Rates Of Primary Graft Dysfunction Research Articles

Impaired esophagogastric junction relaxation and lung transplantation outcomes.

The implications of impaired esophagogastric junction relaxation (i.e. esophagogastric junction outflow obstruction and achalasia) in lung transplants recipients (LTRs) are unclear. Thus, we examined the prevalence and clinical outcomes of LTRs with an abnormally elevated integrated relaxation pressure (IRP) on high-resolution manometry before lung transplantation (LTx). After IRB approval, we reviewed data on LTRs who underwent LTx between January 2019 and August 2022 with a preoperative median IRP >15mmHg. Differences in overall survival and chronic lung allograft dysfunction (CLAD)-free survival between LTRs with a normalized median IRP after LTx (N-IRP) and those with persistently high IRP (PH-IRP) were assessed using Kaplan-Meier curves and the log-rank test. During the study period, 352 LTx procedures were performed; 44 (12.5%) LTRs had an elevated IRP before LTx, and 37 (84.1%) completed a postoperative manometry assessment (24 [70.6%] males; mean age, 65.2 ± 9.1years). The median IRP before and after LTx was 18.7 ± 3.8mmHg and 12 ± 5.6mmHg, respectively (P < 0.001); the median IRP normalized after LTx in 24 (64.9%) patients. Two-year overall survival trended lower in the N-IRP group than the PH-IRP group (77.2% vs. 92.3%, P =0.086), but CLAD-free survival (P =0.592) and rates of primary graft dysfunction (P =0.502) and acute cellular rejection (P =0.408) were similar. An abnormally elevated IRP was common in LTx candidates; however, it normalized in roughly two-thirds of patients after LTx. Two-year survival trended higher in the PH-IRP group, despite similar rates of primary graft dysfunction and acute cellular rejection as well as similar CLAD-free survival between the groups.

Early Outcomes in Patients With LVAD Undergoing Heart Transplant via Use of the SherpaPak Cardiac Transport System.

Heart transplant (HT) in recipients with left ventricular assist devices (LVADs) is associated with poor early post-HT outcomes, including primary graft dysfunction (PGD). As complicated heart explants in recipients with LVADs may produce longer ischemic times, innovations in donor heart preservation may yield improved post-HT outcomes. The SherpaPak Cardiac Transport System is an organ preservation technology that maintains donor heart temperatures between 4 °C and 8 °C, which may minimize ischemic and cold-induced graft injuries. This analysis sought to identify whether the use of SherpaPak versus traditional cold storage was associated with differential outcomes among patients with durable LVAD undergoing HT. Global Utilization and Registry Database for Improved Heart Preservation-Heart (NCT04141605) is a multicenter registry assessing post-HT outcomes comparing 2 methods of donor heart preservation: SherpaPak versus traditional cold storage. A retrospective review of all patients with durable LVAD who underwent HT was performed. Outcomes assessed included rates of PGD, post-HT mechanical circulatory support use, and 30-day and 1-year survival. SherpaPak (n=149) and traditional cold storage (n=178) patients had similar baseline characteristics. SherpaPak use was associated with reduced PGD (adjusted odds ratio, 0.56 [95% CI, 0.32-0.99]; P=0.045) and severe PGD (adjusted odds ratio, 0.31 [95% CI, 0.13-0.75]; P=0.009), despite an increased total ischemic time in the SherpaPak group. Propensity matched analysis also noted a trend toward reduced intensive care unit (SherpaPak 7.5±6.4 days versus traditional cold storage 11.3±18.8 days; P=0.09) and hospital (SherpaPak 20.5±11.9 days versus traditional cold storage 28.7±37.0 days; P=0.06) lengths of stay. The 30-day and 1-year survival was similar between groups. SherpaPak use was associated with improved early post-HT outcomes among patients with LVAD undergoing HT. This innovation in preservation technology may be an option for HT candidates at increased risk for PGD. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04141605.

Beating Heart Transplant Procedures Using Organs From Donors With Circulatory Death

The use of ex vivo normothermic organ perfusion has enabled the use of deceased after circulatory death (DCD) donors for heart transplants. However, compared with conventional brain death donation, DCD heart transplantation performed with ex vivo organ perfusion involves an additional period of warm and cold ischemia, exposing the allograft to multiple bouts of ischemia reperfusion injury and may contribute to the high rates of extracorporeal membrane oxygenation usage after DCD heart transplantation. To assess whether the beating heart method of DCD heart transplantation is safe and whether it has an acceptable rate of extracorporeal membrane oxygenation use postoperatively. This case series includes 10 patients with end-stage heart failure undergoing DCD heart transplantation at a single academic medical center from October 1, 2022, to August 3, 2023. Data were analyzed from October 2022 to August 2023. Using a beating heart method of implantation of the donor allograft. The main outcome was primary graft dysfunction necessitating postoperative initiation of mechanical circulatory support. Survival and initiation of mechanical circulatory support were secondary outcomes. In this case series, 10 consecutive patients underwent DCD heart transplantation via the beating heart method. Ten of 10 recipients were male (100%), the mean (SD) age was 51.2 (13.8) years, and 7 (70%) had idiopathic dilated cardiomyopathy. Ten patients (100%) survived, and 0 patients had initiation of extracorporeal membrane oxygenation postoperatively. No other mechanical circulatory support, including intra-aortic balloon pump, was initiated postoperatively. Graft survival was 100% (10 of 10 patients), and, at the time of publication, no patients have been listed for retransplantation. In this study of 10 patients undergoing heart transplantation, the beating heart implantation method for DCD heart transplantation was safe and may mitigate ischemia reperfusion injury, which may lead to lower rates of primary graft dysfunction necessitating extracorporeal membrane oxygenation. These results are relevant to institutions using DCD donors for heart transplantation.

Intraoperative Extracorporeal Support during Lung Transplantation: Not Just for the High-Risk Patient.

The use of intraoperative mechanical support during lung transplantation has traditionally been a controversial topic. Trends for intraoperative mechanical support strategies swing like a pendulum. Historically, cardiopulmonary bypass (CPB) was the modality of choice during transplantation. It provides full hemodynamic support including oxygenation and decarboxylation. Surgical exposure is improved by permitting the drainage of the heart and provides more permissive retraction. CPBs contain drainage reservoirs with hand-held pump suction catheters promoting blood conservation through collection and re-circulation. But CPB has its disadvantages. It is known to cause systemic inflammation and coagulopathy. CPB requires high doses of heparinization, which increases bleeding risks. As transplantation progressed, off-pump transplantation began to trend as a preferable option. ECMO, however, has many of the benefits of CPB with less of the risk. Outcomes were improved with ECMO compared to CPB. CPB has a higher blood transfusion requirement, a higher need for post-operative ECMO support, a higher re-intubation rate, high rates of kidney injury and need for hemodialysis, longer ICU stays, higher incidences of PGD grade 3, as well as overall in-hospital mortality when compared with ECMO use. The focus now shifts to using intraoperative mechanical support to protect the graft, helping to reduce ischemia-reperfusion injury and allowing for lung protective ventilator settings. Studies show that the routine use of ECMO during transplantation decreases the rate of primary graft dysfunction and many adverse outcomes including ventilator time, need for tracheostomy, renal failure, post-operative ECMO requirements, and others. As intraoperative planned ECMO is considered a safe and effective approach, with improved survival and better overall outcomes compared to both unplanned ECMO implementation and off-pump transplantation, its routine use should be taken into consideration as standard protocol.

Early elevated donor-derived cell-free DNA levels in heart transplant recipients following precision-controlled cardiac transport system or ice-cooled organ transport.

Recent innovations in temperature-controlled cardiac transportation allow for static hypothermic preservation of transplant organs during transportation. We assessed differences in donor-derived cell-free DNA (dd-cfDNA) using the SherpaPak cardiac transport system (SCTS) and traditional ice transportation. Single-organ heart transplant recipients between January 2020 and January 2022 were included if they had dd-cfDNA measures ≤6weeks post-transplant along with the baseline biopsy at 6weeks as part of the surveillance protocol and no biopsy-confirmed rejection ≤90 days. Elevated dd-cfDNA ≥.20% were compared between groups using logistic regression including a subject effect. Of 65 hearts transplanted, 30 were transported with SCTS and 35 on ice. Recipient characteristics were similar between groups. Donors in the SCTS group were older (34vs. 40 years, p=.04) with a longer total ischemic time (171vs. 212 min, p=.002). Recipients in the SCTS group had a greater risk of elevated dd-cfDNA unadjusted and adjusted for donor age, and prolonged ischemic times>3.5h (Unadjusted odds ratio: 4.9, 95%-CI: 1.08-22.5, p=.039 and Adjusted odds ratio: 5.5, 95%-CI: 1.03-29.6, p=.046). Primary graft dysfunction rates and 1-year mortality were comparable between groups. Elevated dd-cfDNA in patients procured with SCTS may indicate that graft injury was not negated relative to ice transport. However, there were no clinical differences noted in short or long-term outcomes including mortality despite a longer ischemic time in the SCTS group.

The Role of Recipient Thyroid Hormone Supplementation in Primary Graft Dysfunction After Heart Transplantation: A Propensity-Adjusted Analysis

To investigate whether recipient administration of thyroid hormone (liothyronine [T3]) is associated with reduced rates of primary graft dysfunction (PGD) after orthotopic heart transplantation. Retrospective cohort study. Single-center, university hospital. Adult patients undergoing orthotopic heart transplantation. A total of 609 adult heart transplant recipients were divided into 2 cohorts: patients who did not receive T3 (no T3 group, from 2009 to 2014), and patients who received T3 (T3 group, from 2015 to 2019). Propensity-adjusted logistic regression was performed to assess the association between T3 supplementation and PGD. After applying exclusion criteria and propensity-score analysis, the final cohort included 461 patients. The incidence of PGD was not significantly different between the groups (33.9% no T3 group v 40.8% T3 group; p=0.32). Mortality at 30 days (3% no T3 group v 2% T3 group; p=0.53) and 1 year (10% no T3 group v 12% T3 group; p=0.26) were also not significantly different. When assessing the severity of PGD, there were no differences in the groups' rates of moderate PGD (not requiring mechanical circulatory support other than an intra-aortic balloon pump) or severe PGD (requiring mechanical circulatory support other than an intra-aortic balloon pump). However, segmented time regression analysis revealed that patients in the T3 group were less likely to develop severe PGD. These findings indicated that recipient single-dose thyroid hormone administration may not protect against the development of PGD, but may attenuate the severity of PGD.

The association with organ procurement techniques and early cardiac transplant outcomes using cardiac MRI.

Heart transplantation (HT) has historically been limited by organ availability. Use of donation after circulatory death (DCD) donors addresses this limitation by utilizing previously unused hearts through use of the Organ Care System (OCS). This study aimed to determine the impact of procurement and transportation method on allograft structure and function using early post-transplant cardiac magnetic resonance imaging (MRI). Patients who underwent HT at our institution from February 1, 2020, through April 30, 2021 who underwent cardiac MRI imaging<60 days from transplant were included. Recipient and donor characteristics, clinical outcomes, and MRI findings were compared between those who underwent DCD transplantation using the OCS device (DCD-OCS), brain dead donation (DBD) using the OCS device (DBD-OCS), and DBD transported via cold storage (DBD-cold storage) using one-way analysis of variance. A total of 85 patients underwent HT with a cardiac MRI during the study period. Thirty-one (36%) patients received a DCD organ, 16 (19%) received a DBD-OCS organ and 38 (45%) received a DBD-cold storage organ. Rates of primary graft dysfunction (PGD) were significantly higher in DCD transplants (19.5% DCD vs. .0% DBD-OCS and 5.3% DBD-cold storage; p<.050 across three groups), but with no differences in mortality or rejection. There were no differences in cardiac MRI findings between the three transplant types, including presence of gadolinium hyperenhancement after transplant (all p>.050). We observed no differences in early cardiac MRI findings between patients that received DCD and DBD-OCS heart transplants compared with those receiving DBD-cold storage transplants.

The Effect of Ideal/Standard Donor and Marginal Donor Use on Primary Graft Dysfunction After Lung Transplantation in Turkey.

The transplantation waiting list is getting longer day by day with the spread of lung transplantation and awareness of it. However, the donor pool cannot keep up with this rate. Therefore, nonstandard (marginal) donors are widely used. By studying the lung donors presented at our center, we aimed to raise awareness of the donor shortage and compare clinical outcomes in recipients with standard and marginal donors. The data from recipients and donors of lung transplants performed at our center between March 2013 and November 2022 were retrospectively reviewed and recorded. Transplants with ideal and standard donors were classified as group 1, and those with marginal donors were classified as group 2. Primary graft dysfunction rates, intensive care unit, and hospital stay days were compared. Eighty-nine lung transplants were performed. A total of 46 recipients were in group 1 and 43 were in group 2. There were no differences between groups in the development of stage 3 primary graft dysfunction. However, a significant difference was found in the marginal group for developing any stage primary graft dysfunction. Donors were mostly from the western and southern regions of the country and from the education and research hospitals. Because of the donor shortage in lung transplantation, transplant teams tend to use marginal donors. Stimulating and supportive education for healthcare professionals to recognize brain death and public education to raise awareness about organ donation are necessary to spread organ donation throughout the country. Although our results using marginal donors are similar with the standard group, each recipient and donor should be assessed individually.

The Glasgow Experience of Extended Myocardial Protection: A Novel Method of Implantation to Reduce Primary Graft Dysfunction After Heart Transplant

Around 2000 heart transplants are performed in Europe annually. The rates of primary graft dysfunction in Europe are among the highest in the world. With increasing demand for organs and the limited supply of donors, novel techniques such as ex vivo normothermic perfusion have garnered incre-asing interest. We present a series of patients who underwent heart transplant at our unit in which we used a novel implantation technique to reduce primary graft dysfunction. We compared our experience with the novel method detailed in our article (Glasgow experience group) with a contemporary UK cohort (2015-2016) of patients (control group). We performed multivariable logistic regression to compare the Glasgow experience with the control group with primary graft dysfunction as the outcome measure. We adjusted for donor age, recipient diabetes mellitus, urgent listing status, bypass time, and total ischemic time. Among 194 patients in both cohorts, 140 patients (72.1%) were men and 36 (18.6%) had ischemic cardiomyopathy. The odds ratio of primary graft dysfunction in the control group was 2.99 (95% CI, 1.02- 8.75) compared with the Glasgow experience group. Our novel approach was associated with significant reductions in primary graft dysfunction, with a trend toward improved 1-year survival. Larger studies are needed to show differences after further adjustment for known confounders of primary graft dysfunction. We believe this novel technique is safe, cost-effective, and reproducible.

Triaging donor lungs based on a microaspiration signature that predicts adverse recipient outcome

Aspiration is a relative contraindication to accepting donor lungs for transplant and is currently assessed by visual inspection of the airways via bronchoscopy. However, this method is limited as it does not assess for microaspiration. Bile acids measured in large airway bronchial wash (LABW) samples have been shown to be a marker of aspiration in lung transplant recipients. Herein, we investigate the utility of measuring total bile acids (TBA) in donor LABW to predict performance of donor lungs and recipient outcomes. TBA was measured in 605 consecutive lung donors at the Toronto Lung Transplant Program. TBA levels were compared in donor lungs deemed unsuitable for transplant, requiring further assessment on ex vivo lung perfusion (EVLP), and those suitable for direct transplantation using Mann-Whitney-U tests. Relationships between LABW TBA concentrations and recipient outcomes were evaluated using multivariable Cox-PH models and log-rank analysis. Donor TBA was highest in lungs deemed unsuitable for transplant and correlated with clinical assessment of aspiration. LABW TBA concentration correlated with calcium, decreased pH, and increased pro-inflammatory mediators in EVLP perfusate. TBA cut-off of 1245 nM was able to differentiate donor lungs directly declined from those suitable for direct transplantation with a 91% specificity (AUROC: 73%). High donor TBA status was associated with the increased rate of primary graft dysfunction, longer time to extubation, and shorter time to chronic lung allograft dysfunction. In a large retrospective cohort, we observed that donor LABW TBA was associated with suitability of donor lungs for transplant, performance of the organ on EVLP, and adverse recipient outcomes.

782. Infectious Complications of Lung Transplant for COVID-Associated Lung Injury (CALI)

Abstract Background More than 200 orthotopic lung transplants (OLT) have been performed in the United States for patients (pts) with severe CALI. While some outcomes have been reported to generally be good, we conducted this study to describe the infectious outcomes. Methods After IRB approval, a retrospective case review was conducted of pts at Northwestern Memorial Hospital who had undergone OLT for CALI between June 1, 2020 and January 31, 2022. Data was collected from our Enterprise Data Warehouse and primary chart review to describe pts demographics and epidemiology of infectious complications. Results 35 OLTs were included (33 bilateral, 2 single lung; see Table 1). In the two weeks prior to transplant, 65.7% of pts were treated for bacterial, fungal, or mycobacterial infections (Table 2). Post-transplant, 32 (91.4%) of OLTs developed infections (Table 2), with most (28, 80%) developing pneumonia within 30 days of transplant. Five (14.3%) pts had airway complications, 7 (20%) pts required hemodialysis, and 3 (8.6%) pts died within one year of follow-up. Conclusion Infections remain a significant cause of morbidity post-OLT for CALI. Enhanced immunosuppression, long ICU stays post-tx, high rates of primary graft dysfunction and deconditioning likely contributed to this high rate of infection. A matched control group is being collected to compare these outcomes to other OLT pts. Disclosures Michael G. Ison, MD MS, GlaxoSmithKline: Advisor/Consultant|GlaxoSmithKline: Grant/Research Support.

Research Highlights

Research Highlights

Does Overnight Heart Transplantation Lead to Worse Outcomes? Results from a High Volume Transplant Center

<h3>Purpose</h3> Prior studies showed an association between nighttime surgery and worse outcomes after kidney and liver transplants. We evaluated if outcomes are inferior after nighttime heart transplants. <h3>Methods</h3> An institutional registry identified 1087 adult heart transplants between 2010 and 2020. Overnight transplants (incision time 7pm-5am, n=541) were compared to daytime transplants (incision time 5am-7pm, n=546). Outcomes included in-hospital complications, 5-year survival, 5-year incidence of non-fatal major adverse cardiac events (NF-MACE) (myocardial infarction, new congestive heart failure, percutaneous coronary intervention, pacemaker implant, stroke) and treated rejections, with death as a competing risk <h3>Results</h3> Nighttime transplants had similar recipient/donor profile to daytime transplants, except for more pre-transplant blood transfusions (41.2% vs. 33.9%, p=0.01) and geographically closer donors (63, IQR 24-299 vs. 98, IQR 35-348 miles, p=0.02). They had longer aortic cross clamp time (90, IQR 73-111 vs. 86, IQR 70-106 mins, p=0.02) but similar rates of primary graft dysfunction (14.3% vs. 16.5%, p=0.3) and reoperation for bleeding (3.1% vs. 4.2%, p=0.35) compared to daytime transplants. There was no difference in 5-year survival (Figure), NF-MACE (28%, 95% CI 23.4-32.9 vs. 31.4%, 95% CI 26.7-36.3, p=0.33) and rejections (22.9%, 95% CI 19.1-26.9 vs. 19.6%, 95% CI 20.4-28.0, p=0.65) between nighttime and daytime surgery. In multivariate analysis, nighttime surgery was not associated with increased mortality, after adjusting for baseline peripheral vascular disease, multiorgan transplant, urgent status, pre-transplant MCS/inotrope, MELD score, and ischemic time (HR 0.92, 95% CI 0.59-1.42, p=0.69) <h3>Conclusion</h3> Overnight transplants had outcomes comparable to daytime transplants in a high-volume transplant center. We attribute this to system-based practices to improve patient safety.

Clinical Characteristics and Outcomes of Patients With COVID-19–Associated Acute Respiratory Distress Syndrome Who Underwent Lung Transplant

Lung transplantation is a potentially lifesaving treatment for patients who are critically ill due to COVID-19-associated acute respiratory distress syndrome (ARDS), but there is limited information about the long-term outcome. To report the clinical characteristics and outcomes of patients who had COVID-19-associated ARDS and underwent a lung transplant at a single US hospital. Retrospective case series of 102 consecutive patients who underwent a lung transplant at Northwestern University Medical Center in Chicago, Illinois, between January 21, 2020, and September 30, 2021, including 30 patients who had COVID-19-associated ARDS. The date of final follow-up was November 15, 2021. Lung transplant. Demographic, clinical, laboratory, and treatment data were collected and analyzed. Outcomes of lung transplant, including postoperative complications, intensive care unit and hospital length of stay, and survival, were recorded. Among the 102 lung transplant recipients, 30 patients (median age, 53 years [range, 27 to 62]; 13 women [43%]) had COVID-19-associated ARDS and 72 patients (median age, 62 years [range, 22 to 74]; 32 women [44%]) had chronic end-stage lung disease without COVID-19. For lung transplant recipients with COVID-19 compared with those without COVID-19, the median lung allocation scores were 85.8 vs 46.7, the median time on the lung transplant waitlist was 11.5 vs 15 days, and preoperative venovenous extracorporeal membrane oxygenation (ECMO) was used in 56.7% vs 1.4%, respectively. During transplant, patients who had COVID-19-associated ARDS received transfusion of a median of 6.5 units of packed red blood cells vs 0 in those without COVID-19, 96.7% vs 62.5% underwent intraoperative venoarterial ECMO, and the median operative time was 8.5 vs 7.4 hours, respectively. Postoperatively, the rates of primary graft dysfunction (grades 1 to 3) within 72 hours were 70% in the COVID-19 cohort vs 20.8% in those without COVID-19, the median time receiving invasive mechanical ventilation was 6.5 vs 2.0 days, the median duration of intensive care unit stay was 18 vs 9 days, the median post-lung transplant hospitalization duration was 28.5 vs 16 days, and 13.3% vs 5.5% required permanent hemodialysis, respectively. None of the lung transplant recipients who had COVID-19-associated ARDS demonstrated antibody-mediated rejection compared with 12.5% in those without COVID-19. At follow-up, all 30 lung transplant recipients who had COVID-19-associated ARDS were alive (median follow-up, 351 days [IQR, 176-555] after transplant) vs 60 patients (83%) who were alive in the non-COVID-19 cohort (median follow-up, 488 days [IQR, 368-570] after lung transplant). In this single-center case series of 102 consecutive patients who underwent a lung transplant between January 21, 2020, and September 30, 2021, survival was 100% in the 30 patients who had COVID-19-associated ARDS as of November 15, 2021.

The role of mechanical ventilation in primary graft dysfunction in the postoperative lung transplant recipient: A single center study and literature review.

BackgroundPrimary graft dysfunction (PGD) is still a major complication in patients undergoing lung transplantation (LTx). Much is unknown about the effect of postoperative mechanical ventilation on outcomes, with debate on the best approach to ventilation.Aim/PurposeThe goal of this study was to generate hypotheses on the association between postoperative mechanical ventilation settings and allograft size matching in PGD development.MethodThis is a retrospective study of LTx patients between September 2011 and September 2018 (n = 116). PGD was assessed according to the International Society of Heart and Lung Transplantation (ISHLT) criteria. Data were collected from medical records, including chest x‐ray assessments, blood gas analysis, mechanical ventilator parameters and spirometry.ResultsPositive end‐expiratory pressures (PEEP) of 5 cm H2O were correlated with lower rates of grade 3 PGD. Graft size was important as tidal volumes calculated according to the recipient yielded greater rates of PGD when low volumes were used, a correlation that was lost when donor metrics were used.ConclusionOur results highlight a need for greater investigation of the role donor characteristics play in determining post‐operative ventilation of a lung transplant recipient. The mechanical ventilation settings on postoperative LTx recipients may have an implication for the development of acute graft dysfunction. Severe PGD was associated with the use of a PEEP higher than 5 and lower tidal volumes and oversized lungs were associated with lower long‐term mortality. Lack of association between ventilatory settings and survival may point to the importance of other variables than ventilation in the development of PGD.

Post-transplantation outcomes of sensitized patients receiving durable mechanical circulatory support

Sensitization, defined as the presence of circulating antibodies, presents challenges, particularly in patients undergoing heart transplantation (HTx) bridged with durable mechanical circulatory support (MCS). We aimed to investigate the post-transplantation outcomes of sensitized MCS patients.Among 889 consecutively enrolled heart transplant (HTx) recipients between 2010 and 2018, 86 (9.7%) sensitized MCS patients (Group A) were compared with sensitized non-MCS patients (Group B, n = 189), non-sensitized MCS patients (Group C, n = 162), and non-sensitized non-MCS patients (Group D, n = 452) regarding post-HTx outcomes, including the incidence of primary graft dysfunction (PGD), 1-year survival, and 1-year freedom from antibody-mediated rejection (AMR).Sensitized MCS patients (Group A) showed comparable rates of PGD, 1-year survival, and 1-year freedom from AMR with Groups C and D. However, Group A showed significantly higher rates of 1-year freedom from AMR (95.3% vs 85.7%, p = 0.02) and an earlier decline in panel-reactive antibody (PRA) levels (p < 0.01) than sensitized non-MCS patients (Group B). Desensitization therapy effectively reduced the levels of PRA in both Groups A and B. When Group A was further divided according to the presence of preformed donor-specific antibodies (DSA), patients with preformed DSA showed significantly lower rates of 1-year freedom from AMR than those without (84.2% vs 98.5%, p = 0.01).Sensitized MCS patients showed significantly lower rates of AMR and an earlier decline in PRA levels following HTx than sensitized non-MCS patients. Removal of MCS at the time of transplantation might underlie these observations.

Impact of increased donor distances following adult heart allocation system changes: A single center review of 1‐year outcomes

On October 18, 2018, several changes to the donor heart allocation system were enacted. We hypothesize that patients undergoing orthotopic heart transplantation (OHT) under the new allocation system will see an increase in ischemic times, rates of primary graft dysfunction, and 1-year mortality due to these changes. In this single-center retrospective study, we reviewed the charts of all OHT patients from October 2017 through October 2019. Pre- and postallocation recipient demographics were compared. Survival analysis was performed using the Kaplan-Meier method. A total of 184 patients underwent OHT. Recipient demographics were similar between cohorts. The average distance from donor increased by more than 150 km (p = .006). Patients in the postallocation change cohort demonstrated a significant increase in the rate of severe left ventricle primary graft dysfunctionfrom 5.4% to 18.7% (p = .005). There were no statistically significant differences in 30-day mortality or 1-year survival. Time on the waitlist was reduced from 203.8to 103.7 days (p = .006). Changes in heart allocation resulted in shorter waitlist times at the expense of longer donor distances and ischemic times, with an associated negative impact on early post-transplantation outcomes. No significant differences in 30-day or 1-year mortality were observed.

Lung transplantation for acute exacerbation of interstitial lung disease

BackgroundAcute exacerbations of interstitial lung diseases (AE-ILD) have a high mortality rate with no effective medical therapies. Lung transplantation is a potentially life-saving option for patients with AE-ILD, but its...

Primary graft dysfunction.

Primary graft dysfunction (PGD) is a devastating complication in the acute postoperative lung transplant period, associated with high short-term mortality and chronic rejection. We review its definition, pathophysiology, risk factors, prevention, treatment strategies, and future research directions. New analyses suggest donation after circulatory death and donation after brain death donors have similar PGD rates, whereas donors >55 years are not associated with increased PGD risk. Recipient pretransplant diastolic dysfunction and overweight or obese recipients with predominant abdominal subcutaneous adipose tissue have increased PGD risk. Newly identified recipient biomarkers and donor and recipient genes increase PGD risk, but their clinical utility remains unclear. Mixed data still exists regarding cold ischemic time and PGD risk, and increased PGD risk with cardiopulmonary bypass remains confounded by transfusions. Portable ex vivo lung perfusion (EVLP) may prevent PGD, but its use is limited to a handful of centers. Although updates to current PGD treatment are lacking, future therapies are promising with targeted therapy and the use of EVLP to pharmacologically recondition donor lungs. There is significant progress in defining PGD and identifying its several risk factors, but effective prevention and treatment strategies are needed.

Procedural mechanical support for lung transplantation.

The use of procedural mechanical support during lung transplantation (LTx) varies between centers and the optimal support strategy is still controversially discussed. The two main questions are if cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO) should be preferred and whether mechanical support should be reserved for specific patient groups or a routine use can be recommended. Recent cohort studies have consistently shown that LTx on CPB leads to inferior outcomes when compared to venoarterial (va)-ECMO. Thus, ECMO should be preferred in lung transplantation except for special indications. Despite its higher invasiveness, ECMO offers some pivotal advantages over off-pump lung transplantation. It has been shown to remarkably reduce rates of primary graft dysfunction, supporting the concept of a routine intraoperative ECMO use in LTx. Although randomized-controlled trials addressing this question are still lacking, current evidence appears to favor the routine use of ECMO support during lung transplantation.