LUNG TRANSPLANTATION AN OVERVIEW. JNANESH THACKER. M.Ch. CON. CARDIAC SURGEON. HINDUJA HOSPITAL
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1 LUNG TRANSPLANTATION AN OVERVIEW. JNANESH THACKER. M.Ch. CON. CARDIAC SURGEON. HINDUJA HOSPITAL
2 LUNG TRANSPLANTATION. HEART TRANSPLANTATION. HEART-LUNG TRANSPLANTATION.
3 IS LUNG TRANSPLANTATION.. A SCIENCE FICTION? EXPERIMENTAL SURGERY? A DEFINITIVE TREATMENT FOR END STAGE LUNG DISEASE?
4 GOAL OF THIS TALK. TO SHOW THAT LUNG TRANSPLANTATION IS A DEFINITIVE TREATMENT FOR END STAGE LUNG DISEASE. END STAGE MAY BE DUE TO COPD. INTERSTITIAL LUNG DISEASE. PULMONARY HYPERTENSION. AWARENESS FOR ORGAN DONATION.
5 CONTENT. HISTORY OF LTx. MOST EXPERIENCED CENTERS IN THE WORLD. THE PROCESS OF LUNG TRANSPLANTATION. WHICH PATIENTS NEED LUNG TRANSPLANTATION? WHEN TO REFER A PATIENT FOR LUNG TRANSPLANTATION? WHERE TO REFER? WHAT IS AN IDEAL DONOR. HOW TO SELECT AN ACCEPTABLE DONOR.
6 CONTENT. HOW TO PRESERVE THE LUNGS? HOW LONG THE LUNGS CAN BE OUT OF THE BODY SAFELY? SHOULD WE DO SINGLE LUNG OR DOUBLE LUNG TRANSPLANTATION? WHAT IS THE IMMUNOSUPPRESSION PROTOCOL? HOW DO WE PROTECT AGAINST INFECTION AFTER IMMUNOSUPPRESSION WHAT IS THE LONG TERM FOLLOW UP? TECHNIQUE OF SURGERY. TRANSPLANT TEAM.
7 LUNG TRANSPLANTATION COMPARED TO MAXIMAL MEDICAL TREATMENT. (Thalbut G, Mal H, Castier Y, Survival Benefit of Lung transplantation for patients with IPF J Thorac Cardiovasc Surg 2003; 126: ) N= : Lung transplantation. 16: Died on the Waiting List. 2 Active on the Wait List. Lung Transplantation reduced risk of death by 75%.
8 8 COPD\IPF\PH
9 THREE MOST EXPERIENCED CENTERS IN THE WORLD. UNIVERSITY OF PITTSBURGH HANNOVER 1109 TORONTO GENERAL HOSPITAL 1071 Clinical Transplants 2009.
10 HISTORY : FIRST LUNG TRANSPLANT BY JAMES HARDY,UNIVERSITY OF MISSISSIPPI : FIRST SUCCESSFUL LUNG TRANSPLANTATION BY JOEL COOPER, UNIVERSITY OF TORONTO.
11 WHAT IS..the Tx Jargon.? UNOS. (UNITED NETWORK OF ORGAN SHARING)? OPO (ORGAN PROCUREMENT ORGANISATION)? C.O.R.E. (PITTSBURGH) GIFT OF LIFE. (PHILADELPHIA) LAS SCORE. (LUNG ALLOCATION SCORE)?
12 THE GOAL OF TRANSPLANTATION. THE GOAL OF ALL TRANSPLANTATION IS: MAXIMUM SURVIVAL BENEFIT with an IMPROVED QUALITY OF LIFE.
13 THE PROCESS OF LUNG TRANSPLANTATION.
14 4 MOST IMPORTANT POINTS OF DONOR CHEST X-RAY. EVALUATION. ABG. PaO2 > 300 mm of Hg on FiO2 of 100% and PEEP of 5. TV = 10ml/kg. (P/F Ratio >/= 3) BRONCHOSCOPY : No injury/ No infection. EYE BALL TEST. (INSPECTION AND PALPATION OF THE LUNGS AFTER OPENING THE CHEST)
15 15 EXPANDING THE DONOR POOL.
16 AN EVENING ON CALL! IT IS MID-NIGHT.A PAGER BEEPS A SHRILL NOTE.. SOMETHING HAS STARTED TO ROLL.
17 ALL TEAMS MEET AT ER/HELLIPAD. ALL TEAMS MEET AT THE MAIN GATE OF THE HOSP.
18 OPO VEHICLE ARRIVES.
19 OFF TO THE AIRPORT.
20 IN THE PLANE.
21 ARRIVAL AT THE DONOR CITY AIRPORT.
22 GETTING INTO THE WAITING AMBULANCE.
23 IN THE AMBULANCE.
24 ARRIVING AT DONOR HOSPITAL.
25 TO THE DONOR OR.
26 IN THE DONOR OR. ALL TEAMS.
27 THE LUNG TEAM.
28 HEART IS THE FIRST TO COME OUT.
29 LUNGS.OUT.
30 THANKS EVERYONE!!!!
31 PREPARATION FOR IMPLANTATION.
32 WHICH PATIENTS NEED LUNG TRANSPLANTATION. WHEN TO REFER? WHEN TO LIST?
33 DEVELOPMENT OF INTERNATIONAL GUIDELINES FOR PATIENT SELECTION. In 1998 Transplant physicians representing ISHLT, AMERICAN SOCIETY OF TRANSPLANT PHYSICIANS, AMERICAN THORACIC SOCIETY, THE EUROPEAN RESPIRATORY SOCIETY, AND THORACIC SOCIETY OF AUSTRALIA AND NEW ZEALAND met to develop International Guidelines for Patient Selection. Am J Respir Crit Care Med 1998; 158:
34 DISEASE SPECIFIC GUIDELINES. THESE GUIDELINES SUGGEST ANSWERS TO TWO QUESTIONS UNDER EACH DIAGNOSIS. WHEN TO REFER A PATIENT FOR LUNG TRANSPLANTATION? WHEN TO LIST THE PATIENT? (J Heart Lung Transplant 2006; 25: )
35 COPD: BODE INDEX. Celli BR, Caverley PMA, et al Respir med 2005;99: FEV1 (% predicted) (Obstructive lung disease) Six min walk test.(m). Exercise. >/= </= 35 >/= </=149 MMRD Dyspnea scale BMI >21 </=21 MMRD = MODIFIED MEDICAL RESEARCH COUNCIL
36 COPD. WHEN TO REFER? WHEN BODE INDEX IS > 5.
37 COPD. WHEN TO LIST? BODE INDEX Hospitalization with exacerbation. (PCO2 > 55 mm Hg) Pulmonary Hypertension, Cor Pulmonale or both despite O2 therapy. FEV1 <20% and either DLCO<20% or homogenous emphysema.
38 TIMING FOR EVALUATION AND LISTING FOR LUNG TRANSPLANTATION (GUIDELINES 2006) The unpredictable and catastrophic progression, make timing for evaluation and listing a crucial decision. 1. REFFERAL AND EVALUATION AT INITIAL DIAGNOSIS OF IPF/UIP. 2. WHEN THE PATIENT REQUIRES 4 LITERS OF OXYGEN ON EXERTION. 3. ANY AMOUNT ON REST.
39 PAH. WHEN TO REFER? NYHA III or IV irrespective of on- going therapy. Rapidly progressive disease.
40 PAH. WHEN TO LIST? PERSISTANT NYHA III or IV IRRESPECTIVE OF ONGOING THERAPY. DECLINING 6MWT. LOW (<362 m) FAILING THERAPY WITH EPOPROSTENOL OR EQUIVALENT CARDIAC INDEX < 2 L/min/m2 RIGHT ATRIAL PRESSURE > 15 mm Hg.
41 WHERE TO REFER?
42 HINDUJA HOSPITAL. DR. ZARIR UDWADIA. M.D. MEDICAL DIRECTOR OF LUNG TRANSPLANTATION. DR. JNANESH THACKER. M. Ch. SURGICAL DIRECTOR OF LUNG TRANSPLANTATION. END STAGE HEART AND LUNG DISEASE OPD. EVERY MONDAY 1 TO 5 PM. THIRD FLOOR, THIRD WING.
43 WHICH PATIENTS WE SHOULD NOT OPERATE?
44 ABSOLUTE CONTRAINDICATIONS. Guidelines: MALIGNANCY WITHIN THE LAST TWO YEARS (EXCEPT SQUAMOUS AND BASAL CELL SKIN CANCER.) UNTREATABLE DYSFUNCTION OF SECOND ORGAN e.g. CAD not amenable to PCI or bypass surgery./ Heart-Lung Transplantation. NON CURABLE EXTRAPULMONARY INFECTIONS. e.g. Chronic Active Hepatitis B and C, and HIV. CHEST WALL OR SPINAL DEFORMITIES. These increase the perioperative risk greatly. Therefore survival benefit favors medical management.
45 ABSOLUTE CONTRAINDICATIONS. (Guidelines: 2006) DOCUMENTED NON COMPLIANCE. UNTREATABLE PSYCHIATRIC OR PSYCHOLOGICAL CONDITION LEADING TO NON COMPLIANCE. ABSENCE OF RELIABLE AND CONSISTENT SOCIAL SUPPORT. ACTIVE SUBSTANCE ABUSE OR ACTIVE WITHIN THE LAST 6 MONTHS. (J Heart Lung transplant 2006; 25: )
46 HOW DO WE PRESERVE THE LUNGS?
47 LUNG PRESERVATION SOLUTION. PERFEDEX With 1 ampoule of PGE-1.
48 LUNG PRESERVATION. ANTEGRADE IN THE PULMONARY ARTERY ON THE MAIN OR TABLE AFTER CROSS CLAMP) 70 ml/kg. RETROGRADE IN ALL THE PULMONARY VEINS. (APPROX 500cc IN EACH ON THE BACK TABLE) 2.8 Liters
49 HOW LONG CAN WE PRESERVE THE LUNGS?
50 COLD ISCHEMIA TIME? Kidney 72 hrs LUNG 11 hrs HEART 6 hrs
51 TECHNIQUE OF SURGERY.
52 RECIPIENT SURGERY. BRONCHIAL ANASTOMOSIS : 3-0 PROLENE CONTINOUS. PULMONARY ARTERY ANASTOMOSIS : 5-0 POLYPROPYLENE CONTINOUS. PULMONARY VENOUS ANASTOMOSIS : 4-0 POLYPROPELENE CONTINOUS.
53 Bronchial Anastomosis Stay sutures Phrenic Nerve PA SPV IPV 3-0 Prolene Running PA Stay suture
54 Pulmonary Arterial Anastomosis 5-0 Prolene Running
55 Left Atrial Anastomosis Stay Sutures 4-0 Prolene Running
56 Antero-Axillary Thoracotomy
57 Antero-Axillary Thoracotomy
58 Antero-Axillary Thoracotomy
59 Antero-Axillary Thoracotomy
60 WHAT IMMUNOSUPPRESSION?
61 IMMUNOSUPPRESSION PROTOCOL INDUCTION: CAMPATH (ALEMTUZIMAB) 30 mgs SLOWLY OVER 2 hrs AFTER PREMEDICATION WITH BENADRYL, PARACETAMOL AND 1 GM. SOLUMEDROL ) MAINTAINANCE: CALCENUERINE INHIBITORS: PROGRAF (TACROLIMUS) CYCLOSPORINE. CELL CEPT. (MYCOPHENOLATE MOEFETIL) LOW DOSE STEROIDS. (PREDNISONE 5 mgs / day)
62 HOW TO PREVENT INFECTION?
63 INFECTION PROPHYLAXIS. BACTERIAL : ANCEF and ASTREONAM. FUNGAL : VORICONAZOL 6 mgs / kg STARTED 4 HOURS POST-OP. CMV : VALGANCYCLOVIR 900 mgs PO BiD, or 450 mgs PO Bid. C. DIFF : METRONIDAZOL 250 mgs PO TID. TOXO : ( D +/ R -) : SEPTRAN DS/ PYRIMETHAMINE LUECOVORINE/ DAPSONE P. CARINII : SEPTRAN DS/PYRIMETHAMINE/
64 WHAT IS THE LONG TERM FOLLOW UP?
65 SURVELLAINCE OF REJECTION AND INFECTION (UPMC PROTOCOL.) TRANSBRONCHIAL FIBEROPTIC BIOPSY. BRONCHOALVEOLAR LAVAGE. (BAL) EVERY 6 TO 8 WEEKS.
66 GRADES OF ACUTE CELLULAR REJECTION. NO REJECTION : GRADE 0. MINIMAL REJECTION : GRADE 1. MILD REJECTION : GRADE 2. MODERATE REJECTION : GRADE 3. SEVERE REJECTION : GRADE 4.
67 TREATMENT OF REJECTION. for MILD, MODERATE AND SEVERE ONLY. MILD : SOLUMEDROL 1 GM IV X 3 MODERATE : RATG (Rabblt Anti Thymocyte Globulin) (THYMOGLOBULIN) 1.5 mgs/kg X 3 SEVERE : CAMPATH 30 mg IV X 1
68 FRESH SPECIMENS ARE CUT AND PROCESSED 4. ANOTHER PIECE IS FIXED IN GLUTERALDEHYDE FOR ELECTRON MICROSCOPIC STUDIES. 5. LASTLY A PIECE IS CRYOPRESERVED FOR IMMUNOLOGIC AND MOLECULAR STUDIES. 6. HEMATOXYLIN AND EOSIN STAINING IS ENOUGH FOR ROUTINE DIAGNOSTIC STUDIES.
69 Dr. G.B. Daver, Vascular & Thoracic Surgeon Dr. J. Thacker, Vascular & Thoracic Surgeon Dr. Deepak Naphade, CVT Surgeon Dr. Z.F. Udwadia, Pulmonologist Dr. Ashok Mahashur, Pulmonologist Dr. R. Soman, Physician Dr. A. Hegde, Intensivist Dr. C.K. Ponde, Cardiologist Dr. Rajani, Cardiologist
70 Dr. Navneet Kumar, Cardiologist Dr. Ameya Udyavar, Cardiologist Dr. Supriya Gajendragadkar, Anaesthetist Dr. Jacquline D mello, Anaesthetist Dr. Manju Bhutani, Anaesthetist Dr. Camilla Rodrigues, Microbiologist Dr. Anjali Shetty, Microbiologist Dr. Chitra Madivale, Histopathologist Dr. R.B. Deshpande, Histopathologist Dr. A.S. Deshpande, Blood Bank Dr. Suganthi Iyer, Asst.Director Legal & Medical
71 Dr. Jatin Kothari, Nephrologist Dr. Sirsat, Nephrologist Dr. Sunita Kalangi, Manager, Medical Coordination Dr. Sarita Khobrekar, Director, Medical Coordination Ms. Reema, Dietician Mr. Jagannath Kalugade, Perfutionist Dr. Sucheta Desai, Transplant Coordinator Residents of Chest Medicine, Critical Care medicine, Anesthesiology, Infectious diseases, Cardiology & CVTS
72 THANK YOU.
73 LUNG ALLOCATION. (MAY 4, 2005) On May 4, 2005 the historic Lung Allocation of Seniority on the wait list was changed to Scoring System, which generated a number from 0 to 100.
74 LAS (Lung Allocation Score) (0 to 100.) 1. AGE. 2. HEIGHT. 3. WEIGHT. 4. DIAGNOSIS. 5. FUNCTIONAL STATUS. 6. DIABETES. 7. ASSISTED VENTILATION. 8. SUPPLEMENTAL O2. 9. PERCENT PREDICTED FVC. 10. PA-SYSTOLIC PRESSURE. 11. MEAN PULMONARY ARTERY PRESSURE. 12. PULMONARY CAPILLARY WEDGE MEAN. 13. Current PCO Highest PCO Lowest PCO Change in PCO MWT DISTANCE IN FT. 18. S CREATININE. Factors used to predict waiting List survival. (blue) Factors used to predict post transplant survival. (underlined)
75 PULMONARY FIBROSIS. WHEN TO REFER? HISTOLOGIC OR RADIOLOGIC EVIDENCE OF USUAL INTERSTITIAL PNUEMONIA (UIP) HISTOLOGIC EVIDENCE OF FIBROTIC NON SPECIFIC INTERSTITIAL PNUEMONIA (NSIP )
76 PULMONARY FIBROSIS. WHEN TO LIST? RADIOLOGIC OR HISTOLOGICAL EVIDENCE OF UIP (USUAL INTERSTITIAL PNUEMONIA) AND ANY ONE OF THE FOLLOWING: DLCO < 30% predicted. 10% or greater decrease in FVC over 6 months. Desaturation below 88% during 6 min walk test. Honeycombing on HRCT with fibrosis score > 2 HISTOLOGICAL EVIDENCE OF NSIP AND ANY OF THE FOLLOWING: DLCO < 35% 10% or greater decrease in FVC over 6 months. 15% or greater decrease in DLCO over 6 months.
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