1. Lung Transplantation and Concomitant Cardiac Surgery: Is It Justified? Reshma Biniwale, M.D. Division of Cardiothoracic Surgery David Geffen School of Medicine, UCLA

2. Disclosure Statement No relevant financial relationships to disclose I will NOT discuss off label use and/or investigational use of any drugs/devices.

3. 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 2000-2013 o 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

4. 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

5. Study design and Methods Exclusion criteria: 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 χ 2 test was used for categorical variables. Patient survival was determined using Kaplan-Meier analysis; log-rank analysis was utilized for comparisons.

6. Study Endpoints Primary Endpoint: 5-year patient survival Secondary Endpoints 1) 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)

7. Incidence of Concomitant Cardiac Surgery in Lung Transplant Recipients in 4 Years Intervals CCS

8. Donor Demographics

9. Recipient Demographics

10. Transplant Characteristics

11. CCS Group PFO – patent foramen ovale TV – tricuspid valveMV – mitral valve AoV – aortic valvePV – pulmonic valve LAA – left atrial appendage AAA – ascending aortic aneurysm RAM – right atrial mass

12. Perioperative Clinical Outcomes

13. Major Adverse Cardiac Events up to 5-years Post-transplant

14. Survival Curves of Lung Transplantation Recipients with and without Concomitant Cardiac Surgery 50% for CCS 55% for Control

15. Subgroup Analysis I Kaplan-Meier Survival by Type of CCS Procedure (CABG vs. Other)

16. Subgroup Analysis II Kaplan-Meier Survival by Age of Recipients (Transplants: August 2000 – August 2013)

17. Subgroup Analysis III Kaplan-Meier Survival by Age of CCS Recipients (Age < 65 vs. Age ≥ 65)

18. 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

19. 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

20. 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.

21. Recipient Pre-Operative Right Heart Catherization Values