Transplantation |

The Impact of Protocolized Management for a Lobar Lung Transplantation on Posttransplant Early Outcomes FREE TO VIEW

Norihisa Shigemura, MD; Balakrishnan Mahesh, MD; Maria Crespo, MD; Matthew Morrell, MD; Joseph Pilewski, MD; James Luketich, MD; Jonathan D'Cunha, MD
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University of Pittsburgh Medical Center, Pittsburgh, PA

Chest. 2015;148(4_MeetingAbstracts):1078A. doi:10.1378/chest.2265709
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SESSION TITLE: Lung Transplantation

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Wednesday, October 28, 2015 at 04:30 PM - 05:30 PM

PURPOSE: Lobar lung transplantation (LLT) is a viable option for the recipients who are challenged by size mismatch. However, it should be also recognized that this option has additional risks to increase incidences of major complications and mortality as compared to standard LT in particular for the critically ill patients. Protocolized and multidisciplinary approach for post LLT management should be advocated.

METHODS: Critically ill patients with end-stage lung disease underwent LLT between 2009 and 2013 (n=37). Their short-term outcomes and incidence of major complications were retrospectively reviewed and compared between those who were managed with and without the ‘UPMC LLT protocol’, which includes prolonged use of inhaled nitric oxide, pulmonary artery catheter monitoring until 24hours post-extubation, strict negative fluid balance management, aggressive bronchoscopic management for surveillance and toileting as well as steroid minimizing approach for immunosuppression.

RESULTS: 37 patients received an anatomic lobectomy with individual ligation techniques at back-table followed by double lung transplantation with cardiopulmonary bypass or ECMO. Indications for transplantation included those who were on the ventilator, on ECMO prior to transplant, and LAS above 60 with size restrictions. The recipients treated with the protocol (n=20) had their 30-day mortality of 5.0% while those without (n=17) had 11%. Each group experienced one early bronchial stump dehiscence. Atypical progression of severe PGD with significantly elevated pulmonary artery pressures was experienced in 3 cases of those without the protocol (18%) where two cases were placed on ECMO afterwards. Among those with the protocol, only one case (5%) experienced this progressive PGD.

CONCLUSIONS: Our experience has demonstrated that protocolized and multi-disciplinary management are critical for success. Thus, we have adopted a systematic approach that has allowed us to advocate for LLT as a potentially viable option for critically ill patients with small chests who may not have exhausted all options.

CLINICAL IMPLICATIONS: Our largest experiences with a lobar lung transplantation for the critically sick patients have demonstrated the importance of posttransplant protocolized and multi-disciplinary management for successful transplant outcomes in this patient population with the highest risks.

DISCLOSURE: The following authors have nothing to disclose: Norihisa Shigemura, Balakrishnan Mahesh, Maria Crespo, Matthew Morrell, Joseph Pilewski, James Luketich, Jonathan D'Cunha

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