06/04/2013 ISHLT. 2 International Conference on Respiratory Physiotherapy ARIR Genova, March 21 23, 2013
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1 LUNG TRANSPLANTS The Journal of Heart and Lung Transplantation, International Conference on Respiratory Physiotherapy ARIR Genova, March 21 23, 2013 LUNG TRANSPLANTATION:STATE OF THE ART L. Santambrogio lants Number of Transp Bilateral/Double Lung Single Lung PATHOLOGY The Journal of Heart and Lung Transplantation, 2012 SURVIVAL The Journal of Heart and Lung Transplantation, CF IPF COPD Alpha-1 IPAH Re-Tx 100 CF (N=5,608) COPD (N=11,948) IPF (N=7,540) s % of transplants Survival (%) Transplant Year ISHLT Years 1
2 QUALITY OF LIFE The Journal of Heart and Lung Transplantation, 2012 LUNG TRANSPLANT Potential donor alert ANTHROPOMETRIC DATA: Age, sex, weight, height CV(m) = 6,103 x h (meters) 0,028 x a 4,654 CV(f) = 4,664 x h (meters) 0, x a 3,284 FUNCTIONAL DATA: PaO2 AT 100% FiO2 with 5 PEEP fiberbronchoscopy Chest X-ray LUNGS IN THE BAG BACK TABLE PREPARATION ORGAN ARRIVAL 2
3 EXTRA-CORPOREAL CIRCULATION If serious hypoxemia, hypercapnia, p pulmonary hypertension, or hemodynamic dysfunction Central Peripheral DIAGNOSIS Severe Respiratory Failure Lung transplant Management process THERAPY Lung Specialist CF Center Pathologist Thoracic Surgeon Physiotherapist Anesthesiologist REFERRAL LISTING TX FOLLOW UP Collaboration in the decision- making process POST-OPERATIVE OPERATIVE MANAGEMENT Immunosuppression: Induction therapy (IL-2) Maintenance therapy Calcineurin inhibitors: Cyclosporine (Neoral, Sandimune), Tacrolimus (FK-506, Prograf) Antimetabolite drugs: Azathioprine (Imuran), Mycophenolate (Cellcept) Corticosteroids Monitoring of spirometry parameters trans-bronchial biopsies Continous physiotheray Evaluation of the onset of complications: Rejection -BOS Infections International Guidelines for the Selection of Lung Transplant Candidates American Journal of Respiratory and Critical Care Medicine, 1998 More than 6,400 lung transplants have been performed since the first successful operations in the early 1980s (1). Lung transplant programs now exist in many countries. Internationally, the number of donor organs available is far fewer than the number of patients with end-stage lung disease. Because of this, many candidates die on the waiting list, and the average wait to receive a donor organ may approach 2yr (2). Overall survivals are between 60 and 65% at 2 yr and approximately 40% at 5yr (1). Lung transplantation remains a developing field within pulmonary medicine and thoracic surgery. 3
4 International Guidelines for the Selection of Lung Transplant Candidates The Journal of Heart and Lung Transplantation, 2006 Lung transplantation is now a generally accepted therapy for the management of awide range of severe lung disorders, with evidence supporting quality of life and survival benefit for lung transplant recipients (2). However, the number of donor organs available remains far fewer than the number of patients with end-stage lung disease who might potentially benefit from the procedure. LUNG TRANSPLANT Shortage of lung donors Exponential increase in the number of patients on waiting list, without a proportional amount of increase in the number of lung donors. Eurotransplant Functional Pathology Lung Transplant SHORTAGE OF LUNG DONORS HIGH MORTALITY ON WAIT LIST SHORTAGE OF DONORS Increase the donor pool: Possible strategies: Legislative system Sensibilisation campaign to raise publec awareness and training of hospital personelle Allocation Decrease the number of retransplants Potential donor management Expanded donor criteria 4
5 School Hospital PUBLIC OPINION HOSPITAL STAFF Education and training Intensive Care Unit (medical and nursing personelle Surgeons DONOR MANAGEMENT Background The lung is a fragile organ The quality of the donor lung is correlated with the probability bilit of PGD in the recipient i (short-term term outcome), which in turn is a risk factor for BOS (long-term outcome) Only in 15% of donors lungs are considered suitable for transplantation (Chang AC, 2006) DONOR MANAGEMENT Brain Death Instability: Loss of vasomotor control / perfusion deficit Loss of thermoregulation Hormonal imbalance (diabetes insipidus, hypothyroidism) Neurogenic polmonary edema (interstitial edema + alveolar hemorrhage) 5
6 ECMO: Emergency National Program 2010 ECMO and LUNG TRANSPLANT Bridging urgency of wait list patients Rationale: -CO2 removal - oxygenation - hemodynamic support (right ventricular) Advantages: - Patients not intubated - Patients are awake, physical therapy (PT) is possible - less anticoagulation is needed BRIDGE LT - OUR EXPERIENCE AGE (yrs) 1 58 FIBROSIS DIAGNOSIS ECMO PRE (DAYS) VM PRE 21 VV YES DONOR MARGINAL (INFECTIVE) OUTCOME (AT 60 DAYS) Our experience: 2 24 CF 14 VV YES OPTIMAL 3 34 FIBROSIS 1,5 VV NO MARGINAL (AGE) 4 46 BOS (RE-TX 3 yrs) 12 VV NO OPTIMAL 5 22 CF (B. CEPACIA) 2 VV NO OPTIMAL 6 19 CF BOS (8 MTHS) VV NO MARGINAL (GAS EXCHANGE) DECEASED 7 25 CF 11 VV NO MARGINAL (EVLP) 8 24 CF 3 VV YES OPTIMAL 9 33 CF 9 VV NO OPTIMAL FIBROSIS 5 VV NO MARGINAL (GAS EXCHANGE) CF 8 VV YES MARGINAL (EVLP) DECEASED FIBROSIS 4 VV NO MARGINAL (GAS EXCHANGE) CF 9 VV YES MARGINAL (GAS EXCHANGE) 6
7 EXPANDED CRITERIA DONORS Ex-Vivo Lung Perfusion (EVLP) Preservation possibility to optimally conserve the harvested organ for long periods of time Resuscitation possibility to treat contusion, atelectasis, aspiration, infections, neurogenic edema in marginal lungs. Conditioning possibility of immune and genic therapy in order to induce tollerance Our experience: clinical stage 1st CASE M 24 yrs Medical history CF (Pseudomonas) 2000 left pleurodesis 2011 put on waiting list for Tx Our experience: clinical stage Marginal potential donor alert 03/2011 Exacerbation of infection Hypoxic-hypercapnic respiratory failure Admission in ICU and non- invasive ventilation Awake ECMO Urgent lung transplant list 7
8 En bloc double lung harvest Tracheal intubation Lung ventilation Gas exchange improvement 8
9 Topical cooling BLTx on vv-ecmo (1 in the world) 14 marzo 2011 Timing 1st Case h. 3:00 CROSS-CLAMPING CLAMPING (PO2 190 mmhg) h. 6:00 DONOR LUNGS IN OPERATING ROOM h. 7:00 PREPARATION LUNGS EX SITU h. 7:30 START OF WARM EVLP h. 9:00 PO2 300 mmhg h. 9:30 END OF COLD EVLP h. 10:00 PO2 530 mmhg h. 10:30 INTUBATION h. 11:30 INCISION h. 15:30 RIGHT LUNG DECLAMPING h. 19:00 LEFT LUNG DECLAMPING h. 21:00 TRASFER IN I.C.U. Post-operativeoperative course Immediate functional recovery of transplanted organs Extubation after 12 hrs Patient removed from ECMO after 24 hrs from lung transplant 9
10 Discharge on postop. day 16 TRAPIANTO DI POLMONE Conclusions PFR: FVC 3,01 l (53%) FEV 1 2,90 l (61%) EGA in aa: po 2 76 mmhg pco 2 43 mmhg ph 7,46 so 2 97,3% Future Decrease in mortality of patients on waiting list Increase of organ procurement Increased survival of transplanted patients Research Guidelines URGENCY ECMO MARGINAL DONOR EVLP NON HEART BEATING DONOR LESS BOS ANTI-REJECTION DRUGS 10
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