1. Optimizing lung transplant outcomes in the adult and pediatric patient. Cynthia S. Herrington, MD Associate Professor of Surgery Keck School of Medicine University of Southern California

2. Optimizing Lung Transplant Outcomes Holy SRTR International practices and outcomes and where the pitfalls exist --ISHLT How to asses a program when the wheels fall off the bus

3. The Adults Optimizing Lung Transplant Outcomes

4. AGE DISTRIBUTION OF ADULT LUNG TRANSPLANT RECIPIENTS BY ERA 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

5. ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival (Transplants: January 1994 - June 2008) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

6. ADULT LUNG TRANSPLANTATION Procedure Type within Indication, by Year 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

7. ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival by Era (Transplants: January 1988 – June 2008) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

8. ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival by Age Group (Transplants: January 1990 – June 2008) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

9. ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival by Gender (Transplants: January 1990 – June 2008) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

10. ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival By Diagnosis (Transplants: January 1990 – June 2008) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

11. ADULT LUNG TRANSPLANTATION Kaplan-Meier Survival By Diagnosis Conditional on Survival to 1 Year (Transplants: January 1990 – June 2008) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

12. ADULT LUNG TRANSPLANTS (1996-6/2008) Risk Factors for 1 Year Mortality (N=13,079) *Other = All diagnoses other than COPD, IPAH, IPF, cystic fibrosis, pulmonary fibrosis, bronchiectasis, alpha-1 antitrypsin deficiency, retransplant and LAM. Reference group = COPD/Emphysema, Single lung 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

13. ADULT LUNG TRANSPLANTS (1996-6/2008) Risk Factors for 1 Year Mortality (N=13,079) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

14. ADULT LUNG TRANSPLANTS (1996-6/2008) Risk Factors for 1 Year Mortality (N=13,079) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

15. ADULT LUNG TRANSPLANTS (1996-6/2008) Borderline Significant Risk Factors for 1 Year Mortality (N=13,079) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

16. ADULT LUNG TRANSPLANTS (1/1996-6/2008) Risk Factors for 1 Year Mortality Recipient Age 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

17. ADULT LUNG TRANSPLANTS (1996-6/2004) Risk Factors for 5 Year Mortality (N=7,609) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

18. ADULT LUNG TRANSPLANTS (1996-6/2004) Risk Factors for 5 Year Mortality (N=7,609) Reference group = COPD/Emphysema, Single lung 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

19. ADULT LUNG TRANSPLANTS (1996-6/2004) Risk Factors for 5 Year Mortality (N=7,609) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

20. ADULT LUNG TRANSPLANTS (1996-6/2004) Borderline Significant Risk Factors for 5 Year Mortality (N=7,609) *Other = All diagnoses other than COPD, IPAH, IPF, cystic fibrosis, pulmonary fibrosis, bronchiectasis, alpha-1 antitrypsin deficiency, retransplant and LAM. Reference diagnosis group = COPD/Emphysema, Single lung 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

21. ADULT LUNG TRANSPLANTS (1/1996-6/2004) Risk Factors for 5 Year Mortality Recipient Age 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

22. ADULT LUNG RECIPIENTS Longitudinal Analysis Functional Status of Surviving Recipients (Follow-ups: April 1994 – June 2009) For the Same Patients 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

23. ADULT LUNG RECIPIENTS Employment Status of Surviving Recipients (Follow-ups: April 1994 – June 2009) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

24. ADULT LUNG RECIPIENTS: Rehospitalization Post-transplant of Surviving Recipients (Follow-ups: April 1994 - June 2009) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

25. POST-LUNG TRANSPLANT MORBIDITY FOR ADULTS Cumulative Prevalence in Survivors within 1 Year Post-Transplant (Follow-ups: April 1994 - June 2009) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

26. POST-LUNG TRANSPLANT MORBIDITY FOR ADULTS Cumulative Prevalence in Survivors within 1 and 5 Years Post-Transplant (Follow-ups: April 1994 - June 2009) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

27. POST-LUNG TRANSPLANT MORBIDITY FOR ADULTS Cumulative Prevalence in Survivors within 10 Years Post-Transplant (Follow-ups: April 1994 - June 2009) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

28. FREEDOM FROM BRONCHIOLITIS OBLITERANS SYNDROME For Adult Lung Recipients (Follow-ups: April 1994-June 2009) Conditional on Survival to 14 days 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

29. FREEDOM FROM BRONCHIOLITIS OBLITERANS SYNDROME STRATIFIED BY INDUCTION USE For Adult Lung Recipients (Follow-ups: April 1994-June 2009) Conditional on Survival to 14 days 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

30. FREEDOM FROM MALIGNANCY For Adult Lung Recipients (Follow-ups: April 1994-June 2009) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

31. ADULT LUNG TRANSPLANT RECIPIENTS: Cause Of Death (Deaths: January 1992- June 2009) CAUSE OF DEATH 0-30 Days (N = 1,966) 31 Days – 1 Year (N = 3,387) >1 Year – 3 Years (N = 3,073) >3 Years – 5 Years (N = 1,737 ) >5 Years – 10 Years (N = 2,014) >10 Years (N = 483) BRONCHIOLITIS6 (0.3%)159 (4.7%)781 (25.4%)508 (29.2%)507 (25.2%)95 (19.7%) ACUTE REJECTION74 (3.8%)61 (1.8%)48 (1.6%)10 (0.6%)15 (0.7%)1 (0.2%) LYMPHOMA1 (0.1%)86 (2.5%)63 (2.1%)28 (1.6%)46 (2.3%)23 (4.8%) MALIGNANCY, OTHER4 (0.2%)100 (3.0%)202 (6.6%)151 (8.7%)219 (10.9%)47 (9.7%) CMV096 (2.8%)29 (0.9%)5 (0.3%)4 (0.2%)0 INFECTION, NON-CMV396 (20.1%)1,205 (35.6%)710 (23.1%)329 (18.9%)363 (18.0%)81 (16.8%) GRAFT FAILURE557 (28.3%)589 (17.4%)591 (19.2%)327 (18.8%)379 (18.8%)87 (18.0%) CARDIOVASCULAR213 (10.8%)144 (4.3%)118 (3.8%)82 (4.7%)99 (4.9%)36 (7.5%) TECHNICAL162 (8.2%)76 (2.2%)18 (0.6%)8 (0.5%)12 (0.6%)6 (1.2%) OTHER553 (28.1%)871 (25.7%)513 (16.7%)289 (16.6%)370 (18.4%)107 (22.2%) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

32. Children Optimizing Lung Transplant Outcomes

33. AGE DISTRIBUTION OF PEDIATRIC LUNG RECIPIENTS By Year of Transplant Analysis includes living donor transplants NOTE: This figure includes only the pediatric lung transplants that are reported to the ISHLT Transplant Registry. Therefore, these numbers should not be interpreted as the rate of change in pediatric lung procedures performed worldwide. 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

34. NUMBER OF CENTERS REPORTING PEDIATRIC LUNG TRANSPLANTS BY CENTER VOLUME Analysis includes living donor transplants 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

35. PEDIATRIC LUNG TRANSPLANTS: DIAGNOSIS DISTRIBUTION BY LOCATION Transplants between January 2000 and June 2009 NOTE: Unknown diagnoses were excluded from this tabulation. Total number of transplants reported: Europe = 237 North America = 498 Other = 41 Analysis includes living donor transplants 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

36. LUNG TRANSPLANTATION Kaplan-Meier Survival by Age Group (Transplants: January 1990 - June 2008) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

37. PEDIATRIC LUNG TRANSPLANTATION Kaplan-Meier Survival by Procedure Type (Transplants: January 1990 - June 2008) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

38. PEDIATRIC LUNG TRANSPLANTATION Kaplan-Meier Survival by Age Group (Transplants: January 1990 - June 2008) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

39. PEDIATRIC LUNG TRANSPLANTATION Conditional Kaplan-Meier Survival by Age Group (Transplants: January 1990 - June 2008) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

40. PEDIATRIC LUNG TRANSPLANTATION Kaplan-Meier Survival by Donor Type for Recipients Age 12-17 Years (Transplants: January 1990 - June 2008) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

41. PEDIATRIC LUNG RE-TRANSPLANTS Between January 1994 and June 2009 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

42. PEDIATRIC LUNG RETRANSPLANTS Survival for Transplants Performed Between January 1994 and June 2008 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

43. PEDIATRIC LUNG RECIPIENTS Longitudinal Analysis Functional Status of Surviving Recipients For the Same Patients (Follow-ups: April 1994-June 2009) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

44. PEDIATRIC LUNG RECIPIENTS Rehospitalization Post-transplant of Surviving Recipients (Follow-ups: April 1994 - June 2009) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

45. POST-LUNG TRANSPLANT MORBIDITY FOR PEDIATRICS Cumulative Prevalence in Survivors within 1 Year Post-Transplant (Follow-ups: April 1994 - June 2009) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

46. Optimizing the outcomes…..evaluate program vulnerabilities by doing root cause analysis on each death Take risks proportional to the stability of the program Optimizing Lung Transplant Outcomes

47. ADULT LUNG TRANSPLANT RECIPIENTS: Cause Of Death (Deaths: January 1992- June 2009) CAUSE OF DEATH 0-30 Days (N = 1,966) 31 Days – 1 Year (N = 3,387) >1 Year – 3 Years (N = 3,073) >3 Years – 5 Years (N = 1,737 ) >5 Years – 10 Years (N = 2,014) >10 Years (N = 483) BRONCHIOLITIS6 (0.3%)159 (4.7%)781 (25.4%)508 (29.2%)507 (25.2%)95 (19.7%) ACUTE REJECTION74 (3.8%)61 (1.8%)48 (1.6%)10 (0.6%)15 (0.7%)1 (0.2%) LYMPHOMA1 (0.1%)86 (2.5%)63 (2.1%)28 (1.6%)46 (2.3%)23 (4.8%) MALIGNANCY, OTHER4 (0.2%)100 (3.0%)202 (6.6%)151 (8.7%)219 (10.9%)47 (9.7%) CMV096 (2.8%)29 (0.9%)5 (0.3%)4 (0.2%)0 INFECTION, NON-CMV396 (20.1%)1,205 (35.6%)710 (23.1%)329 (18.9%)363 (18.0%)81 (16.8%) GRAFT FAILURE557 (28.3%)589 (17.4%)591 (19.2%)327 (18.8%)379 (18.8%)87 (18.0%) CARDIOVASCULAR213 (10.8%)144 (4.3%)118 (3.8%)82 (4.7%)99 (4.9%)36 (7.5%) TECHNICAL162 (8.2%)76 (2.2%)18 (0.6%)8 (0.5%)12 (0.6%)6 (1.2%) OTHER553 (28.1%)871 (25.7%)513 (16.7%)289 (16.6%)370 (18.4%)107 (22.2%) 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

48. ADULT LUNG RECIPIENTS Maintenance Immunosuppression at Time of Follow-up For follow-ups between January 2002 through June 2009 Analysis limited to patients receiving prednisone NOTE: Different patients are analyzed in Year 1 and Year 5 Analysis is limited to patients who were alive at the time of the follow-up 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

49. ADULT LUNG RECIPIENTS Kaplan-Meier Survival by Maintenance Immunosuppression Combinations Conditional on Survival to 1 Year (Transplants: January 2000-June 2008) Analysis limited to patients receiving prednisone 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

50. ADULT LUNG TRANSPLANTATION: Indications for Single Lung Transplants (Transplants: January 1995 - June 2009) *Other includes: Sarcoidosis: 2.0% Bronchiectasis: 0.4% Congenital Heart Disease: 0.3% LAM: 0.9% OB (non-ReTx): 0.5% Miscellaneous:5.3% 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

51. ADULT LUNG TRANSPLANTATION: Indications for Bilateral/Double Lung Transplants (Transplants: January 1995 - June 2009) *Other includes: Sarcoidosis: 3.0% Bronchiectasis: 4.4% Congenital Heart Disease: 1.3% LAM: 1.2% OB (non-ReTx): 1.2% Miscellaneous:5.8% 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

52. ADULT LUNG TRANSPLANTS (1/1996-6/2008) Risk Factors for 1 Year Mortality 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

53. ADULT LUNG TRANSPLANTS (1/1996-6/2008) Risk Factors for 1 Year Mortality Center Volume 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

54. ADULT LUNG TRANSPLANTS (1/1996-6/2004) Risk Factors for 5 Year Mortality 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

55. ADULT LUNG TRANSPLANTS (1/1996-6/2004) Risk Factors for 5 Year Mortality Donor Age 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141

56. ADULT LUNG TRANSPLANTS (1/1996-6/2004) Risk Factors for 5 Year Mortality Center Volume 2010 ISHLT J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141