PREVENTING/MANAGING (SEVERE) PRIMARY GRAFT DYSFUNCTIONZachary Kon, MD

Assistant Professor of Cardiothoracic Surgery

Surgical Director, Lung Transplantation Program

Surgical Director, Pulmonary Hypertension and Thromboendarterectomy Program

AATS Mechanical Circulatory Support Symposium

March 8, 2018

Disclosures• Breethe Inc. – SAB member, Consultant• Medtronic, Inc. – Consultant, Speaker

• Cryolife, Inc. – SAB member, Consultant

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IRI PGD EGF

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EGF

IRI

PGD

• Airway obstruction• Venous anastomotic obstruction • Left ventricular dysfunction• Hemothorax/Pneumothorax

2005 ISHLT Consensus 2016 ISHLT Consensus

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Defining PGD

1) Snell GI, et al. J Heart Lung Transplant. 2017 Oct;36(10):1097-1103.2) Christie J, et al. Am J Respir Crit Care Med. 2005;171:1312-1316.

Modifiable/Avoidable/Preventable PGD Risk Factors

PGD

Recipient

Operation

Preservation

Donor

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• Female • BMI>25• PAH• Sarcoidosis

• Age (<21 or >45>)• Race (African American)• Female • Smoker• Prolonged mechanical ventilation• Aspiration• Head trauma• Hemodynamic instability• Undersized lungs

• Single lung transplantation• Use of cardiopulmonary bypass• Excessive blood transfusion• High reperfusion FiO2>0.4• Rapid reperfusion• Warming during implantation

• Prolonged ischemic time• Choice of preservation solution• Route of preservation solution

• Modest TV

• Appropriate PEEP

• Fluid Restriction

• Steroids?

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Donor Management

Angel LF, et al. Am J Respir Crit Care Med. 2006 Sep;174(6):710-6.

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EVLP

12 Cypel M, et al. N Engl J Med. 2011 Apr 14;364(15):1431-40.

13 Wallinder A, et al. Eur J Cardiothorac Surg. 2014 Jan;45(1):40-4

14 Boffini M, et al. Eur J Cardiothorac Surg. 2014 Nov;46(5):789-93.

15 Slama A, et al. J Heart Lung Transplant. 2017 Jul;36(7):744-753.

16 Eberlein M, et al. Ann Thorac Surg. 2013 Aug;96(2):457-63.

17 Magouliotis DE, et al. Gen Thorac Cardiovasc Surg. 2018 Jan;66(1):38-47.

18 Moser B, et al. Eur J Cardiothorac Surg. 2018 Jan 1;53(1):178-185.

19 Raphael J, et al. J Heart Lung Transplant. 2017 Sep;36(9):948-956.

• Supportive

• ARDS protective ventilation– Early, aggressive use of ECMO?

• Fluid management

• Inhaled pulmonary vasodilators?– iNO– Prostaglandins

• Retransplantation

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Management of PGD

Veno-venous Veno-arterial• Pros

– Hemodynamic support

– “Offloads” the lungs

• Cons– Harlequin syndrome with peripheral

cannulation

– Increased blood transfusion?

– Lower probability of rehabilitation

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ECMO for PGD (VV vs VA)

• Easily cannulated in the OR or at bedside

• Easier management

• Can be decannulated at bedside

• Physiologic blood flow through allografts

• Oxygenation of allograft

22 Mulvihill MS, et al. J Heart Lung Transplant. In press.

Future Novel Therapies

23 Van Raemdonck D, et al. J Heart Lung Transplant. 2017 Oct;36(10):1121-1136.

24 1) Zinne N, et al. PLoS One. 2018 Mar 5;13(3):e0193168.

25Mehaffey JH, et al. Ann Thorac Surg. 2017 Jun;103(6):1723-1729.

Extended Ischemic Time

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27 1) Hsin MK, et al. J Heart Lung Transplant. 2016 Jan;35(1):130-6.

Conclusions• Primary graft dysfunction is a clinical diagnosis based on pulmonary infiltrates and poor

gas exchange

• Its cause is multifactorial and likely represents multiple mechanisms of lung injury

• Donor, recipient, organ preservation and operative variables all play a role

• Avoid multiple non-modifiable risk factors if possible

• Supportive care for injured lungs

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THANK YOU