1. An International Case Study of Lung Transplantation
Selim M. Arcasoy, M.D.
Professor of Medicine
Medical Director, Lung Transplantation Program
Director, Interstitial Lung Disease Program
New York-Presbyterian Hospital
Columbia University Medical Center

2. The Impact of Lung Disease
Chronic, progressive and disabling symptoms
Breathlessness, cough, sputum production
Decline in functional status and quality of life
Greater than 35 million Americans have lung disease
Financial cost to society (>$150 billion per year)
Decreased work days and productivity, disability, costs of medical care
Premature mortality
Number 3 killer in the U.S. behind heart disease & cancer
400,000 Americans die of lung disease every year
Responsible for one in six deaths

3. Four Major Lung Diseases Treatable with Lung Transplantation
Chronic obstructive pulmonary disease (COPD)
Emphysema/chronic bronchitis due to tobacco smoking or alpha1-antitrypsin deficiency (genetic)
12 million have COPD, 12 million are under-diagnosed
Pulmonary fibrosis (scarring of the lungs)
End result of more than 200 diseases
Affects >500,000 Americans
Cystic fibrosis (CF): A genetic disease
~30,000 Americans have CF with 1,000 new cases/yr
Pulmonary hypertension

4. Cystic Fibrosis Patient 1
9-year old girl
Diagnosed with CF at age 4 months
Recurrent respiratory infections and low body weight
Developed pulmonary MRSA infection 2 years prior
Nine hospitalizations for intravenous antibiotics
Lung function at 30% of predicted for her age and needs to use 3 LPM of supplemental oxygen
Family makes contact with our Lung Txp Program
Required tests ordered and performed in Turkey
Tests reviewed and family moves to U.S. for evaluation

5. Cystic Fibrosis Patient 1
First visit on April 6, 2007
Further testing and consultations
Multidisciplinary team discussion
Placed on the active lung transplant list
Recurrent infections while awaiting transplant
Lung transplantation on November 25, 2009

7. Cystic Fibrosis Patient 2. A Case of Good Fortune
Older sister of our first patient
Diagnosed at age 7 years
Much healthier than her younger sister
Attending school in the U.S. as her family moved for her sister’s transplant
Becomes sicker in 2010
Lung function drops from 51% to 22%
Hospitalized with fever and respiratory failure
Urgent lung transplant evaluation and listing
Lung transplantation performed on Sep 17, 2010

9. End-stage Lung

11. And, here they are….

12. Stages of Respiratory Disease and Failure

13. History of Lung Transplantation
JD Hardy, MD
June 11, 1963
36 patients underwent lung transplantation between 1963 and 1975 with no long-term survivors
Introduction of cyclosporine in 1978
First successful heart-lung Tx performed in 1981, single lung Tx in 1983 and double lung Tx in 1986
First successful kidney transplant
First successful liver transplant
First successful heart transplant

14. Number of Lung Transplants in the Last 3 Decades
JHLT. 2013 Oct; 32(10):
2013

15. Who is a Candidate for Lung Transplant? General Guidelines
YES
Advanced lung disease with limited lifespan and severe functional limitation
Lack of alternative therapies
Demonstrated compliance with therapy and follow-up
Strong family support NO
Active or recent cancer
Advanced dysfunction of a major organ system
Untreatable infection
Substance addiction
Documented noncompliance and lack of family support
A complex decision that requires extensive evaluation
and multidisciplinary team discussion

16. Lung Transplantation on a Scale Risk-Benefit Balance
Benefits
Survival
Function
Quality of Life
Risks
Mortality
Morbidity
Complexity
Patient
Expectations
Patient characteristics
Type of lung disease
Other medical illnesses
Prognosis without transplant

17. Steps From Initial Evaluation to Transplantation
First visit to meet the transplant team
Focus on initial patient screening, assessment of patient/family motivation, and education
Extensive testing and consultations
Multidisciplinary team meeting for a decision
Potential outcomes:
Immediate active listing
Accepted as a potential future candidate, but needs to meet certain goals or get sicker
Denial because of contraindications

19. Transplant Listing and The Call
Patients are placed on the active national list
All listed patients are assigned a Lung Allocation Score (LAS) based on their clinical characteristics
Age, disease, lung, heart and kidney function, labs
Score ranging from 0 (less ill) to 100 (gravely ill)
Waiting period with significant regional variation
Donor and recipient matched by blood type and size
Transplant has to occur within 6 to 8 hours after removal of lungs from the donor

21. Ex Vivo Lung Perfusion “Lung In A Box”

23. Extracorporeal Membrane Oxygenation (ECMO)

24. Case 3

25. Before And After

28. NewYork-Presbyterian Hospital Lung Transplant Volume Per Year
New Program 28

29. New York-Presbyterian Hospital Lung Transplant Survival 7/01/2001 - 12/31/2012 (n = 559)
NYPH vs UNOS 1-year: 91% vs 84%
5-year: 68% vs 53%
10-year: 47% vs 28%

30. Functional Status Before and After Lung Transplantation
This figure shows the functional status reported on the 1-year, 3-year, 5-year and 10-year annual follow-ups. Because all follow-ups between April 1994 and June 2006 were included, the bars do not include the same patients.

31. Employment Status Before and After Lung Transplantation
This figure shows the employment status reported on the 1-year, 3-year, 5-year and 10-year annual follow-ups. Because all follow-ups between April 1994 and June 2006 were included, the bars do not include the same patients.