www.fundacionfavaloro.org

Brain Death Lung Donors Procurement And Prediction Of Primary Graft Dysfunction ISHLT

Grade 3 After Lung Transplantation In Argentina

Bertolotti, A; Gomez , B; Absi, D; Osses, J; Caneva, J; Ahumada, R; Wagner, G; Favaloro, RR.

Favaloro Foundation University Hospital, Buenos Aires, Argentina

www.fundacionfavaloro.org

Report of the ISHLT Working Group on Primary Graft Dysfunction (2005)

www.fundacionfavaloro.org

Grading of Severity for PGD

Classification according to different time-points

•T-zero (T0): Defined as within 6 hours of final lung reperfusion.•T24, T48 and T72:Times will be measured after T0±6 hours

www.fundacionfavaloro.org

J Heart Lung Transplant 2005;24:1460–67

• Clinical Markers• Biological Markers• Lung Preservation• Methods of Preservation• Temperature and Volume of Preservation Solution• Inflation or Ventilation• Storage Temperature• Oxygenation• Preservation Solution• Retrograde Flush• Ischemic Time

www.fundacionfavaloro.org

Objectives:

• To analyze characteristics and maintenance of brain death

lung donors (BDLD) and their relationship with the

development of postoperative primary graft dysfunction

ISHLT grade 3 (PGD3) at a single center in Argentina

www.fundacionfavaloro.org

• Since 2007 the ISHLT grading system was adopted and data were collected prospectively at a single institution in Argentina.

• Retrospective / Single Institution: January 2007 to June 2011

• Lung Transplant Recipients: 81 lung transplants were performed in 77 recipients

Methods

www.fundacionfavaloro.org

Methods

• Incidence and Clasification of Primary Graft Disfunction: – Grade 0 to 3 (T0-72)

• Univariate analysis to identify potential predictors of PGD 3 at T zero (t student; Wilcoxon Mann Whitney; Chi square or Pearson) – Pre-harvest BDLD maintenance and demographic variables were

analysed

• In-hospital mortality

www.fundacionfavaloro.org

www.fundacionfavaloro.org

Indications for Transplantation

13; 16%

36; 45%

19; 23%

4; 5%

5; 6%

1; 1%

3; 4%

Bronchiectasis CF

COPD IPF

Pulmonary hypertension Others

Re-Tx

81 Transplants on 77 Recipients

www.fundacionfavaloro.org

PopulationType of Transplant Procedure

57%

43%

SLT BLT

Clinical Status at Transplant

68%

12%

19%

1%

Elective Hospitalized+NIV Ventilated ECMO

www.fundacionfavaloro.org

Population

Cardiopulmonary By pass Requirement

26%

Off Pump CPB

Preservation Solution LPDS (Perfadex™) 100%

Ischemic Time (mean±SD) 340±88 min (max.: 465 min)

CPB Time (mean±SD) 183±89 min (max.: 367 min)

Lung Donor Managment at Harvesting Procedure:•Bronchoscopy•Albumin iv 500 mg + Metilprednisolone bolus•Antegrade and retrograde flush of preservation solution (60 ml/kg)

Implant Procedure:

www.fundacionfavaloro.org

Age (mean ± SD) 31±12 years

Male 75% (61/81)

Cause of Death Stroke 40% (32/81)

Head Trauma 58% (47/81)

Smoking History 16% (13/81)

Results

Brain Death Lung Donors: General Characteristics

www.fundacionfavaloro.org

Ventilated > 48 hs 16% (13/81)

Abnormal Chest X-ray 11% (9/81)

Purulent Airway Secretions 27% (22/81)

PaO2/FiO2 (mean ± SD) 477±88

RUPV 548±66

RLPV 533±83

LUPV 537±75

LLPV 491±91

Results

BDL Donors: Respiratory Parameters

www.fundacionfavaloro.org

Results:

Vasoactive Drugs 82% (67/81)

Dopamine 55% (45/81)Dose /kg/min (mean±SD)ɣ 3.7±4.1

Norepinephrine 48% (39/81)Dose /kg/min (mean±SD)ɣ 0.09±0.16

Dop+Norep 18% (15/81)

CVP (mean±SD) 6.8±2

CVP > 9 14% (12/81)

Cardiac Arrest + CPR 8% (7/81)

Hypotension (<60 mmHg) 17% (14/81)

BDL Donors: Hemodynamic Parameters During Maintenance

www.fundacionfavaloro.org

Results

Incidence of PGD T0 to T72 (ISHLT Grading System)

(81 transplant/77 patients)

18% 25% 40%17%

Nº o

f tra

nspl

ants

PGD Grade

www.fundacionfavaloro.org

In-hospital Mortality: PGD 3 (T0)vs. PGD < 3 (T0)

Results

8

110%

20%

40%

60%

80%

100%

PGD 3 PGD <3

Death Alive

p<0,00553%

17%

www.fundacionfavaloro.org

Results:

Variables: Brain Death Lung Donor PGD 3 (n=15) PGD < 3 (66) p value

Donor Age (mean±SD) yearsDonor Age >45 years

32±1113% (2)

30±1321% (14)

0.60.3

Donor Sex (Female)Donor/Recipient Gender Missmatch: FM MF

20% (3)0% (0)20% (3)

26% (17)10% (7)

24% (16)

0.40.50.5

Cause of Death: Stroke 53% (8) 59% (39) 0.5

Head Trauma 40% (6) 39% (26) 0.5

Abnormal Chest X-ray 7% (1) 12% (8) 0.4

Smoking history 13% (2) 17% (11) 0.5

Purulent Airway Secretion 27% (4) 27% (18) 0.6

Ventilated > 48hs 20% (3) 15% (10) 0.4

PaO2/ FiO2 446±64 484±91 0.1

CVP > 8 mmHg 27% (4) 30% (20) 0.5

DopamineDopamine DoseNorepinephrineNorepinephrine DoseDop + Norep.

60% (9)3.8±3.453% (8)

0.09±0.1333% (5)

54% (36)3.9±4.3

47% (31)0.09±0.1715% (10)

0.40.90.40.90.1

Cardiac Arrest + CPR 28% (4) 4% (3) 0.006

Sistemic Hypotension (< 60 mmHg) 47% (7) 10% (7) 0.003

Prediction of PGD 3 T0: Univariate Analysis

www.fundacionfavaloro.org

Discussion:Limits of the stydy

• Retrospective analysis in a small population• There is a bias on donor selection ( most of them

were “optimal donors”)• The findings in the univariate analysis of PGD

prediction ( hypotension, cardiac arrest and CPR) failed in a multivariate analysis.

www.fundacionfavaloro.org

• BDLD characteristics and maintenance of cadaveric donors didn’t show a relationship with the development of PGD3 in this cohort of patients

• PGD 3 T0 is related to a high early mortality and is mandatory to identified predictors to avoid or diminish its incidence.

Conclusions

www.fundacionfavaloro.org

Thank you for your attention…