TIMING FOR TRANSPLANT: ARE WE ALWAYS LATE?
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1 SCDU CARDIOCHIRURGIA Università degli Studi di Torino Città della Salute e della Scienza Direttore: Prof. Mauro Rinaldi TIMING FOR TRANSPLANT: ARE WE ALWAYS LATE? Mauro Rinaldi
2 LUNG TRANSPLANTATION Transplantation is now a generally accepted therapy for the management of a wide range of severe lung disorders Evidence supporting improved quality of life and survival benefit for transplant recipients
3 TIMING OF LISTING J Heart LungTransplant 2015;34:1 15
4 PUSHING THE LIMITS AF M, 48 y-old (1969), B group, 49 Kg x 180 cm 1979 ASD O Secundum 10 y-old 1993 ASD closure (sternotomy) 2002 PH center (PA 98/42/63 IC 2.6) 2003 sildenafil 2007 ambrisentan (PA 104/24/53, IC 3.9) 2012 FA, Giant PA, LCMS compression: BMS of LM 2014 SOB NYHA III 2016 mpa 47, CI 3,2, 6MWT 465m: Indication to URGENT transplant LISTING
5 CHEST X-RAY
6 LUNG CT SCAN Right Ventricle Septal shift Left Ventricle
7 LUNG CT SCAN Right PA Pulmonary Artery Left PA LM stent
8 PULMONARY HYPERTENSION TYPES OF TRANSPLANT HEART AND LUNG TX DOMINO-TX LUNG TRANSPLANT
9 HEART AND LUNG TRANSPLANTATION IN THE PAST CONCERNS about RV dysfunction NOWADAYS only in case of severe LV dysfunction systolic or DYASTOLIC LV dysfunction
10 INDICATIONS HEART AND LUNG TRANSPLANTATION EISENMENGER SYNDROME due to congenital heart disease not amenable for conservative correction PRIMARY PH with severe LV dysfunction LUNG DISEASE with end-stage cardiac disease
11 POST-TX HEART REMODELING PRE-TRAPLANT SIX MONTHS AFTER TX
12 DOMINO TRANSPLANTATION Yacoub M: 1987 PPH recipient: HLTx Use the heart of the recipient of a H-L Tx as a graft for a recipient with end-stage heart disease with pulmonary hypertension
13 Adult Lung Transplants Indications (Transplants: January 1995 June 2016) Diagnosis SLT (N=18,207) BLT (N=36,046) TOTAL (N=54,253) COPD 7,266 (39.9%) 9,539 (26.5%) 16,805 (31.0%) IIP 6,449 (35.4%) 6,990 (19.4%) 13,439 (24.8%) CF 218 (1.2%) 8,266 (22.9%) 8,484 (15.6%) ILD-not IIP 1,078 (5.9%) 1,925 (5.3%) 3,003 (5.5%) A1ATD 797 (4.4%) 1,912 (5.3%) 2,709 (5.0%) Retransplant 922 (5.1%) 1,269 (3.5%) 2,191 (4.0%) IPAH 88 (0.5%) 1,481 (4.1%) 1,569 (2.9%) Non CF-bronchiectasis 67 (0.4%) 1,413 (3.9%) 1,480 (2.7%) Sarcoidosis 312 (1.7%) 1,026 (2.8%) 1,338 (2.5%) PH-not IPAH 135 (0.7%) 690 (1.9%) 825 (1.5%) LAM/tuberous sclerosis 146 (0.8%) 381 (1.1%) 527 (1.0%) OB 73 (0.4%) 395 (1.1%) 468 (0.9%) CTD 140 (0.8%) 282 (0.8%) 422 (0.8%) Cancer 7 (0.0%) 27 (0.1%) 34 (0.1%) Other 509 (2.8%) 450 (1.2%) 959 (1.8%) 2017 JHLT Oct; 36(10):
14 Adult Lung Transplants Procedure Type within Indication, by Year 100% 90% 80% Bilateral/Double Lung Transplant Single Lung Transplant % of Transplants 70% 60% 50% 40% 30% 20% 10% 0% AT Def COPD IPF IPAH 2015 JHLT Oct; 34(10): 33(10):
15 SINGLE LUNG TRANSPLANTATION PULMONARY HYPERTENSION Optimization of donors pool Potential reduction of waiting list time and mortality More difficult clinical management High risk of V/O mismatch (IRI and BOS) Emergency strategy only
16 BILATERAL LUNG TRANSPLANTATION PULMONARY HYPERTENSION Lower risk of IRI / PGD Absence of V/O mismatch Two grafts for one patient
17 100 Adult Lung Transplants Kaplan-Meier Survival by Diagnosis (Transplants: January 1990 June 2013) Alpha-1 (N=2,904) CF (N=7,336) COPD (N=15,064) Survival (%) IPF (N=10,438) IPAH (N=1,584) Sarcoidosis (N=1,136) All pair-wise comparisons were significant at p < 0.05 except Alpha-1 vs. IPAH, Alpha-1 vs. Sarcoidosis, COPD vs. IPAH, COPD vs. Sarcoidosis, IPAH vs. Sarcoidosis Median survival (years): Alpha-1=6.5; CF=8.5; COPD=5.5; IPF=4.7; IPAH=5.7; Sarcoidosis= Years 2015 JHLT Oct; 34(10): 33(10):
18 Adult Lung Transplants Kaplan-Meier Survival by Diagnosis Conditional on Survival to 3 Months (Transplants: January 1990 June 2013) Alpha-1 (N=2,522) CF (N=6,510) COPD (N=13,446) IPF (N=8,844) IPAH (N=1,203) Sarcoidosis (N=964) Survival (%) All pair-wise comparisons were significant at p < 0.05 except Alpha-1 vs. Sarcoidosis, COPD vs. IPF, CF vs. IPAH, and IPAH vs. Sarcoidosis 20 0 Median survival (years): Alpha-1=7.8; CF=10.0; COPD=6.2; IPF=5.8; IPAH=9.2; Sarcoidosis= Years 2015 JHLT Oct; 34(10): 33(10):
19 TURIN LUNG TRANSPLANT PROGRAM From January 1993 to October 2017: 338 Lung Transplants Mean Age ± yrs Gender 98 (33,3%) F/ 198 (66,3%) M DL / SL tx 204 (60.3%) / 134 (39.7%)
20 TURIN LUNG TRANSPLANT PROGRAM From January 1993 to October 2017: 338 Lung Transplants 30 EVLP program
21 NEJM April 2011
22 TURIN LUNG TRANSPLANT PROGRAM From January 2008 to June 2018: 195 Lung Transplants 40 pts 20% 60 pts 11pts 7% 31% 9 pts 5% 72 pts 37% Vascular IPF COPD CF Other
23 TURIN LUNG TRANSPLANT PROGRAM From January 2008 to June 2018: 195 Lung Transplants Age at transplant Male sex Waiting time on the waiting list Mechanical ventilation before transplant ECMO before transplant Urgent LTx Ex vivo lung perfusion Bilateral lung transplantion Mean ischemic time 49 ± 15 (11-69) years 123 (62%) pts 256 ± 329 (1-2402) days 18 (9%) pts 14 (7%) pts 23 (12%) pts 32 (16%) pts 157 (80%) pts 376 ± 184 ( ) min
24 TURIN LUNG TRANSPLANT PROGRAM NEED OF ECMO AFTER LTX ECMO after LTx (n=25) No ECMO after LTx (n=170) p value spap 51 ± 20 mmhg 39 ± 13 mmhg < 0.01 mpap 36 ± 16 mmhg 25 ± 9 mmhg < 0.01 Need for CPB during transplant 17 (68%) pts 43 (25%) pts < 0.01 Mechanical ventilation before TX 6 (24%) pts 12 (7%) pts < 0.01 ECMO before transplant 6 (24%) pts 8 (5%) pts < 0.01 Urgent LTx 7 (28%) pts 16 (9%) pts < 0.01 Donor age 49 ± 10 years 43 ± 14 years < 0.01
25 TURIN LUNG TRANSPLANT PROGRAM ECMO after LTx (n=25) No ECMO after LTx (n=170) p Number of transfused RBC units* 5 [IQR 2-11] 1 [IQR 0-3] < 0.01 Length of ICU stay* 28 days [IQR ] 6 days [IQR 3-15] < 0.01 Length of mechanical ventilation* 8.2 days [IQR ] 1 day [IQR 0.8-3] < 0.01 In-hospital mortality 11 (44%) 13 (7.6%) < 0.01 * median
26 TURIN LUNG TRANSPLANT PROGRAM INDEPENDENT RISK FACTORS FOR POST-TX ECMO RR 3.1 RR 3.3 RR 1.6 RR 7.8 ** ** ** ** p<0.05
27 IPF and COPD POPULATION From July 2005 to October 2016: 109 Lung Transplants IPF COPD Mean age Gender Mean PAP 54 pts 55 pts 56.6±8.3 yrs 29 F / 80 M 27.4±8.2 mmhg 66 pts 61% 43 pts 39% COPD 32 pts 75% PH NO PH IPF 11 pts 25%
28
29 PULMONARY HYPERTENSION POPULATION From July 2005 to October 2016: 175 Lung Transplants 3 Pts 4 Pts Eisenmenger PAH 125 pts 72% 50 pts 28% 43 Pts Parenchymal PH NO PH
30 LONG TERM SURVIVAL OF LUNG TRANSPLANTED PTS WITH OR WITHOUT PH NO HYPERTENSIVE PH (30) HYPERTENSIVE PH (43) Cumulative Proportion Surviving p= Survival Time (days)
31 Cattedra di Cardiochirurgia UNIVERSITA DEGLI STUDI DI TORINO ASOU CITTA DELLA SALUTE E DELLA SCIENZA PROGRAMMA DI TRAPIANTO ORGANI TORACICI Direttore: Prof. M. Rinaldi Cardiochirurgia Prof. M. Boffini Dott. D. Ricci Dott. M. Attisani Dott. C. Barbero Dott. F. Scalini Dott. E. Simonato Malattie Infettive Prof. Di Perri Prof. F. De Rosa Direzione Sanitaria Dott. A. Scarmozzino Anestesia e Rianimazione Prof. L. Brazzi Dott.ssa A. Trompeo Dott.ssa D. Pasero Dott. A. Sales Dott. V. Fanelli Dott. A. Costamagna Pneumologia Prof.ssa Bucca Dott. P. Solidoro Dott.ssa D. Libertucci Dott.ssa L. Mercante Chirurgia Toracica Prof. A. Oliaro Dott. P. Lausi
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