J.G. Allen1, E.S. Weiss1, C.A. Merlo2, W.A. Baumgartner1, J.V. Conte1, A.S. Shah1 1Johns Hopkins University School of Medicine, Baltimore, MD; 2Johns Hopkins University School of Medicine, Baltimore, MD Purpose: Few studies have been conducted examining the effect of race in human lung transplantation(LTX). The United Network for Organ Sharing(UNOS) database provides a unique opportunity to address this issue by examining outcomes of race matching for a large cohort of patients. Methods and Materials: We retrospectively reviewed the UNOS dataset to identify 11,323 adult patients receiving primary LTX between 1997 and 2007. Patients were stratified by donor/recipient race matching and further divided into groups of specific race. All cause mortality was examined with Cox proportional hazard regression incorporating 16 variables. 30d, 90d, 1yr mortality and rejection in the 1st yr were examined. Post-LTX survival was modeled via the Kaplan-Meier(KM) method. Results: Of 11,323 patients, 7,414(65%) were race matched (71% of Caucasians,n⫽7,104; 22% of African Americans,n⫽184; 28% of Hispanics,n⫽117; and 11% of Asians,n⫽9). 4,862(43%) patients died during the study. Donor-recipient race matching did not impact 30d or 90d mortality; however, 1 yr mortality was significantly decreased (OR 0.78 [0.66-0.94],p⫽0.008). Race matching decreased risk adjusted cumulative mortality (Hz ratio 0.89 [0.81-0.99],p⫽0.036). KM modeling showed a significant effect of race matching on survival. Race matching did not impact rejection in the 1st year. Notably, when deaths in the 1st year were excluded, the effect of race matching was no longer significant. Conclusions: Our study represents the largest cohort evaluating the effect of race matching in LTX. Race matching resulted in a significant improvement in long term survival. This improvement appears to be governed by survival in the 1st year after LTX. Race matching did not decrease rejection.
553 Size-Reduced Lung Transplantation: Is It a Solution for Small Recipients? G. Marulli1, M. Loy1, A. Zuin1, C. Breda1, P. Feltracco2, L. Battistella1, K.L. Oliani1, F. Rea1 1Thoracic Surgery, Padova, Italy; 2Anaesthesiology, Padova, Italy Purpose: The paucity of donor lungs has become a challenging problem, particularly for small or paediatric recipients where the difficulty in organ size matching often leads to prolonged waiting time and/or increased waiting list mortality. To allow larger lungs to be downsized for use in smaller recipients, many Centres adopted pulmonary tailoring (by means of a peripheral wedge resection or lobectomy), others used lobar transplantation, but no general agreement on this procedure is present yet. Aim of our study was to
The Journal of Heart and Lung Transplantation February 2009
compare waiting list time, perioperative complications, mortality and long term survival of patients with size-reduced lung transplantation (Group A) with recipients of size-matched lung grafts (Group B). Methods and Materials: This is a retrospective study using a prospective database of lung transplantations performed between 1996 and 2007. Group A included 22 patients who received surgical size reduction, Group B 161 patients who received standard lung transplantation. Results: Size reduction was achieved by wedge resection (n⫽8), middle lobectomy and wedge resection on left side (n⫽3), middle lobectomy and left lobar transplantation (n ⫽5) and left lobar transplantation (n⫽6). Mean waiting time was lesser in group B (19⫾18.9 vs 10⫾8.9 months, p⫽0.0003). No statistically significant difference was seen between Group A and B regarding the 30-day mortality rates (13.6% vs 9.3%, p⫽0.52), rate of bronchial healing problems (4.5% vs 8.2%, p⫽0.55) or postoperative bleeding requiring surgical revision (4.5% vs 3.1%, p⫽0.72). Also Group A and B showed a comparable long-term survival (5-year survival 49.2% vs 48.7%, p⫽0.92). Conclusions: Downsizing the lung graft either by nonanatomical resection or lobar transplantation is a safe and reliable procedure to overcome size disparity between donor and recipients. It allows enlargement of the donor pool, especially for small and paediatric recipients, with a potential to reduce waiting time and waiting list mortality. Short and long term results are comparable with standard lung transplantation.
554 Outcomes of 212 Lung Transplantations Using Extended Donor Criteria C.K.N. Wan, K. Jackson, A. Oreopoulos, P.Z.T. Wang, K.C. Stewart, J. Weinkauf, J. Mullen, D. Modry, D. Lien University of Alberta, Edmonton, AB, Canada Purpose: Despite scarcity of donor lungs, extended donor criteria remain controversial. Outcomes of lung transplantation using marginal donors were studied. Methods and Materials: Between January 2000 and February 2008, 212 single(15%) or double lung(85%) transplantations were performed utilizing extended donor lung criteria, as defined by one or more of the followings: 1)age⬎55; 2)abnormal chest radiograph; 3)PaO2:FiO2 ⬍300mmHg; 4)tobacco history⬎20 years; 5)evidence of chest trauma; 6)evidence of aspiration/sepsis; 7)previous cardiopulmonary surgery; 8)positive sputum gram stain; 9)presence of purulent secretions on bronchoscopy. Medical records on survival and bronchiolitis obliterans syndrome(BOS) were reviewed. Results: Mean age of recipients was 50⫾13. Thirty-eight percent were female. Cardiopulmonary bypass was utilized in 154 cases(73%). Except for those with positive hepatitis B or C serology, all patients received induction immunosuppression. Early mortality was 3.3%. Survival at 3-, 5-, and 7-years were 74%, 66% and 60%, while survival free from any degree of BOS were 69%, 52% and 22% respectively. Univariate analysis revealed prior thoracic surgery, small recipient chest size, post-transplant length of intubation, left lung ischemic time, and advanced coronary artery disease to be associated with overall mortality, while prior thoracic surgery, post-transplant length of intubation and donor BMI were independent predictors in multivariate analysis. On the other hand, osteoporosis was found to be the only associated variable and independent predictor of BOS posttransplant. Conclusions: Extended donor criteria for lung transplantation led to acceptable early and midterm survival. Incidence of BOS also appeared to be acceptable, at least up to midterm followup.
The Journal of Heart and Lung Transplantation Volume 28, Number 2S
J. Thekkudan, C.A. Rogers, R.S. Bonser, N.R. Banner The Royal College of Surgeons of England, London, United Kingdom
555 Older Donor for Older Recipient in Lung Transplantation Y. Toyoda, C. Bermudez, G. Speziali, S. Gilbert, J. Bhama, E. Gongora, L. Garcia, M. Zenati, R. Zomak, D. Zaldonis, B. Johnson, M. Crespo, J. Pilewski University of Pittsburgh Medical Center, Pittsburgh Purpose: Recently, older patients have increasingly been placed on the lung transplant waiting list in many centers. However, there is ethical dilemma with accepting older recipients due to donor shortage for available lungs. In this report, we evaluated the outcome of older recipients using older donors vs. younger donors to determine if it is reasonable for older recipients to receive older donor lungs. Methods and Materials: One hundred forty four lung transplants were performed by a single surgeon (YT) from March 2006 to August 2008. Retrospective analysis was conducted for 40 patients who were 65 years old or older at the time of lung transplantation. The patients were divided into two groups. Group A had donors who were younger than 50 years old and Group B 50 years old and older. Results: Idiopathic pulmonary fibrosis was the most common diagnosis (25 patients, 63%) followed by emphysema (13, 33%). Group A had 27 patients (age 68⫾1, range 65-74, 20 male and 7 female) whereas Group B had 13 patients (age 69⫾1, range 66-81, 11 male and 2 female). Double lung transplantation was performed in 12 patients (44%) in Group A and 7 (54%) in Group B (P⫽0.74). The donor age was 31⫾2 (14-49) years in Group A vs. 57⫾2 (50-73) in Group B (p⬍0.001). There were no significant differences between Group A vs. B in donor gender (15 male, 12 female vs. 9 male, 4 female), use of cardiopulmonary bypass (5 patients, 19% vs. 3 patients, 23%), cardiopulmonary bypass time (248⫾56 vs. 247⫾24 minutes), ischemic time (322⫾11 vs. 364⫾26 minutes). Postoperatively, 2 patients (7%) required ECMO for primary graft failure in Group A vs. 1 (8%) in Group B (p⫽1.0). The duration of mechanical ventilation was within 48 hours after lung transplants in 17 patients (63%) in Group A vs. 6 (46%) in Group B (p⫽0.5). The 30, 60 and 180 day survival was 100%, 93%, and 93% in Group A vs. 100%, 100%, and 92% in Group B. There was no significant difference in over-all survival between groups (p⫽0.69, Log Rank). Conclusions: It is reasonable to utilize lungs from older donors for older recipients. Long-term outcome needs to be assessed. 556 Antithymocyte Globulin Induction Therapy for Adult Heart Transplantation
Purpose: Induction therapy (IT) with antithymocyte globulin (ATG) after heart transplantation (HTx) has never been assessed in a clinical trial. We investigate trends in use of ATG and its relationship to outcome following HTx in a national cohort. Methods and Materials: Between Jul 95 and Mar 07, 2087 HTx were performed. Patients given OKT3 or IL2-receptor anatagonist, retransplants, heterotopic and multi-organ transplants were excluded (n⫽96), leaving 1991 HTx for analysis. Results: 1071 (54%) patients received IT with ATG. The proportion of patients given ATG increased from 26% in 95/6 to 80% in 06/7 (p⬍0.01). The age and gender distributions of recipients and donors were similar in the ATG and non-ATG groups (pⱖ0.27). The proportion of non-ambulatory patients was higher in the ATG group (25% vs 15%, p⬍0.01). The ATG group contained more patients with DCM (48% vs 44%) and fewer with IHD (32% vs 42%) (p⬍0.01). The median ischaemia time was longer for the ATG group (198min vs 186min, p⬍0.01). Patients in the ATG group were more likely to receive mycophenolate (34% vs 9%, p⬍0.01) and tacrolimus (7% vs 2%, p⬍0.01). The proportion of patients with eGFR⬍60ml/min/ 1.73m2 was higher in the ATG group (47% vs 40%, p⬍0.01). Survival was the same in the two groups at 1-year (81%, p⫽0.96). The number of treated rejection episodes in the 1st year was lower in the ATG group (1.24 vs 1.67, ratio 0.87, p⫽0.035), as was the proportion of patients treated for rejection (59% vs 65%, p⬍0.01). The eGFR at 1-year was, on average, 7% (95%CI 3-11%, p⬍0.01) higher for patients in the ATG group compared with the non-ATG group. The distribution of causes of death within 1-year (malignancy, primary graft dysfunction, rejection, infection or graft vasculopathy) was similar in the two groups (p⫽0.08). Conclusions: There has been a trend towards an increased use of IT. During this time the indication for HTx has changed and the severity of heart failure increased. There was no change in overall survival but ATG induction was associated with a decreased incidence of rejection and better renal function at 1-year. 557 Immunosuppressive Intensity Should Be Reduced in Heart Transplant Recipients Greater Than 70 Years of Age J.D. Pal1, J.G. Rogers2, C.A. Milano1 1Duke University, Durham, NC; 2Duke University, Durham, NC Purpose: To evaluate rejection rates and complications of immunosuppressive therapy on heart transplant recipients over the age of 70 years. Methods and Materials: A United Network of Organ Sharing (UNOS) database query was performed to investigate age-related mortality, infectious and renal complications, and rejection episodes for heart transplant recipients over the age of 70 (N⫽310) compared to patients younger than 70 (N⫽40584) from 1988 to 2006. Results: Overall one- and five- year survival for heart transplant recipients over the age of 70 was 81% and 63%, compared to 84% and 71% for recipients under 70 years of age. Hospitalizations for infectious complications were similar for the two groups at one year (17.3% vs. 17.2%), but increased amongst older survivors at five years (10.9%) compared to younger patients (7.8%). Renal dysfunction was more prevalent at one and five years in the older age group (26.6% and 35.7%) compared to recipients under 70 (18.9% and 24.5%). Rejection episodes were less common amongst older patients at both one and five years (22.3% and 21%) vs. 43.5% and 36.6% in the younger age group. Conclusions: Current immunosuppression regimens are not routinely adjusted for older heart transplant recipients. We demonstrate