1. www.fundacionfavaloro.org Brain Death Lung Donors Procurement And Prediction Of Primary Graft Dysfunction ISHLT Grade 3 After Lung Transplantation In Argentina Bertolotti, A; Gomez, B; Absi, D; Osses, J; Caneva, J; Ahumada, R; Wagner, G; Favaloro, RR. Favaloro Foundation University Hospital, Buenos Aires, Argentina

2. www.fundacionfavaloro.org Report of the ISHLT Working Group on Primary Graft Dysfunction (2005)

3. www.fundacionfavaloro.org Grading of Severity for PGD Classification according to different time-points T-zero (T0): Defined as within 6 hours of final lung reperfusion. T24, T48 and T72: Times will be measured after T0±6 hours

4. www.fundacionfavaloro.org J Heart Lung Transplant 2005;24:1460–67 Clinical Markers Biological Markers Lung Preservation Methods of Preservation Temperature and Volume of Preservation Solution Inflation or Ventilation Storage Temperature Oxygenation Preservation Solution Retrograde Flush Ischemic Time

5. www.fundacionfavaloro.org Objectives: To analyze characteristics and maintenance of brain death lung donors (BDLD) and their relationship with the development of postoperative primary graft dysfunction ISHLT grade 3 (PGD3) at a single center in Argentina

6. www.fundacionfavaloro.org Since 2007 the ISHLT grading system was adopted and data were collected prospectively at a single institution in Argentina. Retrospective / Single Institution: January 2007 to June 2011 Lung Transplant Recipients: 81 lung transplants were performed in 77 recipients Methods

7. www.fundacionfavaloro.org Methods Incidence and Clasification of Primary Graft Disfunction: –Grade 0 to 3 (T0-72) Univariate analysis to identify potential predictors of PGD 3 at T zero (t student; Wilcoxon Mann Whitney; Chi square or Pearson) –Pre-harvest BDLD maintenance and demographic variables were analysed In-hospital mortality

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9. Indications for Transplantation 81 Transplants on 77 Recipients

10. www.fundacionfavaloro.org Population

11. www.fundacionfavaloro.org Population Preservation SolutionLPDS (Perfadex™) 100% Ischemic Time (mean±SD)340±88 min (max.: 465 min) CPB Time (mean±SD)183±89 min (max.: 367 min) Lung Donor Managment at Harvesting Procedure: Bronchoscopy Albumin iv 500 mg + Metilprednisolone bolus Antegrade and retrograde flush of preservation solution (60 ml/kg) Implant Procedure:

12. www.fundacionfavaloro.org Age (mean ± SD)31±12 years Male75% (61/81) Cause of DeathStroke40% (32/81) Head Trauma58% (47/81) Smoking History16% (13/81) Results Brain Death Lung Donors: General Characteristics

13. www.fundacionfavaloro.org Ventilated > 48 hs16% (13/81) Abnormal Chest X-ray11% (9/81) Purulent Airway Secretions27% (22/81) PaO2/FiO2 (mean ± SD)477±88 RUPV548±66 RLPV533±83 LUPV537±75 LLPV491±91 Results BDL Donors: Respiratory Parameters

14. www.fundacionfavaloro.org Results: Vasoactive Drugs82 % (67/81) Dopamine 55 % (45/81) Dose ɣ /kg/min (mean±SD) 3.7±4.1 Norepinephrine 48 % (39/81) Dose ɣ /kg/min (mean±SD) 0.09±0.16 Dop+Norep 18 % (15/81) CVP (mean±SD) 6.8±2 CVP > 9 14 % (12/81) Cardiac Arrest + CPR8 % (7/81) Hypotension (<60 mmHg)17 % (14/81) BDL Donors: Hemodynamic Parameters During Maintenance

15. www.fundacionfavaloro.org Results Incidence of PGD T 0 to T 72 (ISHLT Grading System) (81 transplant/77 patients) 18%25%40%17% Nº of transplants PGD Grade

16. www.fundacionfavaloro.org In-hospital Mortality: PGD 3 (T0)vs. PGD < 3 (T0) Results p<0,005 53% 17%

17. www.fundacionfavaloro.org Results: Variables: Brain Death Lung DonorPGD 3 (n=15)PGD < 3 (66) p value Donor Age (mean±SD) years Donor Age >45 years 32±11 13% (2) 30±13 21% (14) 0.6 0.3 Donor Sex (Female) Donor/Recipient Gender Missmatch: FM MF 20% (3) 0% (0) 20% (3) 26% (17) 10% (7) 24% (16) 0.4 0.5 Cause of Death: Stroke 53% (8)59% (39) 0.5 Head Trauma 40% (6)39% (26) 0.5 Abnormal Chest X-ray 7% (1)12% (8) 0.4 Smoking history 13% (2)17% (11) 0.5 Purulent Airway Secretion 27% (4)27% (18) 0.6 Ventilated > 48hs 20% (3)15% (10) 0.4 PaO 2 / FiO 2 446±64484±91 0.1 CVP > 8 mmHg 27% (4)30% (20) 0.5 Dopamine Dopamine Dose Norepinephrine Norepinephrine Dose Dop + Norep. 60% (9) 3.8±3.4 53% (8) 0.09±0.13 33% (5) 54% (36) 3.9±4.3 47% (31) 0.09±0.17 15% (10) 0.4 0.9 0.4 0.9 0.1 Cardiac Arrest + CPR 28% (4)4% (3) 0.006 Sistemic Hypotension (< 60 mmHg) 47% (7)10% (7) 0.003 Prediction of PGD 3 T0: Univariate Analysis

18. www.fundacionfavaloro.org Discussion: Limits of the stydy Retrospective analysis in a small population There is a bias on donor selection ( most of them were “optimal donors”) The findings in the univariate analysis of PGD prediction ( hypotension, cardiac arrest and CPR) failed in a multivariate analysis.

19. www.fundacionfavaloro.org BDLD characteristics and maintenance of cadaveric donors didn’t show a relationship with the development of PGD3 in this cohort of patients PGD 3 T0 is related to a high early mortality and is mandatory to identified predictors to avoid or diminish its incidence. Conclusions

20. www.fundacionfavaloro.org Thank you for your attention…