An International Case Study of Lung Transplantation Selim M. Arcasoy, M.D. Professor of Medicine...
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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
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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
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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
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Cystic FibrosisPatient 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
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Cystic FibrosisPatient 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
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Cystic FibrosisPatient 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
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End-stage Lung
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And, here they are….
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Stages of Respiratory Disease and Failure
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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• 1954 - First successful kidney transplant• 1967 - First successful liver transplant• 1968 - First successful heart transplant
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Number of Lung Transplants in the Last 3 Decades
JHLT. 2013 Oct; 32(10): 965-978
2013
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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
Who is a Candidate for Lung Transplant?General Guidelines
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
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Patient characteristicsType of lung disease
Other medical illnessesPrognosis without transplant
Risks Mortality Morbidity Complexity
Benefits Survival Function Quality of Life
Lung Transplantation on a ScaleRisk-Benefit Balance
PatientExpectations
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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
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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
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Ex Vivo Lung Perfusion“Lung In A Box”
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Extracorporeal Membrane Oxygenation
(ECMO)
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Case 3
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Before And After
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25
14
20 18 1922
26
35
43
5155
46
57
51
59
67
0
10
20
30
40
50
60
70
80
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
NewYork-Presbyterian HospitalLung Transplant Volume Per Year
1996-2012
New Program
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New York-Presbyterian HospitalLung Transplant Survival
7/01/2001 - 12/31/2012 (n = 559)
SurvivalNYPH vs UNOS1-year: 91% vs 84%5-year: 68% vs 53%10-year: 47% vs 28%
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Functional Status Before and After Lung Transplantation
0%
20%
40%
60%
80%
100%
Pre-Tx 5 Years Post-Tx
Requires Total Assistance
Performs with SomeAssistance
No Activity Limitations
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Employment Status Before and After Lung Transplantation
0%
20%
40%
60%
80%
100%
Pre-Tx 5 Years Post-Tx
Working Part Time
Working Full Time
Retired
Not Working
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