mental health , characteristic of mentally healthy person .pptx
Mira Klein: Lung Transplantation after ex vivo lung perfusion
1. Lung transplantation after ex vivo lung perfusion:
Is the quality of reconditioned donor organs as
good as the standard ones?
16TH EUROPEAN CONFERENCE ON PERFUSION EDUCATION AND
TRAINING IN BARCELONA
1 OCTOBER 2016
MIRA KLEIN, HIRSLANDEN ZURICH, KALAIDOS UNIVERSITY
MARIANNE SCHÄRLI, KALAIDOS UNIVERSITY
Mira Klein 16th ECoPEaT, Barcelona, 1 October 2016 1
2. DISCLOSURE OF CONFLICT OF INTEREST
THERE IS NO CONFLICT OF INTEREST!
Mira Klein 16th ECoPEaT, Barcelona, 1 October 2016 2
3. Mira Klein 3
INTRODUCTION
• Lung transplantation (LTX) the only chance for long-term survival for
patients with end-stage lung diseases
• Only 15 – 30 % of available donor lungs are suitable for transplantation
(van Raemdonck et al., 2009)
• To expand the usage of suitable organs, ex vivo lung perfusion (EVLP) has
been established for marginal donor lungs
• Three different protocols used worldwide: «Toronto», «Lund», «Organ-
Care-System»
• Equipment, perfusate composition, perfusion and ventilation strategy
16th ECoPEaT, Barcelona, 1 October 2016
4. Mira Klein 16th ECoPEaT, Barcelona, 1 October 2016 4
RESEARCH QUESTION
«Has a pre-treatment of donor lungs with ex vivo lung
perfusion an impact on the early clinical outcome after
lung transplantation compared to lungs conventionally
transplanted?»
5. Mira Klein 5
LUNG TRANSPLANTATION – STANDARD CRITERIA
(ISHLT INTERNATIONAL SOCIETY OF HEART AND LUNG TRANSPLANTATION)
• Donor age < 55 years
• < 20 pack-years smoking history
• Matching size donor/recipient
• PF ratio (paO2 / FiO2) > 300 mmHg (40 kPa)
• Absence of infection
• Absence of purulent bronchial secretion
• Compatibility of blood groups
• No history of chest trauma
• No history of cardio-pulmonary surgery
16th ECoPEaT, Barcelona, 1 October 2016
6. Mira Klein 6
LUNG TRANSPLANTATION – STANDARD
PROCEDURE – COLD STORAGE
• After explantation: Cold flush ante- and retrograde 60 ml/kg donor weight
• Extracellular solution (contains dextran 40, sodium, potassium, glucose –
Perfadex®; Vitrolife, Gothenburg, Sweden)
• Cold storage for transport, 4 – 8 °C
• Inflation to 50% of total capacity with FiO2 50%
• Ischemic time < 6 h (< 8 h)
• Relative risk for 1-year-mortality increasing after 4.5 h (Christie, Edwards &
Kucheryavaya; 2010)
16th ECoPEaT, Barcelona, 1 October 2016
7. Mira Klein 16th ECoPEaT, Barcelona, 1 October 2016 7
EX VIVO LUNG PERFUSION - GOALS
• Increase number of usable donor lungs by reconditioning and reassessing
marginal organs primarily rejected for transplantation
• Safe usage of doubtful donor lungs
• Decrease mortality on the waiting lists
8. Mira Klein 8
EX VIVO LUNG PERFUSION - STRATEGY
• Simulation of physiologic in vivo situation
• Ventilation and perfusion of the normothermic lung
• Recruitment of atelectasis
• Reconditioning under physiologic circumstances
• Reassessment of organ function
• Bronchoscopic clearence
• Removal of pulmonary thrombus
• Improvement of microvascular circulation
• Recovering by preservation of normal metabolism
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9. Mira Klein 9
EX VIVO LUNG PERFUSION - CONCEPT
• Reconditioning: Perfusion with oxygenated Steen Solution® (XVIVO
Perfusion, Sweden) and ventilation
• After reaching normothermia reassessment of organ function
• During reassessment perfusion with a deoxygenated solution (oxygenator
is «ventilated» with gas-mixture of 93% CO2 and 7% N2) to imitate venous
blood composition in the pulmonary artery
• FiO2 100% and pO2 > 40 kPa (300 mmHg) or FiO2 21% and pO2 > 13 kPa
(98 mmHg) and pCO2 < 6 kPa (45 mmHg) lungs will be accepted to be
transplantable
• Conservation of lungs until transplantation
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10. Mira Klein 10
MATERIALS AND METHODS
• Systematic literature review; selection of 11 clinical trails (2009 – 2015)
• Identification of two compareable groups: Standard procedure (StLTX) and
LTX after EVLP (EVLP-LTX)
• Analysis of early clinical outcomes after Lung Transplantation
• Parameters: Postoperative ventilation hours (MV), postoperative length of
ICU (LOS-ICU) and hospital stay (LOS-HOS), postoperative 30-day/1-year
survival
• Interviews with four experts to validate findings from literature research
16th ECoPEaT, Barcelona, 1 October 2016
12. No significant differences could be found between the two groups
(EVLP-LTX and StLTX)
Mira Klein 12
RESULTS AND FINDINGS
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13. Mira Klein 13
DISCUSSION
• EVLP offers a reliable tool to expand donor pool for lung transplantation
• Safety and reliability of the procedure were shown in different studies
• But… The procedure is expensive, demands time and requires a number of
specialized staff
• Usability depends on the location of transplantation center, social and
health systems of the country
• No significant differences between the three used EVLP-protocols could be
found
• All procedures are comparable to the standard protocol
• Experts confirm the findings of literature
• Individual motivation for choosing a protocol
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14. Mira Klein 16th ECoPEaT, Barcelona, 1 October 2016 14
CONCLUSION
• Treatment of donor lungs with EVLP has no negative impact on the early
postoperative outcome after lung transplantation.
• The number of available and useable donor lungs increased after
implementation of EVLP.
15. Mira Klein 15
REFERENCES
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Boszo, S., Vasanthan, V., Luc, J. G., Kinaschuk, K., Freed, D., & Nagendran, J. (2015). Lung Transplantation From Donors After Circulatory death Using Ex Vivo Lung Perfusion. Canadian Respiratory
Journal, 22 (1), 47-51.
Christie, J., Edwards, L., & Kucheryavaya, A. (2010), 27th official adult lung and heart-lung transplant report. The Registry of the International Society for Heart and Lung Transplantation (29),
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Zych, B., Popov, A. F., Stavri, G., Bashford, A., Bahrami, T., Amrani, M., et al. (2012). Early Outcomes of Bilateral Sequential Single Lung Transplantation After Ex Vivo Lung Evaluation and
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