By Transplant
| Transplant | 1 Year | 5 Years |
| Single (SL) | 70% | 40% |
| Bilateral (BL) | 70% | 48% |
EXTENDED OUTLINE
I. Introduction
A. 1963-Hardy @ U Mississippi 1st human lung transplant à 18d survival
B. 1963-83 - 44 lung transplants w/o success [bronchial anastomosis/MOF]
C. 1983 - Toronto Lung Transplant Group @ 6-yr survival
II. End-Stage lung disease
A. Obstructive lung disease
1. Chronic elevation in airway resistance
a) Decreased exp flow rates (FEV1, FVC, FEV1/FVC)
b) Air trapping ( TLC and FRC)
2. Prognostic factors = age, degree of airway obstruction (FEV1)
3. COPD
4. Alpha-1 antitrypsin deficiency emphysema
a) Lack protection against neutrophil elastase in distal airways
b) Severe bullous emphysema by 4th or 5th decade
B. Cystic fibrosis (CF) (1/2,000 live births)
1. Most common end-stage obstructive disease 1st-3rd decades
2. Thick secretions, poor ciliary fxn => mucus plugging, pulm sepsis
C. Restrictive lung disease - idiopathic pulmonary fibrosis (IPF)
1. Decreased Lung volumes and exp flow
2. Decreased diffusing capacity
D. Pulmonary hypertension
1. Primary pulmonary hypertension (PPH):Mortality correlates w/CVP >10mmHg, PA(mean) >60mmHg, CI<2L/min
2. Eisenmengers syndrome:Ca-channel blockers may [increase or decrease???] PA pressures
E. Others: sarcoidosis, chemo/RT-induced fibrosis, lymphangiomatosis
III. Recipient selection
A. Mean waiting time 9-12 mo. (Wash U) 13.5 mo. (US)
IV. Preoperative evaluation and management of recipients
A. All pts enrolled in cardiopulmonary rehab
III. Choice of procedure
A. Obstructive lung disease
1. Early single lung transplant (SLT)àhyperinflating native lung, crowding, V/Q mismatch
a) Oversizing donor lung
b) Proper preservation technique
2. SLT for: >55yo, high risk), prior surgery, asymmetric dz
3. Bilateral lung transplant (BLT) for: younger,bilat dz,small donor
B. CF (and other septic lung disease)=> BLT due to infection risk in native lung
C. IPF
1. SLT theoretically ideal- decrease compliance and PA pressures in native lung favor allograft ventilation and perfusion
2. BLT for large individual, especially with nl lung volumes
D. PPH - Ht-lung transplant, traditionally
1. SLT has been successful
a) Post-op management difficult, nearly all pulm flow to allograft
b) Late graft problem=severe V/Q mismatch
2. BLT may provide better long-term result
IV. Timing of transplantation
A. Pts w/life expectancy 12-24 mo
B. ~30% will receive transplant w/in 1 year
C. Risk of dying on the waiting list:PPH, IPF, CF >>> COPD
V. Other criteria
A. Age (not absolute): BLT=55, SLT=65
B. Ventilatory support- no longer an absolute contraindication (already listed)
C. Corticosteroid therapy - data suggest:
1. low-dose prednisone does not airway complications
2. low-dose steroids may allograft bronchial circulation
D. Prior surgery - no longer a contraindication, in general
VI. Criteria for donor lung suitability
A. 20-25% of multiple organ donors have suitable lungs
B. Size - TLC, VC estimated by height/weight - oversize 20% for SLT
C. Donor lung scarcity
1. Use marginal lungs
2. Single lung assessment (2-lumen ETT, PA clamping)
3. Living related donor (for pediatric CF patients)
Technique of Lung Preservation and Extraction
I. Lung preservation
A. Prostaglandin E-1 before inflow occlusion (vasodilatation + other benefits)
B. PA flush w/3L cold Euro-collins
C. Extraction of lungs semi-inflated w/100% O2 (grafts use it)
D. Transport under hypothermia (0-1°C)
E. Topical cooling during implantation
II. Donor lung extraction
A. Median sternotomy, dissection
1. Isolate SVC and IVC
2. Separate aorta and PA-Cardiopleg. cannula in aorta, cannulate distal PA
3. Incise posterior pericardium, exposing distal trachea
B. Graft flushing
1. Bolus PGE-1 (500 mg)
2. Inflow occlusion (ligate SVC, clamp IVC)
3. Vent R heart - transect IVC
4. X-C aorta, administer cardioplegia
5. Amputate tip of LA appendage, start lung flush
6. Flood chest w/ iced saline, ventilate w/100% O2
C. Extract heart
1. Transect cavae and aorta
2. LA incision is last, leaving a cuff of atrium
D. Extract lungs
1. Divide trachea between two firings of TA-30
2. (Divide esophagus superiorly and inferiorly)
3. Transect descending thoracic aorta
4. Transport on ice
Lung Transplantation Procedure
I. Anesthetic considerations
A. PA catheter
B. Left-sided 2-lumen ETT
C. Initial bronchoscopy and aspiration for CF patients
D. Avoid pulmonary tamponade
E. CPB for:
1. Hemodynamic instability
2. Pulmonary vascular dz
3. Poor allograft function in BLT
II. Technique
A. Incision
1. SLT-posterolateral thoracotomy
2. BLT - bilateral transverse thoracosternotomy (clamshell) {5th IC space for COPD, 4th for CF}
B. Choice of side - avoid surgery, remove better lung - in BLT, worse lung transplanted 1st
C. R/O PFO in PPH-intra-op TEE
D. In SLT, CPB is selective - trial of PA clamping
III. Lung implantation
A. Divide 1st PA branch between ligatures, the staple PA trunk
B. Mobilize both pulmonary veins (PV) intrapericardially
C. Transect bronchus-R=just proximal to RUL takeoff, L=1-2 rings above bifurcation- hemostasis
D. Topical cooling - iced gauze around graft
E. Brocnchial anastomosis
1. Continuous 4-0 mono-absorbable for membranous
2. Telescope cartilaginous arches figure-of-8 interrupted sutures
3. Ometopexy no longer used
F. PA anastomosis - 5-0 mono-non
G. LA anastomosis - 4-0 mono-non
H. De-air
1. Antegrade (release PA clamp)
2. Retrograde (release LA clamp)
I. Bronchoscopy
IV. Post-operative Management
A. ICU post-op - quantitative perfusion scan
B. Pain control - epidural
C. Ventilator
1. SLT: COPD=no PEEP, PPH=10cm PEEP x 36h
2. Weaning - PPH=sedated, paralyzed x 36h, others=early wean
D. Postural drainage (lat x 24h), chest PT
E. Hemodynamics: dopamine for diuresis, PGE-1
F. Bronchoscopy - OR, POD1, pre-extubation, and prn
G. Infection
1. Abx prophylaxis: CF - per recipient cultures; others, per donor, or ancef x 3-4d
2. HSV prophylaxis: acyclovir 200mg BID for ³ 2 yr
3. PCP:Septra-DS - one bid q M-W-F
4. Candida: nystatin
5. CMV
a) Attempt to match, avoid CMV neg recip/CMV pos donor
b) Prophylaxis=gancyclovir
H. Immunosuppression
1. Triple regimen: cyclosporine, azathioprine, corticosteroids
2. Antithymocyte globulin (ATGAM) x 8 days
V. Follow-up strategies
A. Clinical f/u - remain in town x 3 months
B. PFTs - primarily FEV1 - Monthly in 1st year
C. CXR - schedule similar to PFTs + prn
D. Bronchoscopy (FOB) with transbrochial bx (TBLB)
1. 3-4wk post-op, 3mo, 6mo, 1yr, then annually
2. Direct TBLB to areas w/infiltrates
E. Open lung bx-when TBLB inconclusive in face of clinical, physiologic deterioration
VI. Problems (clinical-pathologic entities encountered in the lung transplant recipient)
A. Acute rejection -more common than other solid-organ allografts
1. Incidence unknown - virtually all in 1st 3-4wks post-tx
2. From 1st 3-5 days post-op to years later
3. Clinical manifestation variable-malaise, mild dyspnea, fever, decreased FEV1, decreased PO2
4. Dx:FOB, TBLB => 84% sens, 100% spec (Ht-lung tx)
5. Tx: High-dose steroids, maintenance prednisone, ATGAM or OKT3 for refractory episodes
B. CMV infection
1. May mimic rejection
2. Dx by TBLB
3. Tx w/gancyclovir (documented infection)
C. Chronic rejection/Bronchiolitis Obliterans syndrome (BOS)
1. Inflammatory disorder of the small airways-histologically, dense fibrosis and scar obliterating bronchial wall and lumen
2. Prevalence as high as 50%
3. Dry or productive cough, dyspnea refractory to bronchodilators
4. Airflow obstruction with progressive ¯ in FEV1
5. Tx: Immunosuppression (empiric)-most pts will progress
D. Bronchial anastomotic complications
1. Usually result from ischemia which =>
a) Air leak or mediastinal collection (early)
b) Stenosis or malacia (late)
2. New dyspnea, stridor or wheeze
3. W/U=CXR, FOB, chest CT
4. Tx:
a) Early (dehiscence) = drainage and conservative measures
b) Late (stricture or malacia) - stent
VII. Results
A. Survival
1. 92% hospital survival
2. 70% 1-yr, 43% 5-yr
3. Small benefit of BLT vs SLT (not significant)
B. Functional results
1. FEV1, ABG, 6-minute walk improved
2. FEV1, PaO2, significantly better after BLT vs SLT
3. BLT associated w/ higher complication rate
C. Pulmonary vascular dz
1. Decreased PAS, CVP, PVRI
2. NYHA class III-IV => I-II
