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

Report of the ISHLT Working Group on Primary Graft Dysfunction (2005)

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

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

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

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

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

Indications for Transplantation 81 Transplants on 77 Recipients

Population

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:

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

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

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

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

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

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) Donor Sex (Female) Donor/Recipient Gender Missmatch: FM MF 20% (3) 0% (0) 20% (3) 26% (17) 10% (7) 24% (16) 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± 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± % (5) 54% (36) 3.9±4.3 47% (31) 0.09± % (10) Cardiac Arrest + CPR 28% (4)4% (3) Sistemic Hypotension (< 60 mmHg) 47% (7)10% (7) Prediction of PGD 3 T0: Univariate Analysis

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.

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

Thank you for your attention…