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1092 PART 10: The Surgical Patient

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HALF-LIFE Alfa-1: 6.2 Years; CF: 7.5 Years; COPD: 5.3 Years;
IPF: 4.4 Years; IPAH: 5.0 Years; Sarcoidosis: 5.3 Years
80

Survival (%) 60 Sarcoidosis (N = 849)

40
IPAH (N = 1,308)
IPF (N = 7,540)
20 COPD (N = 11,948)
CF (N = 5,608)
Alfa-1 (N = 2,490)
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Years
All comparisons with alfa-1 and CF are statistically significant at <0.05; COPD vs. IPF: p < 0.000 1.
FIGURE 115-3. Kaplan-Meier survival by diagnosis for adult lung transplants performed from January 1990 through June 2011. (Reproduced with permission of Christie JD, Edwards LB,
Kucheryavaya AY, et al. The Registry of the International Society for Heart and Lung Transplantation: Twenty-seventh official adult lung and heart-lung transplant report—2010. J Heart Lung
Transplant. 2010 Oct;29(10):1104-1118.)

(transplant benefit). Transplant urgency is subtracted from benefit to give BMIs and greater risk of death at 1 and 5 years. However, this notion
36
a score that is normalized on a scale from 0 to 100, which is the final is being challenged with more recent conflicting reports. Underweight
37
LAS. The higher the score, the greater is the need for transplant. Since the and deconditioned individuals have also been shown to be at risk for
implementation of the LAS, organ allocation has seen a shift to transplant poor outcomes. 36
based on urgency as opposed to wait time duration. As a result, the United Given the critical shortage of lungs available, options to improve donor
States has seen a decrease in wait list times reflecting more appropriate availability include extended criteria donors, non-heart beating donors,
placement and allocation of lungs. 33,34 Wait list mortality has decreased for live lobar lungs, size reduced grafts, and the use of ex vivo lung perfusion
all indications except IPAH. No change in posttransplant survival has for further evaluation and management of marginal lungs. Extended
35
38
been seen compared to survival rates pre-LAS. 34 criteria donors do not meet the criteria outlined above as they may have
atelectasis on their chest x-ray, infiltrates or moderate secretions on bron-
Outcomes: Survival rates are 88% at 3 months, 79% at 1 year, 63% at choscopy. While some studies report equivalent early outcomes, others
3 years, 52% at 5 years, and 29% at 10 years. More recent improvements have demonstrated longer ICU stays and lower pulmonary function with
in survival have been driven by improved management immediately the use of extended donor lungs. Currently, non-heart beating donors
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posttransplant and in the first year. Three-month survival is highest (NHBD) account for about 20% of all deceased organ donors. This shift
for CF (90%) and COPD (91%) and lowest for IPF (85%) and IPAH in practice in addition to the adoption of strategies that include ex vivo
(76%). These differences can be attributed to immediate complications lung perfusion technology and the use of extended criteria donors have
postoperatively such as primary graft dysfunction (see “Postoperative significantly expanded the donor pool. Another strategy to increase trans-
Complications”). Long-term survival for those who survive at least plant opportunities is lobar transplantation from live or deceased donors.
1 year changes in that CF, IPAH, and sarcoidosis have a greater 10-year However, there has been a decreasing trend for lobar lung transplants
survival (48%, 45%, and 41%, respectively) while COPD and IPF have from living donors over the past decade. Many recipients who have small
the worst rates (28%, 30%, respectively) given that these patients are thoracic cavities have a prolonged wait time to find a size matched donor.
older and harbor more comorbid conditions (see Fig. 115-3). Size reduced grafts help provide lungs to these patients and if the mis-
Interestingly, long-term survival is most influenced by cytomegalo- match is significant, lobar transplants from the donor can be performed.
virus (CMV) serologic status of the donor. The underlying reason for While mortality and early function has been found to be equivalent, there
this association is not completely understood, however, may be the is a trend toward more perioperative complications such as bleeding.
immunogenic effect of CMV (see Chap. 68) on rejection and the devel-
opment of bronchiolitis obliterans. Risk factors significantly associated
with survival in the immediate postoperative period and at 1 year are
outlined in Table 115-3.
TABLE 115-3 Risk Factors Associated With Early and 1-Year Mortality
Demographic Shifts in practice: Lung transplant recipient demographic
has changed with time. The median age of recipients in the most recent Early Postoperative Mortality 1-Year Mortality
report from the ISHLT evaluating the 2006-2012 lung transplant era Bronchial dehiscence Higher recipient age
was 55, which has been increasing over the past few decades. The most Severe pulmonary hypertension Bilirubin
striking increases have been in recipients older than 65 years of age. In
the early 2000s, 2.8% of recipients were over the age of 65, compared Need for cardiopulmonary bypass Supplemental oxygen requirements at rest
to almost 10% from 2006 to 2012. With advancing age of recipients, Air leak Lower cardiac output
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intensivists need to appreciate that these patients carry more comorbid Primary graft dysfunction Transplant center volume
conditions and increasingly are undergoing concomitant procedures
such as percutaneous coronary interventions or even combined trans- Recipient percentage predicted FEV 1
plants (heart-lung, lung-liver, lung-kidney). Donor-recipient height difference (larger donors do better)
Obesity continues to be a relative contraindication to lung trans- Data from Paradela M, González D, Parente I, et al. Surgical risk factors associated with lung transplantation.
plantation (BMI >30). ISHLT has noted an association between higher Transplantation Proc. 2009 Jul-Aug;41(6):2218-2220.

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