performed using cardiopulmonary bypass and 63 without. We also compared all lung transplants irrespective of disease groups, 98 having been performed with cardiopulmonary bypass and 117 without. Results: In the chronic obstructive airway disease group, ventilation time was significantly increased in the bypass group as compared to the non-bypass group (median:(interquartile range): bypass 9 hr (2-100), non bypass 6hr (1-55) p⫽0.004. In terms of blood loss, days in ITU, transfusions and length of stay there was no difference between the two groups. When all transplants were analyzed, significant increases in ventilation time (p⫽0.004), blood loss (p⫽0.002) and transfusion requirements (p⫽0.01) were found in the bypass group. 5 year survival was also comparable for all lung transplants between the on and off-bypass groups (on cpb: 38% vs off cpb: 37% p⫽0.89) Conclusion: Whilst significant differences in morbidity where found between the bypass and non-bypass cohorts when all lung transplants were analyzed, these differences were not observed when specific disease groups were analyzed separately. Furthermore, there was no significant difference in survival between the on and off-pump groups. Cardiopulmonary bypass did not increase the morbidity or adversely affect the short or long-term outcome of lung transplantation performed for chronic obstructive airway disease.

The Journal of Heart and Lung Transplantation January 2003 358 SURVEILLANCE BRONCHOSCOPY (SB) IN LUNG TRANSPLANT RECIPIENTS (LTR): RISK VERSUS BENEFIT? T.J. McWilliams,1,2 H.M. Whitford,1,2 S.M. Fowler,1 A.T. Kotsimbos,1 G.I. Snell,1,2 T.J. Williams,1,2 1Department of Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia; 2Department of Respiratory Medicine, Monash University, Melbourne, VIC, Australia The frequency of SB varies widely between transplant centers. At this institution SB with bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) is performed in stable asymptomatic LTR at 0.5 1,2,3, 6, 9, 12, 18 and 24 months and then yearly post LT. The yield in the early period is high but the utility after the 1st year has not been examined in a large group. TBB adds significant risks to this procedure. Aim: To evaluate the frequency of abnormal BAL and TBB results on SB that changed management, and to compare this with procedure related complications. Methods: Data from all SB performed on LTR in 1 year was collected prospectively. We recorded outcomes that effected management on TBB (acute rejection, A2 or greater or histological infection) and on BAL ( pathogenic organism with supportive clinical evidence). This was compared with the incidence of complications (sedation related respiratory depression, bleeding and pneumothorax post TBB) in 3 groups: 0- 3 months, 3 to 12 months and ⬎12 months post LT. Results: 353 bronchoscopies were performed on 129 LTR in one year. 232 were SB. 45.3% of the SB were in LTR ⬍3 months, 38.4% at 3-12 months and 16.4%⬎12 months. See Table 1for results. Bleeding ⬎ 200ml occurred in 13.8% of all SB, over sedation occurred in 7.8%, more often in 0-3 months. Overall pneumothorax rate was ⬍ 1%. Conclusion: Our results are in keeping with previous reports that suggest that SB yields useful results in the 1st 12 months post LT. We found a low yield for TBB post 12 months in stable LTR although the complication rateis similar. The high infection rate in asymptomatic patients ⬎ 12 months post LT suggests that SB with BAL only, may be of benefit in this group. Clinically Significant Results from SB in LTR Time post LT

0–3 Months

3–12 Months

>12 Months

Abnormal TBB Infection on BAL

30 (28.6%) 14 (13.3%)

17 (19.1%) 18 (20.2%)

1 (2.6%) 7 (18.4%)

359 SURVIVAL OF LUNG TRANSPLANT RECIPIENTS WITH CYSTIC FIBROSIS (CF) HARBORING PANRESISTANT BACTERIA OTHER THAN B. CEPACIA, COMPARED TO PATIENTS HARBORING SENSITIVE BACTERIA D. Hadjiliadis,1 M.P. Steele,2 C. Chaparro,1 L.G. Singer,1 R.H. Messier,2 T.K. Waddell,1 M.A. Hutcheon,1 R.D. Davis,2 D.E. Tullis,3 S.M. Palmer,2 S. Keshavjee,1 1Toronto Lung Transplant Program, University of Toronto, Toronto, ON, Canada; 2Duke University Lung Transplant Program, Duke University, Durham, NC; 3 Toronto Adult Cystic Fibrosis Program, University of Toronto, Toronto, ON, Canada Purpose: The impact of panresistant bacteria, other than B. cepacia on the survival after lung transplantation in patients with CF remains controversial. Methods: A retrospective study was performed. All lung transplant recipients with a pre-transplant diagnosis of CF, but without B. cepacia before or after lung transplantation, at the University of Toronto