lung transplantation and concomitant cardiac surgery: is it justified? reshma biniwale, m.d....
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Lung Transplantation and Concomitant Cardiac Surgery: Is It
Justified?Reshma Biniwale, M.D.Division of Cardiothoracic Surgery
David Geffen School of Medicine, UCLA
Disclosure Statement
No relevant financial relationships to disclose
I will NOT discuss off label use and/or investigational use of any drugs/devices.
Study Introduction
• To determine whether early and midterm clinical outcomes of patients who undergo concomitant cardiac surgery at the time of lung transplant are equivalent to those who undergo isolated lung transplantation.
• 620 total Lung Transplant patients identified from 2000-2013o 120 CCS patients (Lung Transplant + concomitant
cardiac surgery)o Matched cohort of 120 Controls (isolated Lung
Transplant)o Criteria: Recipient Age, Era, Diagnosis, Type of
procedure
Study Inclusion Algorithm
620 Lung Transplant Procedures
500 Isolated Lung Transplant
Procedures
Matched Based on Recipient Age, Era, Diagnosis, Lung Allocation Score, and Type of Procedure
120 Lung Transplant
Procedures and CCS
120 Isolated Lung Transplant Procedures
Study design and Methods• Exclusion criteria: age<18 years, multivisceral
transplant, decreased LV function, diffuse coronary artery disease, age>70years with concomitant cardiac disease, multiple C/I
• Inclusion criteria: repairable cardiac disease, redo recipient (25/620)
• The Kruskal-Wallis rank test was used for comparisons of continuous variables between groups, while the χ2 test was used for categorical variables. Patient survival was determined using Kaplan-Meier analysis; log-rank analysis was utilized for comparisons.
Study Endpoints
• Primary Endpoint: 5-year patient survival
• Secondary Endpoints1) post-operative clinical outcomes:
primary graft dysfunction Grade III at 72 hours, ICU and hospital length of stay
2) 5-year major adverse cardiac events (MACCE)
Incidence of Concomitant Cardiac Surgery in Lung Transplant Recipients in 4 Years Intervals
2000-2004 2005-2009 2010-20130.0%
5.0%
10.0%
15.0%
20.0%
25.0%
17.1%18.3%
21.7%
Incidence of Concomitant Cardiac Surgery
CCS
Donor DemographicsVariables Control
Group(N=120)
CCS Group(N=120)
P-value
Age (years) 38.0 ± 15.0 32.4 ± 14.6 0.013*
Male Sex 76 (59.4%) 81 (63.3%) 0.662
Body Mass Index (kg/m2) 30.4 ± 13.7 26.2 ± 11.1 0.032*
Diabetes mellitus 11 (9.3%) 5 (4.3%) 0.203
Cytomegalovirus positive
77 (67.5%) 74 (67.3%) 0.966
Smoking History 48 (46.2%) 40 (38.8%) 0.287
Donor PaO2 at 100% FiO2 443.4 ± 105.0 452.3 ± 111.8 0.572
Cause of Death: 0.055
Anoxia 17 (14.3%) 16 (13.7%) -
Cerebrovascular accident
55 (35.3%) 34 (29.1%) -
Central Nervous System Tumor
0 (0%) 1 (0.9%) -
Head Trauma 42 (35.3%) 60 (51.3%) -
Other 5 (4.2%) 6 (5.1%) -
Recipient Demographics
Variables Control Group(N=120)
CCS Group(N=120)
P-value
Age (years) 56.7 ± 10.3 56.6 ± 11.3 0.624
Male Sex 79 (59.8%) 72 (54.6%) 0.350
Body Mass Index (kg/m2)
24.9 ± 4.4 25.3 ± 4.3 0.584
Diabetes mellitus 22 (18.3%) 17 (14.2%) 0.382
Systemic Hypertension 40 (33.6%) 36 (30.0%) 0.549
Cytomegalovirus positive
81 (67.5%) 76 (63.3%) 0.497
6-minute walk test (ft) 418.6 ± 455.7 406.5 ± 334.2 0.546
Diagnosis: 0.025*
Obstructive Lung Disease
31 (25.8%) 24 (20%) -
Restrictive Lung Disease
80 (66.7%) 78 (65%) -
Cystic Fibrosis 7 (5.8%) 5 (4.2%) -
Primary Pulmonary Hypertension
2 (1.7%) 13 (10.8%) -
Lung Allocation Score 49.2 ± 17.4 46.8 ± 14.6 0.610
Wait Time (days) 170.1 ± 229.1 157.5 ± 188.7 0.803
Transplant Characteristics
Variables Control Group
(N=120)
CCS Group(N=120)
P-value
Type of Transplant: 0.826
Single, Right 16 (13.3%) 15 (12.5%) -
Single, Left 19 (15.8%) 16 (13.3%) -
Double 85 (70.8%) 89 (74.2%) -
Gender Mismatch 36 (30.0%) 36 (30.0%) 0.931
Cytomegalovirus Mismatch 51 (44.7%) 50 (45.5%) 0.914
Number performed on Cardiopulmonary Bypass
90 (75%) 113 (94.2%) < 0.001*
Cardiopulmonary Bypass Time (min)
148.2 ± 102.5
193.3 ± 81.0
< 0.001*
Allograft Ischemia Time (min) 303.2 ± 82.7 326.3 ± 81.7
0.030*
Aortic Cross-Clamp Time (min) - 32.8 ± 32.7 -
Transplant Characteristics
Variables CCS Group
(N=120)
Concomitant Cardiac Procedures:
CABG x 1 17 (14.2%)
CABG x 2 4 (3.3%)
CABG x 3 1 (0.8%)
Patent Foramen Ovale Repair 66 (55.0%)
Tricuspid Valve Repair 34 (28.3%)
Mitral Valve Repair 2 (1.7%)
Pulmonic Valve Repair 1 (0.8%)
Aortic Valve Repair 2 (1.7%)
Modified Maze Procedure 16 (13.3%)
Left Atrial Appendage Ligation
6 (5%)
Ascending Aortic Aneurysm Repair
2 (1.7%)
Removal of Right Atrial Mass 1 (0.8%)
Multiple Cardiac Procedures 29 (24.2%)
CABGx1
CABGx2
CABGx3
PFO Repair
TV Repair
MV Repair
PV Repair
AoV Repair
MAZE
LAA Ligation AAA Repair RAM Removal
CCS Group
PFO – patent foramen ovaleTV – tricuspid valve MV – mitral valveAoV – aortic valve PV – pulmonic valveLAA – left atrial appendageAAA – ascending aortic aneurysmRAM – right atrial mass
Perioperative Clinical Outcomes
Variables Control Group
(N=120)
CCS Group(N=120)
P-value
Median Duration of Invasive Mechanical Ventilation (days)
2 (1-3) 2 (1-4) 0.110
Re-exploration for bleeding 10 (8.3%) 17 (12.9%) 0.153
Operative wound revision 2 (1.7%) 2 (1.7%) 1.0
Postoperative ECMO 3 (2.5%) 3 (2.5%) 1.0
PGD Grade III @ 72 hours 11 (9.6%) 10 (9.3%) 0.956
Intensive Care Unit Stay (days)
6.3 ± 7.6 8.1 ± 18.9 0.423
Hospital Length of Stay (days) 21.0 ± 17.2 26.0 ± 34.6 0.276
30-Day or In-Hospital Mortality
5 (4.2%) 1 (0.8%) 0.098
In-Hospital Cardiac Complications:
Atrial Fibrillation 26 (21.7%) 25 (18.9%) 0.875
Myocardial Infarction 0 (0%) 0 (0%) 1.0
Cerebrovascular accident 0 (0%) 0 (0%) 1.0
Major Adverse Cardiac Events up to 5-years Post-transplant
Variables Control Group
(N=120)
CCS Group(N=120)
P-value
Major Adverse Cardiac Events
5 (5.3%) 6 (5.0%) 0.758
Atrial Fibrillation 4 (2.5%) 5 (3.8%) 0.734
Operative wound revision 0 (0%) 1 (0.8%) 0.316
Redo Revascularization 0 (0%) 1 (0.8%) 0.316
Redo Valve Procedure 0 (0%) 0 (0%) 1.0
Congestive Heart Failure 0 (0%) 1 (0.8%) 0.316
Pulmonary Embolism 1 (0.8%) 0 (0%) 0.316
Survival Curves of Lung Transplantation Recipients with and without Concomitant
Cardiac Surgery
50% for CCS
55% for Control
Subgroup Analysis I
Kaplan-Meier Survival by Type of CCS Procedure(CABG vs. Other)
Subgroup Analysis II
Kaplan-Meier Survival by Age of Recipients(Transplants: August 2000 – August 2013)
Subgroup Analysis III
Kaplan-Meier Survival by Age of CCS Recipients(Age < 65 vs. Age ≥ 65)
Limitations
• Single institution, retrospective• Mean follow up 6.6 years• No data on patients evaluated for lung transplant who were
not acceptable candidates• QOL data not analyzed
Conclusions
• Similar early and midterm clinical outcomes can be achieved in patients who undergo concomitant cardiac surgery at the time of lung transplantation as compared to isolated lung transplant recipients
• Offering lung transplantation to a highly selected group of patients who need concomitant cardiac surgery may be justified
• Continued expansion of the recipient pool needs to weighed against a limited supply of donor organs
Acknowledgment
Co-Authors:David Ross, M.D.Amit Iyengar, M.S.Oh Jin Kwon, B.S.Curtis Hunter, M.D.Jamil Aboulhosn, M.D.David Gjertson, Ph.D.Abbas Ardehali, M.D.
Division of Cardiothoracic Surgery:Murray Kwon M.D.Ahmad Khan M.D.Richard J. Shemin M.D.
Division of Pulmonology:Joseph Lynch III, M.D.Rajan Saggar, M.D.David Sayah, M.D.Michael Shino, M.D.Sam Weigt, M.D. John Belperio, M.D.Ariss Derhovanessian, M.D.
Division of Cardiology:Jamil Aboulhosn, M.D.Olcay Aksoy, M.D.Eric Yang, M.D.
Recipient Pre-Operative Right Heart Catherization Values
Variables Control Group(N=120)
CCS Group(N=120)
P-value
Systolic Pulmonary Arterial Pressure
(mmHg)
42.5 ± 16.2 51.0 ± 20.7 0.001*
Diastolic Pulmonary Arterial Pressure
(mmHg)
18.4 ± 8.8 21.9 ± 10.5 0.009*
Mean Pulmonary Arterial Pressure
(mmHg)
30.5 ± 12.5 41.3 ± 16.7 <0.001*
Pulmonary Vascular Resistance (dynes/cm5)
310.8 ± 244.0
498.3 ± 373.3 <0.001*
Cardiac Output (L/min) 5.2 ± 1.2 5.2 ± 1.3 0.975
Cardiac Index (L/min/m2)
2.9 ± 0.7 2.8 ± 0.7 0.451