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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
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
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
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
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
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
End-stage Lung
And, here they are….
Stages of Respiratory Disease and Failure
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
Number of Lung Transplants in the Last 3 Decades
JHLT. 2013 Oct; 32(10): 965-978
2013
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
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
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
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
Ex Vivo Lung Perfusion“Lung In A Box”
Extracorporeal Membrane Oxygenation
(ECMO)
Case 3
Before And After
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
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%
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
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