The Transplant Drama

N John Castro MD

University of Minnesota Thoracic

Transplant Programs

Disclosures

• Consultant-Surgeon INOVATE HF

Organ Procurement

University of Minnesota Thoracic

Transplant Programs

Organization and communication

Behind the scenes

Lifesource call: Blood type

Age, sex, race, height, and weight

Time of brain death

mechanism of injury, thoracic trauma

Pre hospital course: resuscitation, aspiration, intubation, joules

PMHx: ETOH, drugs, smoking, HTN, diabetes, malignancy…….

Serologies: hepatitis, HIV, CMV, syphilis

Organ Procurement

Behind the scenes:

Cardiac evaluation:

Inotropes

Hemodynamics and fluid status CVP

Labs: troponin

EKG

ECHO

Angiograms: men 35y, female 40y

Acceptable ischemia times 4-5 hours for adults, 8 hours for infants

Organ Procurement

Behind the scenes:

Acceptable cardiac donors:

Age: newborn to 60+

No history of active cardiac disease

No history of severe thoracic trauma

No prolonged CPR, hypotension, hypoxia

Normal EKG

Normal ECHO

Inotrope < 10 mg/kg/h of dopa or dobuta with a CVP 8-12

Organ Procurement

Behind the scenes:

Lung evaluation:

Oxygen challenge 100%/40%

Vent settings

CXR

Sputum: gs/cx fungus

Bronch

Fluid status

Acceptable ischemia time of 6-10

Organ Procurement

Behind the scenes

Acceptable lung donors:

Age: newborn to 60+yrs

No history of pulmonary disease

No history of long term smoking >40py

100% FiO2 >300 PaO2,

40% FiO2 > 100 PaO2

normal serologies, normal paranchyma,

acceptable oxygenation

Organ Procurement

Organization and Communication

Coordinator: Notifies patients and institutes travel plan

Plans timing with lifesource coordinator

Notifies admissions office and 6C/D

Sets up OR and anesthesia times

Notifies junior resident

Clarifies immunosuppression orders and study patients

Tracks down all charts, labs and x-rays

Organizes fellows for donor run and OR

Organizes transportation for donor run with Lifesource

Verifies ABO and PRA

Organ Procurement

The procurement site

You represent the University of Minnesota

Be polite The cardiac team needs to lead the coordinated effort of all

the organ teams. Our organ must be removed first. We,

with consideration of the other teams, need to set the cross

clamp time.

Organ Procurement

The Procurement Site

Check the records: death note, blood type, all of the labs

Check the films and angiograms

Repeat the bronch at staff request

Open the chest as soon as possible to inspect the organs

Timing is everything, estimate cross clamp time

Call transplant surgeon (1st call)

Communicate plan with rest of procurement teams

Keep an eye on anesthesia

Organ Procurement

Organ Procurement

The Procurement Site

Inspecting the organs

Heart: contusions, coronary lesions, calcification,

thrills, abnormal anatomy, pressure

measurements

Lungs: contusions, emboli, consolidated infection,

bullae, lung trauma, masses

Organ Procurement

Organ Procurement

The Procurement Site

Preparing for cross clamp

dissect completely the aorta, SVC, IVC, and PA

loop the SVC

place cannulation sutures in aorta and PA (prolene)

open pleura widely

dissect intra atrial groove

Call transplant surgeon to confirm timing of cross clamp

(2nd call)

Organ Procurement

The Procurement Site

Don’t forget to give the heparin

Tie off SVC……stay away from the SA node

Cut IVC…….keep an eye on the abdominal team

Cross clamp and give plegia

Cut off the tip of left atrium (even if we are not taking the lungs)

Continue to ventilate the donor

Cover heart and lungs with soft slush

Suckers in the chest 2-3

Organ Procurement

The Procurement Site

Perfusion solution

Cardiac Gopher cardioplegic solution (GCS)

KCL 32.0 mEq/L

bicarb 26 mEq/L

Mannitol 13 gm/L

Dextrose 10 mL of 50%

Volume 1-2 liters for adults, 500-1000ml for children, and 250-500ml for infants

Pressure bags set at 140 mm Hg

Organ Procurement

The Procurement Site

Perfusion solution

Lung Perfadex and Prostaglandin

Volume 60 ml/kg with pressure bag set at 140 mm/Hg

Organ Procurement

The Procurement Site

Don’t cut anything you can’t see Heart only: Divide SVC above tie

Divide IVC

Divide aorta at head and neck vessels

Divide pulmonary artery at branches

Open left atrium in the groove swing inferior, then up toward the appendage. Tip the heart superiorly and divide the roof of the left atrium

Pack in container of iced saline solution, evacuate all air

Organ Procurement

Organ Procurement

Organ Procurement

The Procurement Site

Heart-lung block: Divide the SVC above the tie

Divide the IVC

Divide the aorta at the vessels

Right lung divide the IPL, dissect posterior to the hilum in the pre esophageal plane

Repeat on left side

Inflate lungs staple trachea

Pack in container of iced saline solution, evacuate all air

Organ Procurement

Returning home

Make sure to secure the cooler in the plane

Have the Lifesource coordinator call the transplant surgeon

or the U of M coordinator when you leave with the

cross clamp time (3rd call)

When you land, call the U of M coordinator or the OR

(4th call)

Accompany organs to the operating room to receive

appropriate compliments on your surgical skills

Organ Procurement

Operative Techniques of Heart Transplantation

Division of CVTS

University of Minnesota

Recipient Set-UP

• Reprogram PM or AICD

• SG catheter to measure PAP

• Prepare for groin cannulation in multiple

redo or LVAD patients

• TEE probe placement

• CO2 tube in the operative field

Bypass Set-UP

• Aortic cannulation as distal as possible, esp

in previous CABGs and LVAD pts.

• Bicaval cannulation at posterolateral

cavoatrial junction, cava snares

• Bypass initiation when donor heart lands in

the airport

• Cool to 28 to 30’ C

• Aortic x-clamp when donor heart in OR

Recipient Cardiectomy

Recipient and Donor Heart Preparation

• Trim the recipient cardiac chambers and great

vessels based on the size of donor heart

• Inspect donor cardiac chambers for debris or clots

• Inspect PFO in donor heart

• 400 cc retrograde cardiopleagia for donor heart

Implantation – biatrial anastomosis technique

• Originally described by Lower and

Shumway

• 3-0 prolene sutures for both atrial

anastomoses, 4-0 prolene sutures for both

aorta and PA vessel anastomoses

• Donor right atrial incision modified by

Bernard

Left Atrial Anastomosis

Left Atrial Anastomosis

Atrial Conduction Pathways

Right Atrial Anastomosis

Right Atrial Anastomosis

PA Anastomosis

Aortic Anastomosis

Bicaval Anastomosis Technique

• Described by Sarsam in 1993

• RA intact

• LA shape preserved

• Internodal conduction pathways preserved

Atrial Conduction Pathways

Biatrial vs Bicaval Anastomosis Techaniques

• Biatrial: easy to perform, time tested technique, good long-term outcome for both cardiac function and patient survival.

• Bicaval: less atrial rhythm disturbance, improved ECHO findings: smaller LA, RA; less TR, better atrial function; ? Shorter LOS, ? Less RV failure. Technically more challenge esp. in redo, AICD and LVAD pts, size mismatch, SVC stenosis

• Lack of long-term study comparing both function and survivals in these two groups

Technical Safeguards

• Aggressive de-air measures.

• Keep PA graft short to prevent kinking.

• Keep Aortic graft long.

• Enough reperfusion time for donor heart.

• Double check anastomotic lines when

partially supported by bypass

Lung Transplantation

History of Lung Transplantation

• 1963

• 1963 – 1973

• 1973 – 1983

• March 9, 1981

• 1983

Hardy

36 Patients Worldwide

Hiatus

First Successful Heart-Lung Transplant

First Successful Single Lung Transplant

Cooper in Toronto

Recipient Selection Guidelines

• Clinically and physiologically severe disease

• Medical therapy ineffective or unavailable

• Substantial limitation in activities of daily living

• Limited life expectancy

• Adequate cardiac function without significant coronary

artery disease

• Ambulatory with rehabilitation potential

• Acceptable nutritional status

• Satisfactory psychosocial profile and emotional support

system

Recipient Indications

• Chronic Obstructive Pulmonary Disease – 36%

• Antitrypsin – deficiency Emphysema – 7%

• Cystic Fibrosis – 16%

• Idiopathic Pulmonary Fibrosis – 21%

• Primary Pulmonary Hypertension

• Eisenmenger’s syndrome (with ASD or VSD)

• Sarcoidosis

• Occupational Lung Diseases

• Interstitial Lung Disease Secondary to Chemotherapy or Radiation Therapy

Lung and Heart-Lung Donor

Criteria

• Conventional

• ABO compatibility

• Thoracic size match

• Age less than 50 years (heart-lung)

• Age less than 55 years (lung)

• Normal troponin levels (heart-lung)

• Lack of ventricular hypertrophy (heart-lung)

• No history of respiratory disease

• No significant smoking history

Lung and Heart-Lung Donor

Criteria

• No active pulmonary infection

• No significant chest trauma or history of aspiration or cardiopulmonary resuscitation

• No prior cardiac or pulmonary surgery

• Short intubation time

• Lack of purulent secretions; no gram-negative bacteria or fungi on gram stain

• Clear chest X-ray without infiltrates

• Challenge gas greater than 300mm Hg on 100% oxygen

Marginal Donors

• Age over 55 years (lung)

• Age over 50 years (heart-lung)

• Tobacco history longer than 20 pack-years

• Presence of infiltrate on chest X-ray

• Donor ventilation time longer than 5 days

• Donor use of inhaled drugs

Donor Operation • Check Chart Brain Dead, Blood Type, ABG

• CXR

• CT Scan

• Bronchoscopy

• Recruitment Measures

• Serial ABGS

• Pulmonary Vein Gases

• Do no cut what you cannot see

• Prostaglandin

• Pneumoplegia

• Gentle ventilation

• Heart Excision after development of interatrial groove

Recruitment Maneuvers • Bronchoscopy

• Diuresis

• Bag lungs / Eviscerate as gently as possible

• Peep 10

• Low dose Vasopressin 0.04

Recipient Operation • SLT

• Older recipient

• COPD or IPF

• Groin available especially for LSLT

• Amount of pulmonary hypertension

• Snaring of PA or surgeon finger pinch

• Patulous LA anastomosis

Recipient Operation • BSLT

• Surgical Approaches

• Bilateral transaxillary Toyoda at Pittsburgh

• Bilateral posterolateral

• Bilateral anterolateral Patterson at Wash U St. Louis

• Clamshell

• Use of CPB for left lung

CPB / ECMO • OR

• Difficult Transport

• Hemodynamically unstable

• Unable to oxygenate

• May have to crash on via femoral vessels, then position patient

• Postoperatively Primary graft dysfucntion

• Ischemia-reperfusion injury

• Humoral rejection

• Uncommon

Postoperative Resuscitation • Bicarbonate

• Low dose epinephrine

• Vasopressin

• Neo

• Levophed

• FFP

Avoid

• Albumin

• Dobutamine

Immunosuppression

AZA and Prednisone RATG Cyclosporine OKT3 Cyclosporine, Prednisone, and AZA 1985 FK506 / Tacrolimus MMF Tacrolimus, Prednisone, and MMF Use of Induction Therapy

Registry 2009

Bilateral 69% of all lung transplants

Survival 1994 – June 2007

89% at 3 months

79% at 1 year

64% at 3 years

52% at 5 years

29% at 10 years

Between February 2007 and April 2008

24 patients underwent stent placement

49 stents were placed for 36 anastomoses at risk

Airway complications in up to 27% of lung transplant recipients

Indications: Bronchial stenosis 12

Bronchomalacia 12

Both 20

Partial bronchial dehiscence 5

Clinical Experience With a New Removable Tracheobronchial Stent in the Management of Airway Complications After Lung Transplantation S Fernandez-Bussy et al. JHLT July 2009

January 1988 and July 1993

75 lung transplants

Prolonged adynamic ileus (4)

Diaphragmatic hernia after omental wrap (3)

Ischemic bowel (2)

Colitis with hemorrhage (1)

Splenic injury after colonoscopy (1)

Abdominal Complications after Lung Transplantation

PC Smith et al. JHLT January/February 1995

Early

Colonic perforation (4)

Cholilithiasis / choledocholithiasis (2)

Mesenteric pseudoaneurysm (1)

Fungal hepatic abscess (1)

Intraabdominal hemorrhage (1)

Abdominal Complications after Lung Transplantation

PC Smith et al. JHLT January/February 1995

Late

Acute Rejection Episodes

Lymphocytic Bronchiolitis

Cytomegalovirus Pneumonitis

Medication Noncompliance

Reperfusion Injury

Bacterial Pneumonia

Donor Antigen-Specific Reactivity

Gastroesophageal Reflux

Elevated Transforming Growth Factor-Beta

Expression

Risk Factors For The Development of Bronchiolitis Obliterans Syndrome

First 30 days: Graft Failure

Non-CMV Infections

After First Year: BOS

Non-CMV Infections

Between 5 and 10 years: malignancy 12%

Causes of Death

Thank You!