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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
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Report of the ISHLT Working Group on Primary Graft Dysfunction (2005)
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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
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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
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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
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• 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
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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
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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
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PopulationType of Transplant Procedure
57%
43%
SLT BLT
Clinical Status at Transplant
68%
12%
19%
1%
Elective Hospitalized+NIV Ventilated ECMO
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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:
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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
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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
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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
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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
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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%
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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
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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.
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• 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
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Thank you for your attention…