1. LUNG TRANSPLANTATION CURRENT STATUS
Iskander Al-Githmi, MD, FRCSC-GS, FRCSC -Ts , FRCSC-CDs, FACS, FCCP
Division of Cardiothoracic Surgery
King Abdulaziz University Hospital

3. NUMBER OF LUNG TRANSPLANTS REPORTED BY YEAR AND PROCEDURE TYPE
This figure includes only the lung transplants that are reported to the ISHLT Transplant Registry. Therefore, these numbers should not be interpreted as the rate of change in lung procedures performed worldwide.
NOTE: This figure includes only the lung transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as representing changes in the number of lung transplants performed worldwide.
ISHLT
2009

4. AVERAGE CENTER VOLUME Lung Transplants: January 1, 2000 - June 30, 2008
ISHLT
2009

5. Lung Transplantation in KSA
4 transplants at KFH – Jeddah
1996 ,first single lung transplant at KFSH & RC (Riyadh )
First bilateral lung transplant at KFSH & RC (Riyadh )
1998
2001 , the lung transplant unit was established at KFSH & RC ( Jeddah)
Dec. 23,2001, the first successful bilateral lung transplant in the Middle East was performed at KFSH & RC (Jeddah)

6. KFSH&RC – Jeddah Lung Transplantation Program
Patients with end-stage lung diseases, N=13
Indications:
Pulmonary fibrosis (n=8)
Bronchiectasis (n=2)
Pulmonary HTN (n=1)
COPD (n=1)
LAM (n=1)

7. Types of transplantation:
Single lung (n=10)
Bilateral lung (n=3)
Results:
10/13 survived
Mortality 3/13 (n=1 liver failure, n=1 stroke, n=1 T.B.)
1 year survival 95 %

8. Lung transplantation in KSA
KFSH & RC ( Jeddah ) is the only active hospital performing lung transplantation in the Middle East
IPF is the commonest indication followed by Broncheictasis
95% 1 year survival

9. AGE DISTRIBUTION OF LUNG TRANSPLANT RECIPIENTS (1/1985-6/2008)
ISHLT
2009

10. DONOR AGE DISTRIBUTION FOR LUNG TRANSPLANTS (1/1985-6/2008)
ISHLT
2009

11. LUNG TRANSPLANTS: Transplant Recipient Age by Year of Transplant Transplants: January 1, 1987 – June 30, 2008
ISHLT
2009

12. Lung transplantation evaluation process
Cardiothoracic Transplant Surgeon
Transplant Pulmonologist
Transplant Coordinator
Transplant Anesthiologist
Infectious Disease
Nutritionist
Social services
Psychologist
Physiotherapist

13. Recipient Selective Criteria:
End-stage pulmonary disease with life expectancy < 2 yrs.
Absence of severe extra pulmonary diseases.
Strong motivation towards the idea of lung transplantation.
Severe functional limitation, but potential for rehabilitation.
Excellent psychosocial support.
No current smoking or substances abuse

14. Indications:
Obstructive air way disease (29%)
- COPD
- Alpha 1 antitrypsin deficiency
Idiopathic pulmonary fibrosis (19%)
Septic pulmonary disease (16%)
- Bronchiectasis
- cystic fibrosis
Primary pulmonary hypertension (11%)

15. Other Varieties (11%)
e.g. - sarcoidosis
- lymphangioliomyomatosis (LAM)
- eosinophilic granuloma

16. Contra-indications: Age > 65 years Active smoking
Poor compliance with the treatment
Severe active infections (HIV, Hepatitis B & C)

17. Con’t. Active malignancy within the past two years.
Drugs or alcohol abuse.
Dysfunction of major other organs
- renal dysfunction
- untreatable CAD or LV dysfunction
- liver dysfunction
Ventilator dependence
- high mortality
BMI < 16 and BMI > 30
Severe osteoporosis

18. Donor Selection Criteria (Standard):
Age < 55 years
ABO blood group compatibility
No significant lung diseases
Absence of chest trauma
Smoking Hx < 20 pack years
Clear CXR
PaO2 > 300mm Hg on F and PEEP 5 cm for 5 min.
Bronchoscopy – clear
Sputum gram stain- Absence of organisms

19. Donor-Recipient Matching Issues
ABO blood group is the most antigen system
Panel reactive antibodies
Size matching
Undesized: persistent pneumothorax and increase work of breathing.
Oversized: atelectasis and distortion of anatomy

20. Donor Supply Increasing gap between demand and supply Newer strategies
A. Marginal donors
Do not fill these criteria:-
1- Age < 55 yrs
2- Clear Chest X-ray
3- No smoking history
` 4- Sputum gram stain negative
5- Normal gas exchange

21. Donor Supply Living lobar transplantation
Harvesting left lower lobe from one healthy donor & right lower lobe from another ( 25% of TLC for each)
Pioneered by University of southern California (Vaughn Starns).
Impressive result in both children & adults
Associated with Significant morbidity but no fatalities reported

22. Donor Supply Non -heart beating donor (NHBD)
A donor whose death is defined by irreversible cessation of circulatory and respiratory functions (UDDA)
Period of time between a systole and retrieval is controversial , recommendation is 2-5min
NHBD contributes < 1% of the numbers of transplants in USA
In Holland 50% of cadaveric transplants are from NHBD

23. Non-heart beating donor

24. Donor Supply Xenotransplantation
Initial enthusiasm – unlimited donor supply
Hardening factors
1. Severe immune response
2. Apparent incompatibilities between the coagulation systems of the two species
European resp.journal 2003;supp

25. Reconditioning Lung Donor
Donor Supply
Reconditioning Lung Donor

26. Toronto Xvivo Lung Perfusion System

27. Shaf Keshavjee, MD,FRCSC Director of Lung Transplant Program University of Toronto

28. Lung transplantation Single or double lung Wait time -Blood Type -Size
Severity of illness
-Life expectancy while on the waiting list
-Outcome post transplant
Surgical time (6-8 hours)
Hospital stay (14-21 days)
Follow up ( life long, frequent office visits)

29. ADULT LUNG TRANSPLANTATION: Indications for Single Lung Transplants (Transplants: January June 2008)
*Other includes:
Sarcoidosis: 2.1%
Bronchiectasis: 0.4%
Congenital Heart Disease: 0.2%
LAM: %
OB (non-ReTx): 0.5%
Miscellaneous: 6.3%
ISHLT
2009

30. ADULT LUNG TRANSPLANTATION: Indications for Bilateral/Double Lung Transplants (Transplants: January June 2008)
*Other includes:
Sarcoidosis: 2.9%
Bronchiectasis: 4.5%
Congenital Heart Disease: 1.1%
LAM: %
OB (non-ReTx): 1.1%
Miscellaneous: 7.7%
ISHLT
2009

31. ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival (Transplants: January 1994 - June 2007)
Survival was calculated using the Kaplan-Meier method, which incorporates information from all transplants for whom any follow-up has been provided. Since many patients are still alive and some patients have been lost to follow- up, the survival rates are estimates rather than exact rates because the time of death is not known for all patients.
The half-life is the estimated time point at which 50% of all of the recipients have died. The conditional half-life is the estimated time point at which 50% of the recipients who survive to at least 1 year have died. Because the decline in survival is greatest during the first year following transplantation, the conditional survival provides a more realistic expectation of survival time for recipients who survive the early post-transplant period.
Survival rates were compared using the log-rank test statistic.
ISHLT
2009

32. ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival by Procedure Type and Era (Transplants: January 1990 – June 2007) Diagnosis: Idiopathic Pulmonary Fibrosis, Single Lung
Survival was calculated using the Kaplan-Meier method, which incorporates information from all transplants for whom any follow-up has been provided. Since many patients are still alive and some patients have been lost to follow- up, the survival rates are estimates rather than exact rates because the time of death is not known for all patients. Survival rates were compared using the log-rank test statistic.
ISHLT
2009

33. ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival by Procedure Type and Era (Transplants: January 1990 – June 2007) Diagnosis: Idiopathic Pulmonary Fibrosis, Double Lung
Survival was calculated using the Kaplan-Meier method, which incorporates information from all transplants for whom any follow-up has been provided. Since many patients are still alive and some patients have been lost to follow- up, the survival rates are estimates rather than exact rates because the time of death is not known for all patients. Survival rates were compared using the log-rank test statistic.
ISHLT
2009

34. ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival By Diagnosis (Transplants: January 1990 – June 2007)
Survival comparisons
Alpha-1 vs. CF: p <
Alpha-1 vs. COPD: p <
Alpha-1 vs. IPF: p <
Alpha-1 vs. Sarcoidosis: p =
CF vs. COPD: p <
CF vs. IPF: p <
CF vs. IPAH: p <
CF vs. Sarcoidosis: p <
IPAH vs. IPF: p =
COPD vs. IPF: p <
Survival was calculated using the Kaplan-Meier method, which incorporates information from all transplants for whom any follow-up has been provided. Since many patients are still alive and some patients have been lost to follow- up, the survival rates are estimates rather than exact rates because the time of death is not known for all patients. The half-life is the estimated time point at which 50% of all of the recipients have died.
Survival rates were compared using the log-rank test statistic.
ISHLT
2009

35. ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival by Gender (Transplants: January 1990 – June 2007)
Survival was calculated using the Kaplan-Meier method, which incorporates information from all transplants for whom any follow-up has been provided. Since many patients are still alive and some patients have been lost to follow- up, the survival rates are estimates rather than exact rates because the time of death is not known for all patients. The half-life is the estimated time point at which 50% of all of the recipients have died.
Survival rates were compared using the log-rank test statistic.
ISHLT
2009

36. ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival by Age Group (Transplants: January 1990 – June 2007)
Survival was calculated using the Kaplan-Meier method, which incorporates information from all transplants for whom any follow-up has been provided. Since many patients are still alive and some patients have been lost to follow- up, the survival rates are estimates rather than exact rates because the time of death is not known for all patients. The half-life is the estimated time point at which 50% of all of the recipients have died.
Survival rates were compared using the log-rank test statistic.
ISHLT
2009

48. Eur J Cardiothorac Surg 2006;30:846-851

51. Novalung

52. Novalung Technical Data ata
Gas exchange by diffusion across a plasma tight membrane
Heparin coated surface (ACT 120 – 140s)
Low shear stress (blood trauma)
Low resistance (6mmHg at 1.5 l/min)
Blood flow 0.5 – 4.5 L/min
Filling volume = 250 ml saline

53. Novalung as a bridge to lung transplantation
J Thorac Cardiovasc Surg 2006;131:719

54. Initianal experience with novalung as a bridge to lung transplant- Hannover Medical School
N=12 patients
Patients with refractory respiratory failure
Hypercapnea and acidosis despite maximal conventional ventilation
Placed on Novalung as a bridge to lung transplantation

55. Initianal experience with novalung as a bridge to lung transplant- Hannover Medical School
J Thorac Cardiovasc Surg 2006;131:719

56. Initianal experience with novalung as a bridge to lung transplant- Hannover Medical Schoo
10/12 patients successfully bridged to transplantation
8/10 survived lung transplant
Cause of death : multi-organ failure
2 prior, 2 after lung transplant

57. Conclusions
Lung transplantation is life saving procedure for end-stage lung diseases
Mortality on the waiting list remains a major problem
Reduce the gap between demands and supply i.e increase donor supply will decrease mortality on the waiting list
Novalung is a safe and valuable option to bridge patients to lung transplantation.

58. Thank you