Buhl, R.

Deuse, T.

Evrard, P.

Gottlieb, J.

Green, D.

Hoefer, D.

Hoek, R.

Hoetzenecker, K.

Knoop, C.

Kwakkel-vanErp, J. M.

Lang, G.

Langer, F.

Laufer, G.

Luijk, B.

Rondelet, B.

Schramm, R.

Seghers, L.

Smits, J. M.

van Kessel, D. A.

Verleden, G. M.

Verschuuren, E. A.

Vos, R.

Witt, C.

English

University of Groningen

   University of GroningenExceptional LAS Requests in EurotransplantVos, R.; Smits, J. M.; Hoek, R.; Green, D.; Evrard, P.; Knoop, C.; Verleden, G. M.; Rondelet,B.; Kwakkel-vanErp, J. M.; Seghers, L.Published in:Journal of Heart and Lung TransplantationIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2020Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Vos, R., Smits, J. M., Hoek, R., Green, D., Evrard, P., Knoop, C., Verleden, G. M., Rondelet, B., Kwakkel-vanErp, J. M., Seghers, L., van Kessel, D. A., Luijk, B., Verschuuren, E. A., Lang, G., Hoetzenecker, K.,Laufer, G., Hoefer, D., Langer, F., Schramm, R., ... Gottlieb, J. (2020). Exceptional LAS Requests inEurotransplant: Analysis of an 8-year Effort to Improve Lung Allocation for Precarious Patients. Journal ofHeart and Lung Transplantation, 39(4), S375-S376. http://10.1016/j.healun.2020.01.475CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 29-04-2023Abstracts S375Purpose: A total of 180 lung transplantations (LTx) were performed at asingle center in Saudi Arabia. 92% of our donors were marginal. The crite-ria of deceased brain dead donors represent unique differences that bringunique challenges. This report highlights the challenges, managementstrategies and outcomes.Methods: The LTx Program at King Faisal specialist hospital was estab-lished in 2000. Over the last 9 years the program has witnessed rapidgrowth. Retrospective review of 180 patients and their donors that under-went LTx at our center between January 2010 and September 2019.Results: The most common indication for LTx was pulmonary fibrosis(40%), followed by cystic fibrosis (CF)-related bronchiectasis (24%), non-CF-related bronchiectasis (21%), chronic obstructive pulmonary disease(4%), sarcoidosis (3%), Microtithiasis (3%).Regarding Lung donors (LDs)92% of our lungs were marginal. 10% age >55 years, 16% PO2 <300mmhg, 32% abnormal CXR, 22% Purulent secretions on bronchoscopy,83% Prolonged ventilation more than 5 days with a mean duration ofmechanical ventilation (MV) of 9+/-7 (days). Bacterial colonization wasnoted in 74% of LDs, including multidrug-resistant bacteria such as acine-tobacter (31%), klibsiellae (24%) and pseudomonas (12%). Over the last5 years extracorporeal membrane oxygenation (ECMO), was used in21.5% of our LTx as a rescue strategy for grade 3 primary graft dysfunc-tion with 30 days survival of 92% and 1 year survival 88%. Ex vivo lungperfusion was used to expand our pool of LDs, 9 successful cases from 20attempts were performed over the last 5 years. In spite of the liberal utiliza-tion of marginal donors and prolonged post lung transplantation mechani-cal ventilation {Median (range)} 11 (1-145 days), length of ICU stay 14(3-145) and length of hospital stay 36 (12-168), our 30 days, 90 days, 1year, 3 years and 5 years survival rates were 94.3%, 89%, 87.5%, 76% and62.5% respectively which is comparable to the international standards.Conclusion: Shortage of good donors forced us to use extended criteria totransplant moderate and high risk patients. The selective use of Ex vivoand ECMO helped to achieve comparable results. Marginal donors evenwith bacterial colonization can be successfully utilized for LTx.(941)Prone Ventilation in Brain-Dead Organ Donors Acutely IncreasesOxygenation and Results in More Lungs TransplantedG.F. Marklin,1 C. O'Sullivan,1 and R. Dhar.2 1Mid-America Transplant,St Louis, MO; and the 2Neurology, Washington University in St. LouisSchool of Medicine, St Louis, MO.Purpose: A PaO2/FiO2 ratio (PFR) above 300 is a primary donor criterionfor lung transplantation. Absence of cough and respiratory drive in thebrain-dead (BD) donor results in basilar atelectasis, contributing to V/Qmismatching and hypoxemia. We hypothesized that ventilating BD donorsin the prone position would result in better V/Q matching, increased PFR,and more lungs transplanted.Methods: All BD donors at our OPO are treated with a lung-protectiveventilation strategy, recruitment maneuvers and repeated fiberopticbronchoscopy (FOB). Since June 2018, a prone ventilation protocolwas instituted for donors meeting the eligibility criteria: 12-70 yearsold, basilar atelectasis on X-ray or CT, and a PFR <300 after the firstFOB. Eligible donors were placed in the prone position for at least12 hours with all routine treatments continued. PFR was measured atfour, eight, and twelve hours, as well as prior to procurement, andchange calculated from baseline (ΔPO2). The control group consistedof 81 hypoxemic donors treated with routine care in the supine posi-tion in the two years prior.Results: In 14 months, 27 donors met eligibility criteria and were enrolled.Median baseline PFR was 222 mm Hg (IQR 181-270) compared to 187(116-250) in controls (p=0.06). PFR increased more after four hours ofprone ventilation (102 vs. 54 mm Hg, p=0.01), to 348 mm Hg (269-409)versus 264 (156-339) with supine ventilation. At 12-hours, there was atrend for PFR to remain higher: 351 (260-434) vs. 280 (157-358, p=0.13).Final PFR was 385 mm Hg (328-424) vs. 289 mm Hg (219-440, p=0.09)although ΔPO2 was comparable. However, more lungs were transplantedin the prone group (14 of 27 donors, 52%) compared to 23% in the controlgroup, an effect persisting after adjusting for baseline PFR (OR 3.0, 95%CI: 1.2-7.8, p=0.02).Conclusion: Prone ventilation acutely improved oxygenation in hypox-emic BD organ donors with basilar atelectasis relative to those managed inthe supine position and resulted in more lungs transplanted.(942)Disparities in the Lung Allocation Score Due to Geography Have NotChanged Since November 2017L. Benvenuto, M. Aversa, M. Anderson, L. Shah, J. Costa, B.P. Stanifer,H. Robbins, F. D'Ovidio, J. Sonett and S.M. Arcasoy Columbia UniversityMedical Center, New York, NY.Purpose: Differences in geographic donor lung availability affect waitlist out-comes. We hypothesized that the lung allocation score (LAS) at transplant andwaitlist time would vary based on local donor lung availability and that broadergeographic sharing since November 2017 would improve these disparities.Methods: Using UNOS data, we conducted a retrospective cohort study of23,414 lung transplant recipients from January 1, 2006 - December 31,2018. Local lung availability was defined as the ratio of donor lungs towaitlist candidates in the local donation service area. We calculated thelocal lung availability for candidates prior to November 25, 2017. We usedmixed multivariable linear regression and Poisson regression, adjusting fortime dependent LAS changes, to examine the relationship between locallung availability, LAS at transplant and waitlist time. We used Wilcoxonrank-sum to compare LAS at transplant before and after November 2017.Results: Compared to recipients in the top quartile with greatest local lungavailability, recipients in the lowest quartile were transplanted with a LAS6.2 points higher (95% CI: 5.6-6.9, p <0.001) and waited significantly lon-ger, 186 days (95% CI: 178-194) compared with 93 days (95%CI: 88-97),p <0.001. This difference varied by transplant type, with single lungsrecipients transplanted with a LAS 2.0 points higher in the lowest quartile(95%CI: 0.9-3.0, p < 0.001) compared with the top and double lung recipi-ents transplanted with a LAS 8.8 points higher (95% CI: 8.0-9.6, p<0.001)in the lowest quartile compared with the top. At centers in the lowest quar-tile of local lung availability, the LAS at transplant did not meaningfullychange after November 2017 (44.1 § 15.2, compared to 45.7§ 16.3,p=0.042), however the waitlist time did decrease from 206 days (95%CI:192-222) to 155 days, (95% CI: 133-176), p <0.001. The LAS at transplantand waitlist time for recipients did not change at high local lung availabil-ity centers (50.7 § 19.6 compared to 51.3 § 19.6, p=0.38, and 74 days(95%CI: 66-81) compared to 61 days (95%CI: 52-70), p=0.66).Conclusion: Prior to November 2017, low local lung availability was associ-ated with longer waitlist times and higher LAS at transplant that were muchmore pronounced for double lung recipients. Since expanding allocation to 250miles, meaningful differences in LAS at transplant have not yet been observed.(943)Exceptional LAS Requests in Eurotransplant: Analysis of an 8-yearEffort to Improve Lung Allocation for Precarious PatientsR. Vos,1 J.M. Smits,2 R. Hoek,3 D. Green,2 P. Evrard,4 C. Knoop,5G.M. Verleden,1 B. Rondelet,6 J.M. Kwakkel-vanErp,7 L. Seghers,8D.A. van Kessel,9 B. Luijk,9 E.A. Verschuuren,10 G. Lang,11 K.Hoetzenecker,11 G. Laufer,11 D. Hoefer,12 F. Langer,13 R. Schramm,14T. Deuse,15 R. Buhl,16 C. Witt,17 and J. Gottlieb.18 1University HospitalsLeuven, Leuven, Belgium; 2Eurotransplant International Foundation,S376 The Journal of Heart and Lung Transplantation, Vol 39, No 4S, April 2020Leiden, Netherlands; 3Erasmus University Medical Center, Rotterdam,Netherlands; 4Centre Hospitalier Universitaire Universite Catholique deLouvain, Namur Godinne, Belgium; 5Universite Libre de Bruxelles, HôpitalErasme, Bruxelles, Belgium; 6Universite Catholique de Louvain, CHUMont-Godinne, Namur, Godinne, Belgium; 7University Antwerp, UZA,Antwerp, Belgium; 8Erasmus MC, Rotterdam, Netherlands; 9UniversityMedical Center, Utrecht, Utrecht, Netherlands; 10University of Groningen,Groningen, Netherlands; 11Medical University of Vienna, Vienna, Austria;12Medical University Innsbruck, Innsbruck, Austria; 13Saarland UniversityMedical Center, Homburg/Saar, Homburg/Saar, Germany; 14RuhrUniversity of Bochum, Bad Oeynhausen, Germany; 15University HospitalEppendorf, Hamburg, Germany; 16Medizinische Klinik und Poliklinik derUniversit€atsmedizin Mainz, Main, Germany; 17Charite -Universit€atsmedizin Berlin, Berlin, Germany; and the 18Hannover MedicalSchool, Hannover, Germany.Purpose: Following introduction of the lung allocation score (LAS) in 2011,Eurotransplant member centers can apply for an exceptional LAS (eLAS) ifthe calculated LAS insufficiently reflects the perceived transplant benefit for apatient, specifically in case of primary pulmonary hypertension group 1 and 4;combined lung+nonrenal transplantation; rare diseases; or extracorporealsupport. Each eLAS proposal is evaluated by a LAS Review Board, consistingof ≥3 lung transplant experts, which subsequently declines or approves theeLAS request in consensus of ≥3 votes. In case of a lower than accepted score,predefined business rules to assign LAS percentiles are used.Methods: A retrospective analysis of all eLAS requests in Eurotransplantfrom December 2011 until September 2019.Results: Overall, 5183 lung transplants (deceased donors) were performedand 420 eLAS requests were made (Germany 52%, Netherlands 18%, Aus-tria 18%, Belgium 13%), of which 116 (28%) were approved. Most eLASrequests concerned group B/Pulmonary vascular disease (44%), followedby group C/Cystic fibrosis or immunodeficiency disorder (28%), thengroup D/Restrictive lung disease (15%) and finally group A/Obstructivelung disease (11%); whereas 10 patients (2%) were not classified. The pro-portion of accepted eLAS requests significantly differed between countries(Germany 25%, Netherlands 37%, Austria 20%, Belgium 36%) (p=0.042).eLAS requests decreased in the Netherlands following its LAS introduc-tion in 2014 (2011-2014 mean 13/yr vs. 2015-2019 mean 4.6/yr; p=0.060).However, since 2015 an overall annual increasing number of eLASrequests is seen, with doubling of the eLAS requests in 2018 vs. 2015, butno difference in acceptance rate (2015-2018: 22.4%) (Figure). Acceptancerates were 38% for Group B, 21% for Group C, 20% for Group D and 11%for Group A.Conclusion: The observed variations require further investigation to opti-mize lung allocation for specific patient populations in Eurotransplant.(944)Lung Transplantation from Controlled and Uncontrolled Donation afterCirculatory Death Donors. Single Centre ExperienceA. Palleschi,1 V. Musso,1 R. Lorenzo,1 D. Tosi,1 I. Righi,1P. Mendogni,1 V. Rossetti,2 A. Zanella,3 and M. Nosotti.1 1ThoracicSurgery and Lung Transplantation Unit, Fondazione IRCCS Ca’Granda - Ospedale Maggiore Policlinico, Milan, Italy; 2Pneumology Unit,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico,Milan, Italy; and the 3Anesthesia, Critical Care and Emergency,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan,Italy.Purpose: We started our uncontrolled donation after circulatory death(DCD) experience in 2014 with the first successful lung transplantation(LT). After a long period of local logistical reassessment, in 2017 weresumed the process managing both uncontrolled and controlled DCD.This cohort study reviews early outcome of our initial series of LT fromDCD donors and matches it with the outcome of patients transplanted withgraft from donation after brain death (DBD) donors in the same period.Methods: This is a single-institution, retrospective study on data collectedprospectively from adult patients who underwent bilateral LT at our Centrebetween 10/2017 and 07/2019. Our DCD procurement protocol consists of:1) an in situ graft preservation with open-lung approach (cPAP); 2) non-rapid normothermic lung procurement isolated (only-lung uncontrolledsetting) or during abdominal normothermic regional perfusion, namelywithout pleural topical cooling before the start of PA flushing (multiorgancontrolled setting); 3) ex-situ assessment/evaluation with machine perfu-sion (EVLP or OCS) before LT.Results: In the study period 51 subjects respected inclusion criteria(Table). Ten of these were from DCD donors (19.6%; 6 cDCD and 4uDCD). The flow-chart shows the DCD experience (Image).Conclusion: Our DCD program increased the LT number with an adequateearly-intermediate outcome, despite extended periods of warm ischemia.Our results suggest that LT from DCD donors is feasible in controlled anduncontrolled setting, in isolated and combined organs procurement.Variables DCD group DBD groupNumber of lung transplantations 10 41DonorGender, male 9 (90%) 28 (68.3%)Age, years, median (95% CI) 54 (47.3 to 60.1) 50 (37.7 to 53.0)cDCD ISHLT-interval 1, minutes,median (95% CI)12 (5 to 25) NAcDCD ISHLT-interval 3, minutes,median (95% CI)176 (122 to 191) NATime from PA flush to 1st lung reperfusion(without machine perfusion time),minutes, mean (95% CI)640 (505 to 775) 435 (386 to 483)RecipientsGender, male 23 (56%) 5 (50%)Age, years, median (95% CI) 42 (24.9 to 51.5) 37 (31.7 to 48.4)Disease: CF, COPD, IPF 7; 2; 1 (70%; 20%;10%)27; 4; 10 (66%;10%; 24%)LAS, median (95% CI) 40 (34.9 to 49.3) 40.5 (38.4 to 45.5)Machine perfusion rate 100% 17.6%Intraoperative ECMO 6 (60%) 20 (50%)Postop. MV, days, median (95% CI) 2 (1 to 4) 1 (1 to 1)30-day mortality rate 0% 0%1-year mortality rate 0% 2%Best FEV1, mean (95% CI) 82.7 (69.3 to 96.0) 90.1 (84.2 to 95.9)Airway complication 2 (20%) 3 (7.3%)

Exceptional LAS Requests in Eurotransplant:Analysis of an 8-year Effort to Improve Lung Allocation for Precarious Patients

ARTS repository - University of Groningen

   University of GroningenExceptional LAS Requests in EurotransplantVos, R.; Smits, J. M.; Hoek, R.; Green, D.; Evrard, P.; Knoop, C.; Verleden, G. M.; Rondelet,B.; Kwakkel-vanErp, J. M.; Seghers, L.Published in:Journal of Heart and Lung TransplantationIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2020Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Vos, R., Smits, J. M., Hoek, R., Green, D., Evrard, P., Knoop, C., Verleden, G. M., Rondelet, B., Kwakkel-vanErp, J. M., Seghers, L., van Kessel, D. A., Luijk, B., Verschuuren, E. A., Lang, G., Hoetzenecker, K.,Laufer, G., Hoefer, D., Langer, F., Schramm, R., ... Gottlieb, J. (2020). Exceptional LAS Requests inEurotransplant: Analysis of an 8-year Effort to Improve Lung Allocation for Precarious Patients. Journal ofHeart and Lung Transplantation, 39(4), S375-S376. http://10.1016/j.healun.2020.01.475CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 10-09-2023Abstracts S375Purpose: A total of 180 lung transplantations (LTx) were performed at asingle center in Saudi Arabia. 92% of our donors were marginal. The crite-ria of deceased brain dead donors represent unique differences that bringunique challenges. This report highlights the challenges, managementstrategies and outcomes.Methods: The LTx Program at King Faisal specialist hospital was estab-lished in 2000. Over the last 9 years the program has witnessed rapidgrowth. Retrospective review of 180 patients and their donors that under-went LTx at our center between January 2010 and September 2019.Results: The most common indication for LTx was pulmonary fibrosis(40%), followed by cystic fibrosis (CF)-related bronchiectasis (24%), non-CF-related bronchiectasis (21%), chronic obstructive pulmonary disease(4%), sarcoidosis (3%), Microtithiasis (3%).Regarding Lung donors (LDs)92% of our lungs were marginal. 10% age >55 years, 16% PO2 <300mmhg, 32% abnormal CXR, 22% Purulent secretions on bronchoscopy,83% Prolonged ventilation more than 5 days with a mean duration ofmechanical ventilation (MV) of 9+/-7 (days). Bacterial colonization wasnoted in 74% of LDs, including multidrug-resistant bacteria such as acine-tobacter (31%), klibsiellae (24%) and pseudomonas (12%). Over the last5 years extracorporeal membrane oxygenation (ECMO), was used in21.5% of our LTx as a rescue strategy for grade 3 primary graft dysfunc-tion with 30 days survival of 92% and 1 year survival 88%. Ex vivo lungperfusion was used to expand our pool of LDs, 9 successful cases from 20attempts were performed over the last 5 years. In spite of the liberal utiliza-tion of marginal donors and prolonged post lung transplantation mechani-cal ventilation {Median (range)} 11 (1-145 days), length of ICU stay 14(3-145) and length of hospital stay 36 (12-168), our 30 days, 90 days, 1year, 3 years and 5 years survival rates were 94.3%, 89%, 87.5%, 76% and62.5% respectively which is comparable to the international standards.Conclusion: Shortage of good donors forced us to use extended criteria totransplant moderate and high risk patients. The selective use of Ex vivoand ECMO helped to achieve comparable results. Marginal donors evenwith bacterial colonization can be successfully utilized for LTx.(941)Prone Ventilation in Brain-Dead Organ Donors Acutely IncreasesOxygenation and Results in More Lungs TransplantedG.F. Marklin,1 C. O'Sullivan,1 and R. Dhar.2 1Mid-America Transplant,St Louis, MO; and the 2Neurology, Washington University in St. LouisSchool of Medicine, St Louis, MO.Purpose: A PaO2/FiO2 ratio (PFR) above 300 is a primary donor criterionfor lung transplantation. Absence of cough and respiratory drive in thebrain-dead (BD) donor results in basilar atelectasis, contributing to V/Qmismatching and hypoxemia. We hypothesized that ventilating BD donorsin the prone position would result in better V/Q matching, increased PFR,and more lungs transplanted.Methods: All BD donors at our OPO are treated with a lung-protectiveventilation strategy, recruitment maneuvers and repeated fiberopticbronchoscopy (FOB). Since June 2018, a prone ventilation protocolwas instituted for donors meeting the eligibility criteria: 12-70 yearsold, basilar atelectasis on X-ray or CT, and a PFR <300 after the firstFOB. Eligible donors were placed in the prone position for at least12 hours with all routine treatments continued. PFR was measured atfour, eight, and twelve hours, as well as prior to procurement, andchange calculated from baseline (ΔPO2). The control group consistedof 81 hypoxemic donors treated with routine care in the supine posi-tion in the two years prior.Results: In 14 months, 27 donors met eligibility criteria and were enrolled.Median baseline PFR was 222 mm Hg (IQR 181-270) compared to 187(116-250) in controls (p=0.06). PFR increased more after four hours ofprone ventilation (102 vs. 54 mm Hg, p=0.01), to 348 mm Hg (269-409)versus 264 (156-339) with supine ventilation. At 12-hours, there was atrend for PFR to remain higher: 351 (260-434) vs. 280 (157-358, p=0.13).Final PFR was 385 mm Hg (328-424) vs. 289 mm Hg (219-440, p=0.09)although ΔPO2 was comparable. However, more lungs were transplantedin the prone group (14 of 27 donors, 52%) compared to 23% in the controlgroup, an effect persisting after adjusting for baseline PFR (OR 3.0, 95%CI: 1.2-7.8, p=0.02).Conclusion: Prone ventilation acutely improved oxygenation in hypox-emic BD organ donors with basilar atelectasis relative to those managed inthe supine position and resulted in more lungs transplanted.(942)Disparities in the Lung Allocation Score Due to Geography Have NotChanged Since November 2017L. Benvenuto, M. Aversa, M. Anderson, L. Shah, J. Costa, B.P. Stanifer,H. Robbins, F. D'Ovidio, J. Sonett and S.M. Arcasoy Columbia UniversityMedical Center, New York, NY.Purpose: Differences in geographic donor lung availability affect waitlist out-comes. We hypothesized that the lung allocation score (LAS) at transplant andwaitlist time would vary based on local donor lung availability and that broadergeographic sharing since November 2017 would improve these disparities.Methods: Using UNOS data, we conducted a retrospective cohort study of23,414 lung transplant recipients from January 1, 2006 - December 31,2018. Local lung availability was defined as the ratio of donor lungs towaitlist candidates in the local donation service area. We calculated thelocal lung availability for candidates prior to November 25, 2017. We usedmixed multivariable linear regression and Poisson regression, adjusting fortime dependent LAS changes, to examine the relationship between locallung availability, LAS at transplant and waitlist time. We used Wilcoxonrank-sum to compare LAS at transplant before and after November 2017.Results: Compared to recipients in the top quartile with greatest local lungavailability, recipients in the lowest quartile were transplanted with a LAS6.2 points higher (95% CI: 5.6-6.9, p <0.001) and waited significantly lon-ger, 186 days (95% CI: 178-194) compared with 93 days (95%CI: 88-97),p <0.001. This difference varied by transplant type, with single lungsrecipients transplanted with a LAS 2.0 points higher in the lowest quartile(95%CI: 0.9-3.0, p < 0.001) compared with the top and double lung recipi-ents transplanted with a LAS 8.8 points higher (95% CI: 8.0-9.6, p<0.001)in the lowest quartile compared with the top. At centers in the lowest quar-tile of local lung availability, the LAS at transplant did not meaningfullychange after November 2017 (44.1 § 15.2, compared to 45.7§ 16.3,p=0.042), however the waitlist time did decrease from 206 days (95%CI:192-222) to 155 days, (95% CI: 133-176), p <0.001. The LAS at transplantand waitlist time for recipients did not change at high local lung availabil-ity centers (50.7 § 19.6 compared to 51.3 § 19.6, p=0.38, and 74 days(95%CI: 66-81) compared to 61 days (95%CI: 52-70), p=0.66).Conclusion: Prior to November 2017, low local lung availability was associ-ated with longer waitlist times and higher LAS at transplant that were muchmore pronounced for double lung recipients. Since expanding allocation to 250miles, meaningful differences in LAS at transplant have not yet been observed.(943)Exceptional LAS Requests in Eurotransplant: Analysis of an 8-yearEffort to Improve Lung Allocation for Precarious PatientsR. Vos,1 J.M. Smits,2 R. Hoek,3 D. Green,2 P. Evrard,4 C. Knoop,5G.M. Verleden,1 B. Rondelet,6 J.M. Kwakkel-vanErp,7 L. Seghers,8D.A. van Kessel,9 B. Luijk,9 E.A. Verschuuren,10 G. Lang,11 K.Hoetzenecker,11 G. Laufer,11 D. Hoefer,12 F. Langer,13 R. Schramm,14T. Deuse,15 R. Buhl,16 C. Witt,17 and J. Gottlieb.18 1University HospitalsLeuven, Leuven, Belgium; 2Eurotransplant International Foundation,S376 The Journal of Heart and Lung Transplantation, Vol 39, No 4S, April 2020Leiden, Netherlands; 3Erasmus University Medical Center, Rotterdam,Netherlands; 4Centre Hospitalier Universitaire Universite Catholique deLouvain, Namur Godinne, Belgium; 5Universite Libre de Bruxelles, HôpitalErasme, Bruxelles, Belgium; 6Universite Catholique de Louvain, CHUMont-Godinne, Namur, Godinne, Belgium; 7University Antwerp, UZA,Antwerp, Belgium; 8Erasmus MC, Rotterdam, Netherlands; 9UniversityMedical Center, Utrecht, Utrecht, Netherlands; 10University of Groningen,Groningen, Netherlands; 11Medical University of Vienna, Vienna, Austria;12Medical University Innsbruck, Innsbruck, Austria; 13Saarland UniversityMedical Center, Homburg/Saar, Homburg/Saar, Germany; 14RuhrUniversity of Bochum, Bad Oeynhausen, Germany; 15University HospitalEppendorf, Hamburg, Germany; 16Medizinische Klinik und Poliklinik derUniversit€atsmedizin Mainz, Main, Germany; 17Charite -Universit€atsmedizin Berlin, Berlin, Germany; and the 18Hannover MedicalSchool, Hannover, Germany.Purpose: Following introduction of the lung allocation score (LAS) in 2011,Eurotransplant member centers can apply for an exceptional LAS (eLAS) ifthe calculated LAS insufficiently reflects the perceived transplant benefit for apatient, specifically in case of primary pulmonary hypertension group 1 and 4;combined lung+nonrenal transplantation; rare diseases; or extracorporealsupport. Each eLAS proposal is evaluated by a LAS Review Board, consistingof ≥3 lung transplant experts, which subsequently declines or approves theeLAS request in consensus of ≥3 votes. In case of a lower than accepted score,predefined business rules to assign LAS percentiles are used.Methods: A retrospective analysis of all eLAS requests in Eurotransplantfrom December 2011 until September 2019.Results: Overall, 5183 lung transplants (deceased donors) were performedand 420 eLAS requests were made (Germany 52%, Netherlands 18%, Aus-tria 18%, Belgium 13%), of which 116 (28%) were approved. Most eLASrequests concerned group B/Pulmonary vascular disease (44%), followedby group C/Cystic fibrosis or immunodeficiency disorder (28%), thengroup D/Restrictive lung disease (15%) and finally group A/Obstructivelung disease (11%); whereas 10 patients (2%) were not classified. The pro-portion of accepted eLAS requests significantly differed between countries(Germany 25%, Netherlands 37%, Austria 20%, Belgium 36%) (p=0.042).eLAS requests decreased in the Netherlands following its LAS introduc-tion in 2014 (2011-2014 mean 13/yr vs. 2015-2019 mean 4.6/yr; p=0.060).However, since 2015 an overall annual increasing number of eLASrequests is seen, with doubling of the eLAS requests in 2018 vs. 2015, butno difference in acceptance rate (2015-2018: 22.4%) (Figure). Acceptancerates were 38% for Group B, 21% for Group C, 20% for Group D and 11%for Group A.Conclusion: The observed variations require further investigation to opti-mize lung allocation for specific patient populations in Eurotransplant.(944)Lung Transplantation from Controlled and Uncontrolled Donation afterCirculatory Death Donors. Single Centre ExperienceA. Palleschi,1 V. Musso,1 R. Lorenzo,1 D. Tosi,1 I. Righi,1P. Mendogni,1 V. Rossetti,2 A. Zanella,3 and M. Nosotti.1 1ThoracicSurgery and Lung Transplantation Unit, Fondazione IRCCS Ca’Granda - Ospedale Maggiore Policlinico, Milan, Italy; 2Pneumology Unit,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico,Milan, Italy; and the 3Anesthesia, Critical Care and Emergency,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan,Italy.Purpose: We started our uncontrolled donation after circulatory death(DCD) experience in 2014 with the first successful lung transplantation(LT). After a long period of local logistical reassessment, in 2017 weresumed the process managing both uncontrolled and controlled DCD.This cohort study reviews early outcome of our initial series of LT fromDCD donors and matches it with the outcome of patients transplanted withgraft from donation after brain death (DBD) donors in the same period.Methods: This is a single-institution, retrospective study on data collectedprospectively from adult patients who underwent bilateral LT at our Centrebetween 10/2017 and 07/2019. Our DCD procurement protocol consists of:1) an in situ graft preservation with open-lung approach (cPAP); 2) non-rapid normothermic lung procurement isolated (only-lung uncontrolledsetting) or during abdominal normothermic regional perfusion, namelywithout pleural topical cooling before the start of PA flushing (multiorgancontrolled setting); 3) ex-situ assessment/evaluation with machine perfu-sion (EVLP or OCS) before LT.Results: In the study period 51 subjects respected inclusion criteria(Table). Ten of these were from DCD donors (19.6%; 6 cDCD and 4uDCD). The flow-chart shows the DCD experience (Image).Conclusion: Our DCD program increased the LT number with an adequateearly-intermediate outcome, despite extended periods of warm ischemia.Our results suggest that LT from DCD donors is feasible in controlled anduncontrolled setting, in isolated and combined organs procurement.Variables DCD group DBD groupNumber of lung transplantations 10 41DonorGender, male 9 (90%) 28 (68.3%)Age, years, median (95% CI) 54 (47.3 to 60.1) 50 (37.7 to 53.0)cDCD ISHLT-interval 1, minutes,median (95% CI)12 (5 to 25) NAcDCD ISHLT-interval 3, minutes,median (95% CI)176 (122 to 191) NATime from PA flush to 1st lung reperfusion(without machine perfusion time),minutes, mean (95% CI)640 (505 to 775) 435 (386 to 483)RecipientsGender, male 23 (56%) 5 (50%)Age, years, median (95% CI) 42 (24.9 to 51.5) 37 (31.7 to 48.4)Disease: CF, COPD, IPF 7; 2; 1 (70%; 20%;10%)27; 4; 10 (66%;10%; 24%)LAS, median (95% CI) 40 (34.9 to 49.3) 40.5 (38.4 to 45.5)Machine perfusion rate 100% 17.6%Intraoperative ECMO 6 (60%) 20 (50%)Postop. MV, days, median (95% CI) 2 (1 to 4) 1 (1 to 1)30-day mortality rate 0% 0%1-year mortality rate 0% 2%Best FEV1, mean (95% CI) 82.7 (69.3 to 96.0) 90.1 (84.2 to 95.9)Airway complication 2 (20%) 3 (7.3%)

   University of GroningenExceptional LAS Requests in EurotransplantVos, R.; Smits, J. M.; Hoek, R.; Green, D.; Evrard, P.; Knoop, C.; Verleden, G. M.; Rondelet,B.; Kwakkel-vanErp, J. M.; Seghers, L.Published in:Journal of Heart and Lung TransplantationIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2020Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Vos, R., Smits, J. M., Hoek, R., Green, D., Evrard, P., Knoop, C., Verleden, G. M., Rondelet, B., Kwakkel-vanErp, J. M., Seghers, L., van Kessel, D. A., Luijk, B., Verschuuren, E. A., Lang, G., Hoetzenecker, K.,Laufer, G., Hoefer, D., Langer, F., Schramm, R., ... Gottlieb, J. (2020). Exceptional LAS Requests inEurotransplant: Analysis of an 8-year Effort to Improve Lung Allocation for Precarious Patients. Journal ofHeart and Lung Transplantation, 39(4), S375-S376. http://10.1016/j.healun.2020.01.475CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 19-11-2022Abstracts S375Purpose: A total of 180 lung transplantations (LTx) were performed at asingle center in Saudi Arabia. 92% of our donors were marginal. The crite-ria of deceased brain dead donors represent unique differences that bringunique challenges. This report highlights the challenges, managementstrategies and outcomes.Methods: The LTx Program at King Faisal specialist hospital was estab-lished in 2000. Over the last 9 years the program has witnessed rapidgrowth. Retrospective review of 180 patients and their donors that under-went LTx at our center between January 2010 and September 2019.Results: The most common indication for LTx was pulmonary fibrosis(40%), followed by cystic fibrosis (CF)-related bronchiectasis (24%), non-CF-related bronchiectasis (21%), chronic obstructive pulmonary disease(4%), sarcoidosis (3%), Microtithiasis (3%).Regarding Lung donors (LDs)92% of our lungs were marginal. 10% age >55 years, 16% PO2 <300mmhg, 32% abnormal CXR, 22% Purulent secretions on bronchoscopy,83% Prolonged ventilation more than 5 days with a mean duration ofmechanical ventilation (MV) of 9+/-7 (days). Bacterial colonization wasnoted in 74% of LDs, including multidrug-resistant bacteria such as acine-tobacter (31%), klibsiellae (24%) and pseudomonas (12%). Over the last5 years extracorporeal membrane oxygenation (ECMO), was used in21.5% of our LTx as a rescue strategy for grade 3 primary graft dysfunc-tion with 30 days survival of 92% and 1 year survival 88%. Ex vivo lungperfusion was used to expand our pool of LDs, 9 successful cases from 20attempts were performed over the last 5 years. In spite of the liberal utiliza-tion of marginal donors and prolonged post lung transplantation mechani-cal ventilation {Median (range)} 11 (1-145 days), length of ICU stay 14(3-145) and length of hospital stay 36 (12-168), our 30 days, 90 days, 1year, 3 years and 5 years survival rates were 94.3%, 89%, 87.5%, 76% and62.5% respectively which is comparable to the international standards.Conclusion: Shortage of good donors forced us to use extended criteria totransplant moderate and high risk patients. The selective use of Ex vivoand ECMO helped to achieve comparable results. Marginal donors evenwith bacterial colonization can be successfully utilized for LTx.(941)Prone Ventilation in Brain-Dead Organ Donors Acutely IncreasesOxygenation and Results in More Lungs TransplantedG.F. Marklin,1 C. O'Sullivan,1 and R. Dhar.2 1Mid-America Transplant,St Louis, MO; and the 2Neurology, Washington University in St. LouisSchool of Medicine, St Louis, MO.Purpose: A PaO2/FiO2 ratio (PFR) above 300 is a primary donor criterionfor lung transplantation. Absence of cough and respiratory drive in thebrain-dead (BD) donor results in basilar atelectasis, contributing to V/Qmismatching and hypoxemia. We hypothesized that ventilating BD donorsin the prone position would result in better V/Q matching, increased PFR,and more lungs transplanted.Methods: All BD donors at our OPO are treated with a lung-protectiveventilation strategy, recruitment maneuvers and repeated fiberopticbronchoscopy (FOB). Since June 2018, a prone ventilation protocolwas instituted for donors meeting the eligibility criteria: 12-70 yearsold, basilar atelectasis on X-ray or CT, and a PFR <300 after the firstFOB. Eligible donors were placed in the prone position for at least12 hours with all routine treatments continued. PFR was measured atfour, eight, and twelve hours, as well as prior to procurement, andchange calculated from baseline (ΔPO2). The control group consistedof 81 hypoxemic donors treated with routine care in the supine posi-tion in the two years prior.Results: In 14 months, 27 donors met eligibility criteria and were enrolled.Median baseline PFR was 222 mm Hg (IQR 181-270) compared to 187(116-250) in controls (p=0.06). PFR increased more after four hours ofprone ventilation (102 vs. 54 mm Hg, p=0.01), to 348 mm Hg (269-409)versus 264 (156-339) with supine ventilation. At 12-hours, there was atrend for PFR to remain higher: 351 (260-434) vs. 280 (157-358, p=0.13).Final PFR was 385 mm Hg (328-424) vs. 289 mm Hg (219-440, p=0.09)although ΔPO2 was comparable. However, more lungs were transplantedin the prone group (14 of 27 donors, 52%) compared to 23% in the controlgroup, an effect persisting after adjusting for baseline PFR (OR 3.0, 95%CI: 1.2-7.8, p=0.02).Conclusion: Prone ventilation acutely improved oxygenation in hypox-emic BD organ donors with basilar atelectasis relative to those managed inthe supine position and resulted in more lungs transplanted.(942)Disparities in the Lung Allocation Score Due to Geography Have NotChanged Since November 2017L. Benvenuto, M. Aversa, M. Anderson, L. Shah, J. Costa, B.P. Stanifer,H. Robbins, F. D'Ovidio, J. Sonett and S.M. Arcasoy Columbia UniversityMedical Center, New York, NY.Purpose: Differences in geographic donor lung availability affect waitlist out-comes. We hypothesized that the lung allocation score (LAS) at transplant andwaitlist time would vary based on local donor lung availability and that broadergeographic sharing since November 2017 would improve these disparities.Methods: Using UNOS data, we conducted a retrospective cohort study of23,414 lung transplant recipients from January 1, 2006 - December 31,2018. Local lung availability was defined as the ratio of donor lungs towaitlist candidates in the local donation service area. We calculated thelocal lung availability for candidates prior to November 25, 2017. We usedmixed multivariable linear regression and Poisson regression, adjusting fortime dependent LAS changes, to examine the relationship between locallung availability, LAS at transplant and waitlist time. We used Wilcoxonrank-sum to compare LAS at transplant before and after November 2017.Results: Compared to recipients in the top quartile with greatest local lungavailability, recipients in the lowest quartile were transplanted with a LAS6.2 points higher (95% CI: 5.6-6.9, p <0.001) and waited significantly lon-ger, 186 days (95% CI: 178-194) compared with 93 days (95%CI: 88-97),p <0.001. This difference varied by transplant type, with single lungsrecipients transplanted with a LAS 2.0 points higher in the lowest quartile(95%CI: 0.9-3.0, p < 0.001) compared with the top and double lung recipi-ents transplanted with a LAS 8.8 points higher (95% CI: 8.0-9.6, p<0.001)in the lowest quartile compared with the top. At centers in the lowest quar-tile of local lung availability, the LAS at transplant did not meaningfullychange after November 2017 (44.1 § 15.2, compared to 45.7§ 16.3,p=0.042), however the waitlist time did decrease from 206 days (95%CI:192-222) to 155 days, (95% CI: 133-176), p <0.001. The LAS at transplantand waitlist time for recipients did not change at high local lung availabil-ity centers (50.7 § 19.6 compared to 51.3 § 19.6, p=0.38, and 74 days(95%CI: 66-81) compared to 61 days (95%CI: 52-70), p=0.66).Conclusion: Prior to November 2017, low local lung availability was associ-ated with longer waitlist times and higher LAS at transplant that were muchmore pronounced for double lung recipients. Since expanding allocation to 250miles, meaningful differences in LAS at transplant have not yet been observed.(943)Exceptional LAS Requests in Eurotransplant: Analysis of an 8-yearEffort to Improve Lung Allocation for Precarious PatientsR. Vos,1 J.M. Smits,2 R. Hoek,3 D. Green,2 P. Evrard,4 C. Knoop,5G.M. Verleden,1 B. Rondelet,6 J.M. Kwakkel-vanErp,7 L. Seghers,8D.A. van Kessel,9 B. Luijk,9 E.A. Verschuuren,10 G. Lang,11 K.Hoetzenecker,11 G. Laufer,11 D. Hoefer,12 F. Langer,13 R. Schramm,14T. Deuse,15 R. Buhl,16 C. Witt,17 and J. Gottlieb.18 1University HospitalsLeuven, Leuven, Belgium; 2Eurotransplant International Foundation,S376 The Journal of Heart and Lung Transplantation, Vol 39, No 4S, April 2020Leiden, Netherlands; 3Erasmus University Medical Center, Rotterdam,Netherlands; 4Centre Hospitalier Universitaire Universite Catholique deLouvain, Namur Godinne, Belgium; 5Universite Libre de Bruxelles, HôpitalErasme, Bruxelles, Belgium; 6Universite Catholique de Louvain, CHUMont-Godinne, Namur, Godinne, Belgium; 7University Antwerp, UZA,Antwerp, Belgium; 8Erasmus MC, Rotterdam, Netherlands; 9UniversityMedical Center, Utrecht, Utrecht, Netherlands; 10University of Groningen,Groningen, Netherlands; 11Medical University of Vienna, Vienna, Austria;12Medical University Innsbruck, Innsbruck, Austria; 13Saarland UniversityMedical Center, Homburg/Saar, Homburg/Saar, Germany; 14RuhrUniversity of Bochum, Bad Oeynhausen, Germany; 15University HospitalEppendorf, Hamburg, Germany; 16Medizinische Klinik und Poliklinik derUniversit€atsmedizin Mainz, Main, Germany; 17Charite -Universit€atsmedizin Berlin, Berlin, Germany; and the 18Hannover MedicalSchool, Hannover, Germany.Purpose: Following introduction of the lung allocation score (LAS) in 2011,Eurotransplant member centers can apply for an exceptional LAS (eLAS) ifthe calculated LAS insufficiently reflects the perceived transplant benefit for apatient, specifically in case of primary pulmonary hypertension group 1 and 4;combined lung+nonrenal transplantation; rare diseases; or extracorporealsupport. Each eLAS proposal is evaluated by a LAS Review Board, consistingof ≥3 lung transplant experts, which subsequently declines or approves theeLAS request in consensus of ≥3 votes. In case of a lower than accepted score,predefined business rules to assign LAS percentiles are used.Methods: A retrospective analysis of all eLAS requests in Eurotransplantfrom December 2011 until September 2019.Results: Overall, 5183 lung transplants (deceased donors) were performedand 420 eLAS requests were made (Germany 52%, Netherlands 18%, Aus-tria 18%, Belgium 13%), of which 116 (28%) were approved. Most eLASrequests concerned group B/Pulmonary vascular disease (44%), followedby group C/Cystic fibrosis or immunodeficiency disorder (28%), thengroup D/Restrictive lung disease (15%) and finally group A/Obstructivelung disease (11%); whereas 10 patients (2%) were not classified. The pro-portion of accepted eLAS requests significantly differed between countries(Germany 25%, Netherlands 37%, Austria 20%, Belgium 36%) (p=0.042).eLAS requests decreased in the Netherlands following its LAS introduc-tion in 2014 (2011-2014 mean 13/yr vs. 2015-2019 mean 4.6/yr; p=0.060).However, since 2015 an overall annual increasing number of eLASrequests is seen, with doubling of the eLAS requests in 2018 vs. 2015, butno difference in acceptance rate (2015-2018: 22.4%) (Figure). Acceptancerates were 38% for Group B, 21% for Group C, 20% for Group D and 11%for Group A.Conclusion: The observed variations require further investigation to opti-mize lung allocation for specific patient populations in Eurotransplant.(944)Lung Transplantation from Controlled and Uncontrolled Donation afterCirculatory Death Donors. Single Centre ExperienceA. Palleschi,1 V. Musso,1 R. Lorenzo,1 D. Tosi,1 I. Righi,1P. Mendogni,1 V. Rossetti,2 A. Zanella,3 and M. Nosotti.1 1ThoracicSurgery and Lung Transplantation Unit, Fondazione IRCCS Ca’Granda - Ospedale Maggiore Policlinico, Milan, Italy; 2Pneumology Unit,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico,Milan, Italy; and the 3Anesthesia, Critical Care and Emergency,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan,Italy.Purpose: We started our uncontrolled donation after circulatory death(DCD) experience in 2014 with the first successful lung transplantation(LT). After a long period of local logistical reassessment, in 2017 weresumed the process managing both uncontrolled and controlled DCD.This cohort study reviews early outcome of our initial series of LT fromDCD donors and matches it with the outcome of patients transplanted withgraft from donation after brain death (DBD) donors in the same period.Methods: This is a single-institution, retrospective study on data collectedprospectively from adult patients who underwent bilateral LT at our Centrebetween 10/2017 and 07/2019. Our DCD procurement protocol consists of:1) an in situ graft preservation with open-lung approach (cPAP); 2) non-rapid normothermic lung procurement isolated (only-lung uncontrolledsetting) or during abdominal normothermic regional perfusion, namelywithout pleural topical cooling before the start of PA flushing (multiorgancontrolled setting); 3) ex-situ assessment/evaluation with machine perfu-sion (EVLP or OCS) before LT.Results: In the study period 51 subjects respected inclusion criteria(Table). Ten of these were from DCD donors (19.6%; 6 cDCD and 4uDCD). The flow-chart shows the DCD experience (Image).Conclusion: Our DCD program increased the LT number with an adequateearly-intermediate outcome, despite extended periods of warm ischemia.Our results suggest that LT from DCD donors is feasible in controlled anduncontrolled setting, in isolated and combined organs procurement.Variables DCD group DBD groupNumber of lung transplantations 10 41DonorGender, male 9 (90%) 28 (68.3%)Age, years, median (95% CI) 54 (47.3 to 60.1) 50 (37.7 to 53.0)cDCD ISHLT-interval 1, minutes,median (95% CI)12 (5 to 25) NAcDCD ISHLT-interval 3, minutes,median (95% CI)176 (122 to 191) NATime from PA flush to 1st lung reperfusion(without machine perfusion time),minutes, mean (95% CI)640 (505 to 775) 435 (386 to 483)RecipientsGender, male 23 (56%) 5 (50%)Age, years, median (95% CI) 42 (24.9 to 51.5) 37 (31.7 to 48.4)Disease: CF, COPD, IPF 7; 2; 1 (70%; 20%;10%)27; 4; 10 (66%;10%; 24%)LAS, median (95% CI) 40 (34.9 to 49.3) 40.5 (38.4 to 45.5)Machine perfusion rate 100% 17.6%Intraoperative ECMO 6 (60%) 20 (50%)Postop. MV, days, median (95% CI) 2 (1 to 4) 1 (1 to 1)30-day mortality rate 0% 0%1-year mortality rate 0% 2%Best FEV1, mean (95% CI) 82.7 (69.3 to 96.0) 90.1 (84.2 to 95.9)Airway complication 2 (20%) 3 (7.3%)

Proceedings - University of Groningen

   University of GroningenExceptional LAS Requests in EurotransplantVos, R.; Smits, J. M.; Hoek, R.; Green, D.; Evrard, P.; Knoop, C.; Verleden, G. M.; Rondelet,B.; Kwakkel-vanErp, J. M.; Seghers, L.Published in:Journal of Heart and Lung TransplantationIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2020Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Vos, R., Smits, J. M., Hoek, R., Green, D., Evrard, P., Knoop, C., Verleden, G. M., Rondelet, B., Kwakkel-vanErp, J. M., Seghers, L., van Kessel, D. A., Luijk, B., Verschuuren, E. A., Lang, G., Hoetzenecker, K.,Laufer, G., Hoefer, D., Langer, F., Schramm, R., ... Gottlieb, J. (2020). Exceptional LAS Requests inEurotransplant: Analysis of an 8-year Effort to Improve Lung Allocation for Precarious Patients. Journal ofHeart and Lung Transplantation, 39(4), S375-S376. http://10.1016/j.healun.2020.01.475CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 05-12-2023Abstracts S375Purpose: A total of 180 lung transplantations (LTx) were performed at asingle center in Saudi Arabia. 92% of our donors were marginal. The crite-ria of deceased brain dead donors represent unique differences that bringunique challenges. This report highlights the challenges, managementstrategies and outcomes.Methods: The LTx Program at King Faisal specialist hospital was estab-lished in 2000. Over the last 9 years the program has witnessed rapidgrowth. Retrospective review of 180 patients and their donors that under-went LTx at our center between January 2010 and September 2019.Results: The most common indication for LTx was pulmonary fibrosis(40%), followed by cystic fibrosis (CF)-related bronchiectasis (24%), non-CF-related bronchiectasis (21%), chronic obstructive pulmonary disease(4%), sarcoidosis (3%), Microtithiasis (3%).Regarding Lung donors (LDs)92% of our lungs were marginal. 10% age >55 years, 16% PO2 <300mmhg, 32% abnormal CXR, 22% Purulent secretions on bronchoscopy,83% Prolonged ventilation more than 5 days with a mean duration ofmechanical ventilation (MV) of 9+/-7 (days). Bacterial colonization wasnoted in 74% of LDs, including multidrug-resistant bacteria such as acine-tobacter (31%), klibsiellae (24%) and pseudomonas (12%). Over the last5 years extracorporeal membrane oxygenation (ECMO), was used in21.5% of our LTx as a rescue strategy for grade 3 primary graft dysfunc-tion with 30 days survival of 92% and 1 year survival 88%. Ex vivo lungperfusion was used to expand our pool of LDs, 9 successful cases from 20attempts were performed over the last 5 years. In spite of the liberal utiliza-tion of marginal donors and prolonged post lung transplantation mechani-cal ventilation {Median (range)} 11 (1-145 days), length of ICU stay 14(3-145) and length of hospital stay 36 (12-168), our 30 days, 90 days, 1year, 3 years and 5 years survival rates were 94.3%, 89%, 87.5%, 76% and62.5% respectively which is comparable to the international standards.Conclusion: Shortage of good donors forced us to use extended criteria totransplant moderate and high risk patients. The selective use of Ex vivoand ECMO helped to achieve comparable results. Marginal donors evenwith bacterial colonization can be successfully utilized for LTx.(941)Prone Ventilation in Brain-Dead Organ Donors Acutely IncreasesOxygenation and Results in More Lungs TransplantedG.F. Marklin,1 C. O'Sullivan,1 and R. Dhar.2 1Mid-America Transplant,St Louis, MO; and the 2Neurology, Washington University in St. LouisSchool of Medicine, St Louis, MO.Purpose: A PaO2/FiO2 ratio (PFR) above 300 is a primary donor criterionfor lung transplantation. Absence of cough and respiratory drive in thebrain-dead (BD) donor results in basilar atelectasis, contributing to V/Qmismatching and hypoxemia. We hypothesized that ventilating BD donorsin the prone position would result in better V/Q matching, increased PFR,and more lungs transplanted.Methods: All BD donors at our OPO are treated with a lung-protectiveventilation strategy, recruitment maneuvers and repeated fiberopticbronchoscopy (FOB). Since June 2018, a prone ventilation protocolwas instituted for donors meeting the eligibility criteria: 12-70 yearsold, basilar atelectasis on X-ray or CT, and a PFR <300 after the firstFOB. Eligible donors were placed in the prone position for at least12 hours with all routine treatments continued. PFR was measured atfour, eight, and twelve hours, as well as prior to procurement, andchange calculated from baseline (ΔPO2). The control group consistedof 81 hypoxemic donors treated with routine care in the supine posi-tion in the two years prior.Results: In 14 months, 27 donors met eligibility criteria and were enrolled.Median baseline PFR was 222 mm Hg (IQR 181-270) compared to 187(116-250) in controls (p=0.06). PFR increased more after four hours ofprone ventilation (102 vs. 54 mm Hg, p=0.01), to 348 mm Hg (269-409)versus 264 (156-339) with supine ventilation. At 12-hours, there was atrend for PFR to remain higher: 351 (260-434) vs. 280 (157-358, p=0.13).Final PFR was 385 mm Hg (328-424) vs. 289 mm Hg (219-440, p=0.09)although ΔPO2 was comparable. However, more lungs were transplantedin the prone group (14 of 27 donors, 52%) compared to 23% in the controlgroup, an effect persisting after adjusting for baseline PFR (OR 3.0, 95%CI: 1.2-7.8, p=0.02).Conclusion: Prone ventilation acutely improved oxygenation in hypox-emic BD organ donors with basilar atelectasis relative to those managed inthe supine position and resulted in more lungs transplanted.(942)Disparities in the Lung Allocation Score Due to Geography Have NotChanged Since November 2017L. Benvenuto, M. Aversa, M. Anderson, L. Shah, J. Costa, B.P. Stanifer,H. Robbins, F. D'Ovidio, J. Sonett and S.M. Arcasoy Columbia UniversityMedical Center, New York, NY.Purpose: Differences in geographic donor lung availability affect waitlist out-comes. We hypothesized that the lung allocation score (LAS) at transplant andwaitlist time would vary based on local donor lung availability and that broadergeographic sharing since November 2017 would improve these disparities.Methods: Using UNOS data, we conducted a retrospective cohort study of23,414 lung transplant recipients from January 1, 2006 - December 31,2018. Local lung availability was defined as the ratio of donor lungs towaitlist candidates in the local donation service area. We calculated thelocal lung availability for candidates prior to November 25, 2017. We usedmixed multivariable linear regression and Poisson regression, adjusting fortime dependent LAS changes, to examine the relationship between locallung availability, LAS at transplant and waitlist time. We used Wilcoxonrank-sum to compare LAS at transplant before and after November 2017.Results: Compared to recipients in the top quartile with greatest local lungavailability, recipients in the lowest quartile were transplanted with a LAS6.2 points higher (95% CI: 5.6-6.9, p <0.001) and waited significantly lon-ger, 186 days (95% CI: 178-194) compared with 93 days (95%CI: 88-97),p <0.001. This difference varied by transplant type, with single lungsrecipients transplanted with a LAS 2.0 points higher in the lowest quartile(95%CI: 0.9-3.0, p < 0.001) compared with the top and double lung recipi-ents transplanted with a LAS 8.8 points higher (95% CI: 8.0-9.6, p<0.001)in the lowest quartile compared with the top. At centers in the lowest quar-tile of local lung availability, the LAS at transplant did not meaningfullychange after November 2017 (44.1 § 15.2, compared to 45.7§ 16.3,p=0.042), however the waitlist time did decrease from 206 days (95%CI:192-222) to 155 days, (95% CI: 133-176), p <0.001. The LAS at transplantand waitlist time for recipients did not change at high local lung availabil-ity centers (50.7 § 19.6 compared to 51.3 § 19.6, p=0.38, and 74 days(95%CI: 66-81) compared to 61 days (95%CI: 52-70), p=0.66).Conclusion: Prior to November 2017, low local lung availability was associ-ated with longer waitlist times and higher LAS at transplant that were muchmore pronounced for double lung recipients. Since expanding allocation to 250miles, meaningful differences in LAS at transplant have not yet been observed.(943)Exceptional LAS Requests in Eurotransplant: Analysis of an 8-yearEffort to Improve Lung Allocation for Precarious PatientsR. Vos,1 J.M. Smits,2 R. Hoek,3 D. Green,2 P. Evrard,4 C. Knoop,5G.M. Verleden,1 B. Rondelet,6 J.M. Kwakkel-vanErp,7 L. Seghers,8D.A. van Kessel,9 B. Luijk,9 E.A. Verschuuren,10 G. Lang,11 K.Hoetzenecker,11 G. Laufer,11 D. Hoefer,12 F. Langer,13 R. Schramm,14T. Deuse,15 R. Buhl,16 C. Witt,17 and J. Gottlieb.18 1University HospitalsLeuven, Leuven, Belgium; 2Eurotransplant International Foundation,S376 The Journal of Heart and Lung Transplantation, Vol 39, No 4S, April 2020Leiden, Netherlands; 3Erasmus University Medical Center, Rotterdam,Netherlands; 4Centre Hospitalier Universitaire Universite Catholique deLouvain, Namur Godinne, Belgium; 5Universite Libre de Bruxelles, HôpitalErasme, Bruxelles, Belgium; 6Universite Catholique de Louvain, CHUMont-Godinne, Namur, Godinne, Belgium; 7University Antwerp, UZA,Antwerp, Belgium; 8Erasmus MC, Rotterdam, Netherlands; 9UniversityMedical Center, Utrecht, Utrecht, Netherlands; 10University of Groningen,Groningen, Netherlands; 11Medical University of Vienna, Vienna, Austria;12Medical University Innsbruck, Innsbruck, Austria; 13Saarland UniversityMedical Center, Homburg/Saar, Homburg/Saar, Germany; 14RuhrUniversity of Bochum, Bad Oeynhausen, Germany; 15University HospitalEppendorf, Hamburg, Germany; 16Medizinische Klinik und Poliklinik derUniversit€atsmedizin Mainz, Main, Germany; 17Charite -Universit€atsmedizin Berlin, Berlin, Germany; and the 18Hannover MedicalSchool, Hannover, Germany.Purpose: Following introduction of the lung allocation score (LAS) in 2011,Eurotransplant member centers can apply for an exceptional LAS (eLAS) ifthe calculated LAS insufficiently reflects the perceived transplant benefit for apatient, specifically in case of primary pulmonary hypertension group 1 and 4;combined lung+nonrenal transplantation; rare diseases; or extracorporealsupport. Each eLAS proposal is evaluated by a LAS Review Board, consistingof ≥3 lung transplant experts, which subsequently declines or approves theeLAS request in consensus of ≥3 votes. In case of a lower than accepted score,predefined business rules to assign LAS percentiles are used.Methods: A retrospective analysis of all eLAS requests in Eurotransplantfrom December 2011 until September 2019.Results: Overall, 5183 lung transplants (deceased donors) were performedand 420 eLAS requests were made (Germany 52%, Netherlands 18%, Aus-tria 18%, Belgium 13%), of which 116 (28%) were approved. Most eLASrequests concerned group B/Pulmonary vascular disease (44%), followedby group C/Cystic fibrosis or immunodeficiency disorder (28%), thengroup D/Restrictive lung disease (15%) and finally group A/Obstructivelung disease (11%); whereas 10 patients (2%) were not classified. The pro-portion of accepted eLAS requests significantly differed between countries(Germany 25%, Netherlands 37%, Austria 20%, Belgium 36%) (p=0.042).eLAS requests decreased in the Netherlands following its LAS introduc-tion in 2014 (2011-2014 mean 13/yr vs. 2015-2019 mean 4.6/yr; p=0.060).However, since 2015 an overall annual increasing number of eLASrequests is seen, with doubling of the eLAS requests in 2018 vs. 2015, butno difference in acceptance rate (2015-2018: 22.4%) (Figure). Acceptancerates were 38% for Group B, 21% for Group C, 20% for Group D and 11%for Group A.Conclusion: The observed variations require further investigation to opti-mize lung allocation for specific patient populations in Eurotransplant.(944)Lung Transplantation from Controlled and Uncontrolled Donation afterCirculatory Death Donors. Single Centre ExperienceA. Palleschi,1 V. Musso,1 R. Lorenzo,1 D. Tosi,1 I. Righi,1P. Mendogni,1 V. Rossetti,2 A. Zanella,3 and M. Nosotti.1 1ThoracicSurgery and Lung Transplantation Unit, Fondazione IRCCS Ca’Granda - Ospedale Maggiore Policlinico, Milan, Italy; 2Pneumology Unit,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico,Milan, Italy; and the 3Anesthesia, Critical Care and Emergency,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan,Italy.Purpose: We started our uncontrolled donation after circulatory death(DCD) experience in 2014 with the first successful lung transplantation(LT). After a long period of local logistical reassessment, in 2017 weresumed the process managing both uncontrolled and controlled DCD.This cohort study reviews early outcome of our initial series of LT fromDCD donors and matches it with the outcome of patients transplanted withgraft from donation after brain death (DBD) donors in the same period.Methods: This is a single-institution, retrospective study on data collectedprospectively from adult patients who underwent bilateral LT at our Centrebetween 10/2017 and 07/2019. Our DCD procurement protocol consists of:1) an in situ graft preservation with open-lung approach (cPAP); 2) non-rapid normothermic lung procurement isolated (only-lung uncontrolledsetting) or during abdominal normothermic regional perfusion, namelywithout pleural topical cooling before the start of PA flushing (multiorgancontrolled setting); 3) ex-situ assessment/evaluation with machine perfu-sion (EVLP or OCS) before LT.Results: In the study period 51 subjects respected inclusion criteria(Table). Ten of these were from DCD donors (19.6%; 6 cDCD and 4uDCD). The flow-chart shows the DCD experience (Image).Conclusion: Our DCD program increased the LT number with an adequateearly-intermediate outcome, despite extended periods of warm ischemia.Our results suggest that LT from DCD donors is feasible in controlled anduncontrolled setting, in isolated and combined organs procurement.Variables DCD group DBD groupNumber of lung transplantations 10 41DonorGender, male 9 (90%) 28 (68.3%)Age, years, median (95% CI) 54 (47.3 to 60.1) 50 (37.7 to 53.0)cDCD ISHLT-interval 1, minutes,median (95% CI)12 (5 to 25) NAcDCD ISHLT-interval 3, minutes,median (95% CI)176 (122 to 191) NATime from PA flush to 1st lung reperfusion(without machine perfusion time),minutes, mean (95% CI)640 (505 to 775) 435 (386 to 483)RecipientsGender, male 23 (56%) 5 (50%)Age, years, median (95% CI) 42 (24.9 to 51.5) 37 (31.7 to 48.4)Disease: CF, COPD, IPF 7; 2; 1 (70%; 20%;10%)27; 4; 10 (66%;10%; 24%)LAS, median (95% CI) 40 (34.9 to 49.3) 40.5 (38.4 to 45.5)Machine perfusion rate 100% 17.6%Intraoperative ECMO 6 (60%) 20 (50%)Postop. MV, days, median (95% CI) 2 (1 to 4) 1 (1 to 1)30-day mortality rate 0% 0%1-year mortality rate 0% 2%Best FEV1, mean (95% CI) 82.7 (69.3 to 96.0) 90.1 (84.2 to 95.9)Airway complication 2 (20%) 3 (7.3%)

   University of GroningenExceptional LAS Requests in EurotransplantVos, R.; Smits, J. M.; Hoek, R.; Green, D.; Evrard, P.; Knoop, C.; Verleden, G. M.; Rondelet,B.; Kwakkel-vanErp, J. M.; Seghers, L.Published in:Journal of Heart and Lung TransplantationIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2020Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Vos, R., Smits, J. M., Hoek, R., Green, D., Evrard, P., Knoop, C., Verleden, G. M., Rondelet, B., Kwakkel-vanErp, J. M., Seghers, L., van Kessel, D. A., Luijk, B., Verschuuren, E. A., Lang, G., Hoetzenecker, K.,Laufer, G., Hoefer, D., Langer, F., Schramm, R., ... Gottlieb, J. (2020). Exceptional LAS Requests inEurotransplant: Analysis of an 8-year Effort to Improve Lung Allocation for Precarious Patients. Journal ofHeart and Lung Transplantation, 39(4), S375-S376. http://10.1016/j.healun.2020.01.475CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 21-06-2022Abstracts S375Purpose: A total of 180 lung transplantations (LTx) were performed at asingle center in Saudi Arabia. 92% of our donors were marginal. The crite-ria of deceased brain dead donors represent unique differences that bringunique challenges. This report highlights the challenges, managementstrategies and outcomes.Methods: The LTx Program at King Faisal specialist hospital was estab-lished in 2000. Over the last 9 years the program has witnessed rapidgrowth. Retrospective review of 180 patients and their donors that under-went LTx at our center between January 2010 and September 2019.Results: The most common indication for LTx was pulmonary fibrosis(40%), followed by cystic fibrosis (CF)-related bronchiectasis (24%), non-CF-related bronchiectasis (21%), chronic obstructive pulmonary disease(4%), sarcoidosis (3%), Microtithiasis (3%).Regarding Lung donors (LDs)92% of our lungs were marginal. 10% age >55 years, 16% PO2 <300mmhg, 32% abnormal CXR, 22% Purulent secretions on bronchoscopy,83% Prolonged ventilation more than 5 days with a mean duration ofmechanical ventilation (MV) of 9+/-7 (days). Bacterial colonization wasnoted in 74% of LDs, including multidrug-resistant bacteria such as acine-tobacter (31%), klibsiellae (24%) and pseudomonas (12%). Over the last5 years extracorporeal membrane oxygenation (ECMO), was used in21.5% of our LTx as a rescue strategy for grade 3 primary graft dysfunc-tion with 30 days survival of 92% and 1 year survival 88%. Ex vivo lungperfusion was used to expand our pool of LDs, 9 successful cases from 20attempts were performed over the last 5 years. In spite of the liberal utiliza-tion of marginal donors and prolonged post lung transplantation mechani-cal ventilation {Median (range)} 11 (1-145 days), length of ICU stay 14(3-145) and length of hospital stay 36 (12-168), our 30 days, 90 days, 1year, 3 years and 5 years survival rates were 94.3%, 89%, 87.5%, 76% and62.5% respectively which is comparable to the international standards.Conclusion: Shortage of good donors forced us to use extended criteria totransplant moderate and high risk patients. The selective use of Ex vivoand ECMO helped to achieve comparable results. Marginal donors evenwith bacterial colonization can be successfully utilized for LTx.(941)Prone Ventilation in Brain-Dead Organ Donors Acutely IncreasesOxygenation and Results in More Lungs TransplantedG.F. Marklin,1 C. O'Sullivan,1 and R. Dhar.2 1Mid-America Transplant,St Louis, MO; and the 2Neurology, Washington University in St. LouisSchool of Medicine, St Louis, MO.Purpose: A PaO2/FiO2 ratio (PFR) above 300 is a primary donor criterionfor lung transplantation. Absence of cough and respiratory drive in thebrain-dead (BD) donor results in basilar atelectasis, contributing to V/Qmismatching and hypoxemia. We hypothesized that ventilating BD donorsin the prone position would result in better V/Q matching, increased PFR,and more lungs transplanted.Methods: All BD donors at our OPO are treated with a lung-protectiveventilation strategy, recruitment maneuvers and repeated fiberopticbronchoscopy (FOB). Since June 2018, a prone ventilation protocolwas instituted for donors meeting the eligibility criteria: 12-70 yearsold, basilar atelectasis on X-ray or CT, and a PFR <300 after the firstFOB. Eligible donors were placed in the prone position for at least12 hours with all routine treatments continued. PFR was measured atfour, eight, and twelve hours, as well as prior to procurement, andchange calculated from baseline (ΔPO2). The control group consistedof 81 hypoxemic donors treated with routine care in the supine posi-tion in the two years prior.Results: In 14 months, 27 donors met eligibility criteria and were enrolled.Median baseline PFR was 222 mm Hg (IQR 181-270) compared to 187(116-250) in controls (p=0.06). PFR increased more after four hours ofprone ventilation (102 vs. 54 mm Hg, p=0.01), to 348 mm Hg (269-409)versus 264 (156-339) with supine ventilation. At 12-hours, there was atrend for PFR to remain higher: 351 (260-434) vs. 280 (157-358, p=0.13).Final PFR was 385 mm Hg (328-424) vs. 289 mm Hg (219-440, p=0.09)although ΔPO2 was comparable. However, more lungs were transplantedin the prone group (14 of 27 donors, 52%) compared to 23% in the controlgroup, an effect persisting after adjusting for baseline PFR (OR 3.0, 95%CI: 1.2-7.8, p=0.02).Conclusion: Prone ventilation acutely improved oxygenation in hypox-emic BD organ donors with basilar atelectasis relative to those managed inthe supine position and resulted in more lungs transplanted.(942)Disparities in the Lung Allocation Score Due to Geography Have NotChanged Since November 2017L. Benvenuto, M. Aversa, M. Anderson, L. Shah, J. Costa, B.P. Stanifer,H. Robbins, F. D'Ovidio, J. Sonett and S.M. Arcasoy Columbia UniversityMedical Center, New York, NY.Purpose: Differences in geographic donor lung availability affect waitlist out-comes. We hypothesized that the lung allocation score (LAS) at transplant andwaitlist time would vary based on local donor lung availability and that broadergeographic sharing since November 2017 would improve these disparities.Methods: Using UNOS data, we conducted a retrospective cohort study of23,414 lung transplant recipients from January 1, 2006 - December 31,2018. Local lung availability was defined as the ratio of donor lungs towaitlist candidates in the local donation service area. We calculated thelocal lung availability for candidates prior to November 25, 2017. We usedmixed multivariable linear regression and Poisson regression, adjusting fortime dependent LAS changes, to examine the relationship between locallung availability, LAS at transplant and waitlist time. We used Wilcoxonrank-sum to compare LAS at transplant before and after November 2017.Results: Compared to recipients in the top quartile with greatest local lungavailability, recipients in the lowest quartile were transplanted with a LAS6.2 points higher (95% CI: 5.6-6.9, p <0.001) and waited significantly lon-ger, 186 days (95% CI: 178-194) compared with 93 days (95%CI: 88-97),p <0.001. This difference varied by transplant type, with single lungsrecipients transplanted with a LAS 2.0 points higher in the lowest quartile(95%CI: 0.9-3.0, p < 0.001) compared with the top and double lung recipi-ents transplanted with a LAS 8.8 points higher (95% CI: 8.0-9.6, p<0.001)in the lowest quartile compared with the top. At centers in the lowest quar-tile of local lung availability, the LAS at transplant did not meaningfullychange after November 2017 (44.1 § 15.2, compared to 45.7§ 16.3,p=0.042), however the waitlist time did decrease from 206 days (95%CI:192-222) to 155 days, (95% CI: 133-176), p <0.001. The LAS at transplantand waitlist time for recipients did not change at high local lung availabil-ity centers (50.7 § 19.6 compared to 51.3 § 19.6, p=0.38, and 74 days(95%CI: 66-81) compared to 61 days (95%CI: 52-70), p=0.66).Conclusion: Prior to November 2017, low local lung availability was associ-ated with longer waitlist times and higher LAS at transplant that were muchmore pronounced for double lung recipients. Since expanding allocation to 250miles, meaningful differences in LAS at transplant have not yet been observed.(943)Exceptional LAS Requests in Eurotransplant: Analysis of an 8-yearEffort to Improve Lung Allocation for Precarious PatientsR. Vos,1 J.M. Smits,2 R. Hoek,3 D. Green,2 P. Evrard,4 C. Knoop,5G.M. Verleden,1 B. Rondelet,6 J.M. Kwakkel-vanErp,7 L. Seghers,8D.A. van Kessel,9 B. Luijk,9 E.A. Verschuuren,10 G. Lang,11 K.Hoetzenecker,11 G. Laufer,11 D. Hoefer,12 F. Langer,13 R. Schramm,14T. Deuse,15 R. Buhl,16 C. Witt,17 and J. Gottlieb.18 1University HospitalsLeuven, Leuven, Belgium; 2Eurotransplant International Foundation,S376 The Journal of Heart and Lung Transplantation, Vol 39, No 4S, April 2020Leiden, Netherlands; 3Erasmus University Medical Center, Rotterdam,Netherlands; 4Centre Hospitalier Universitaire Universite Catholique deLouvain, Namur Godinne, Belgium; 5Universite Libre de Bruxelles, HôpitalErasme, Bruxelles, Belgium; 6Universite Catholique de Louvain, CHUMont-Godinne, Namur, Godinne, Belgium; 7University Antwerp, UZA,Antwerp, Belgium; 8Erasmus MC, Rotterdam, Netherlands; 9UniversityMedical Center, Utrecht, Utrecht, Netherlands; 10University of Groningen,Groningen, Netherlands; 11Medical University of Vienna, Vienna, Austria;12Medical University Innsbruck, Innsbruck, Austria; 13Saarland UniversityMedical Center, Homburg/Saar, Homburg/Saar, Germany; 14RuhrUniversity of Bochum, Bad Oeynhausen, Germany; 15University HospitalEppendorf, Hamburg, Germany; 16Medizinische Klinik und Poliklinik derUniversit€atsmedizin Mainz, Main, Germany; 17Charite -Universit€atsmedizin Berlin, Berlin, Germany; and the 18Hannover MedicalSchool, Hannover, Germany.Purpose: Following introduction of the lung allocation score (LAS) in 2011,Eurotransplant member centers can apply for an exceptional LAS (eLAS) ifthe calculated LAS insufficiently reflects the perceived transplant benefit for apatient, specifically in case of primary pulmonary hypertension group 1 and 4;combined lung+nonrenal transplantation; rare diseases; or extracorporealsupport. Each eLAS proposal is evaluated by a LAS Review Board, consistingof ≥3 lung transplant experts, which subsequently declines or approves theeLAS request in consensus of ≥3 votes. In case of a lower than accepted score,predefined business rules to assign LAS percentiles are used.Methods: A retrospective analysis of all eLAS requests in Eurotransplantfrom December 2011 until September 2019.Results: Overall, 5183 lung transplants (deceased donors) were performedand 420 eLAS requests were made (Germany 52%, Netherlands 18%, Aus-tria 18%, Belgium 13%), of which 116 (28%) were approved. Most eLASrequests concerned group B/Pulmonary vascular disease (44%), followedby group C/Cystic fibrosis or immunodeficiency disorder (28%), thengroup D/Restrictive lung disease (15%) and finally group A/Obstructivelung disease (11%); whereas 10 patients (2%) were not classified. The pro-portion of accepted eLAS requests significantly differed between countries(Germany 25%, Netherlands 37%, Austria 20%, Belgium 36%) (p=0.042).eLAS requests decreased in the Netherlands following its LAS introduc-tion in 2014 (2011-2014 mean 13/yr vs. 2015-2019 mean 4.6/yr; p=0.060).However, since 2015 an overall annual increasing number of eLASrequests is seen, with doubling of the eLAS requests in 2018 vs. 2015, butno difference in acceptance rate (2015-2018: 22.4%) (Figure). Acceptancerates were 38% for Group B, 21% for Group C, 20% for Group D and 11%for Group A.Conclusion: The observed variations require further investigation to opti-mize lung allocation for specific patient populations in Eurotransplant.(944)Lung Transplantation from Controlled and Uncontrolled Donation afterCirculatory Death Donors. Single Centre ExperienceA. Palleschi,1 V. Musso,1 R. Lorenzo,1 D. Tosi,1 I. Righi,1P. Mendogni,1 V. Rossetti,2 A. Zanella,3 and M. Nosotti.1 1ThoracicSurgery and Lung Transplantation Unit, Fondazione IRCCS Ca’Granda - Ospedale Maggiore Policlinico, Milan, Italy; 2Pneumology Unit,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico,Milan, Italy; and the 3Anesthesia, Critical Care and Emergency,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan,Italy.Purpose: We started our uncontrolled donation after circulatory death(DCD) experience in 2014 with the first successful lung transplantation(LT). After a long period of local logistical reassessment, in 2017 weresumed the process managing both uncontrolled and controlled DCD.This cohort study reviews early outcome of our initial series of LT fromDCD donors and matches it with the outcome of patients transplanted withgraft from donation after brain death (DBD) donors in the same period.Methods: This is a single-institution, retrospective study on data collectedprospectively from adult patients who underwent bilateral LT at our Centrebetween 10/2017 and 07/2019. Our DCD procurement protocol consists of:1) an in situ graft preservation with open-lung approach (cPAP); 2) non-rapid normothermic lung procurement isolated (only-lung uncontrolledsetting) or during abdominal normothermic regional perfusion, namelywithout pleural topical cooling before the start of PA flushing (multiorgancontrolled setting); 3) ex-situ assessment/evaluation with machine perfu-sion (EVLP or OCS) before LT.Results: In the study period 51 subjects respected inclusion criteria(Table). Ten of these were from DCD donors (19.6%; 6 cDCD and 4uDCD). The flow-chart shows the DCD experience (Image).Conclusion: Our DCD program increased the LT number with an adequateearly-intermediate outcome, despite extended periods of warm ischemia.Our results suggest that LT from DCD donors is feasible in controlled anduncontrolled setting, in isolated and combined organs procurement.Variables DCD group DBD groupNumber of lung transplantations 10 41DonorGender, male 9 (90%) 28 (68.3%)Age, years, median (95% CI) 54 (47.3 to 60.1) 50 (37.7 to 53.0)cDCD ISHLT-interval 1, minutes,median (95% CI)12 (5 to 25) NAcDCD ISHLT-interval 3, minutes,median (95% CI)176 (122 to 191) NATime from PA flush to 1st lung reperfusion(without machine perfusion time),minutes, mean (95% CI)640 (505 to 775) 435 (386 to 483)RecipientsGender, male 23 (56%) 5 (50%)Age, years, median (95% CI) 42 (24.9 to 51.5) 37 (31.7 to 48.4)Disease: CF, COPD, IPF 7; 2; 1 (70%; 20%;10%)27; 4; 10 (66%;10%; 24%)LAS, median (95% CI) 40 (34.9 to 49.3) 40.5 (38.4 to 45.5)Machine perfusion rate 100% 17.6%Intraoperative ECMO 6 (60%) 20 (50%)Postop. MV, days, median (95% CI) 2 (1 to 4) 1 (1 to 1)30-day mortality rate 0% 0%1-year mortality rate 0% 2%Best FEV1, mean (95% CI) 82.7 (69.3 to 96.0) 90.1 (84.2 to 95.9)Airway complication 2 (20%) 3 (7.3%)

Dissertations of the University of Groningen

   University of GroningenExceptional LAS Requests in EurotransplantVos, R.; Smits, J. M.; Hoek, R.; Green, D.; Evrard, P.; Knoop, C.; Verleden, G. M.; Rondelet,B.; Kwakkel-vanErp, J. M.; Seghers, L.Published in:Journal of Heart and Lung TransplantationIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2020Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Vos, R., Smits, J. M., Hoek, R., Green, D., Evrard, P., Knoop, C., Verleden, G. M., Rondelet, B., Kwakkel-vanErp, J. M., Seghers, L., van Kessel, D. A., Luijk, B., Verschuuren, E. A., Lang, G., Hoetzenecker, K.,Laufer, G., Hoefer, D., Langer, F., Schramm, R., ... Gottlieb, J. (2020). Exceptional LAS Requests inEurotransplant: Analysis of an 8-year Effort to Improve Lung Allocation for Precarious Patients. Journal ofHeart and Lung Transplantation, 39(4), S375-S376. http://10.1016/j.healun.2020.01.475CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 05-06-2022Abstracts S375Purpose: A total of 180 lung transplantations (LTx) were performed at asingle center in Saudi Arabia. 92% of our donors were marginal. The crite-ria of deceased brain dead donors represent unique differences that bringunique challenges. This report highlights the challenges, managementstrategies and outcomes.Methods: The LTx Program at King Faisal specialist hospital was estab-lished in 2000. Over the last 9 years the program has witnessed rapidgrowth. Retrospective review of 180 patients and their donors that under-went LTx at our center between January 2010 and September 2019.Results: The most common indication for LTx was pulmonary fibrosis(40%), followed by cystic fibrosis (CF)-related bronchiectasis (24%), non-CF-related bronchiectasis (21%), chronic obstructive pulmonary disease(4%), sarcoidosis (3%), Microtithiasis (3%).Regarding Lung donors (LDs)92% of our lungs were marginal. 10% age >55 years, 16% PO2 <300mmhg, 32% abnormal CXR, 22% Purulent secretions on bronchoscopy,83% Prolonged ventilation more than 5 days with a mean duration ofmechanical ventilation (MV) of 9+/-7 (days). Bacterial colonization wasnoted in 74% of LDs, including multidrug-resistant bacteria such as acine-tobacter (31%), klibsiellae (24%) and pseudomonas (12%). Over the last5 years extracorporeal membrane oxygenation (ECMO), was used in21.5% of our LTx as a rescue strategy for grade 3 primary graft dysfunc-tion with 30 days survival of 92% and 1 year survival 88%. Ex vivo lungperfusion was used to expand our pool of LDs, 9 successful cases from 20attempts were performed over the last 5 years. In spite of the liberal utiliza-tion of marginal donors and prolonged post lung transplantation mechani-cal ventilation {Median (range)} 11 (1-145 days), length of ICU stay 14(3-145) and length of hospital stay 36 (12-168), our 30 days, 90 days, 1year, 3 years and 5 years survival rates were 94.3%, 89%, 87.5%, 76% and62.5% respectively which is comparable to the international standards.Conclusion: Shortage of good donors forced us to use extended criteria totransplant moderate and high risk patients. The selective use of Ex vivoand ECMO helped to achieve comparable results. Marginal donors evenwith bacterial colonization can be successfully utilized for LTx.(941)Prone Ventilation in Brain-Dead Organ Donors Acutely IncreasesOxygenation and Results in More Lungs TransplantedG.F. Marklin,1 C. O'Sullivan,1 and R. Dhar.2 1Mid-America Transplant,St Louis, MO; and the 2Neurology, Washington University in St. LouisSchool of Medicine, St Louis, MO.Purpose: A PaO2/FiO2 ratio (PFR) above 300 is a primary donor criterionfor lung transplantation. Absence of cough and respiratory drive in thebrain-dead (BD) donor results in basilar atelectasis, contributing to V/Qmismatching and hypoxemia. We hypothesized that ventilating BD donorsin the prone position would result in better V/Q matching, increased PFR,and more lungs transplanted.Methods: All BD donors at our OPO are treated with a lung-protectiveventilation strategy, recruitment maneuvers and repeated fiberopticbronchoscopy (FOB). Since June 2018, a prone ventilation protocolwas instituted for donors meeting the eligibility criteria: 12-70 yearsold, basilar atelectasis on X-ray or CT, and a PFR <300 after the firstFOB. Eligible donors were placed in the prone position for at least12 hours with all routine treatments continued. PFR was measured atfour, eight, and twelve hours, as well as prior to procurement, andchange calculated from baseline (ΔPO2). The control group consistedof 81 hypoxemic donors treated with routine care in the supine posi-tion in the two years prior.Results: In 14 months, 27 donors met eligibility criteria and were enrolled.Median baseline PFR was 222 mm Hg (IQR 181-270) compared to 187(116-250) in controls (p=0.06). PFR increased more after four hours ofprone ventilation (102 vs. 54 mm Hg, p=0.01), to 348 mm Hg (269-409)versus 264 (156-339) with supine ventilation. At 12-hours, there was atrend for PFR to remain higher: 351 (260-434) vs. 280 (157-358, p=0.13).Final PFR was 385 mm Hg (328-424) vs. 289 mm Hg (219-440, p=0.09)although ΔPO2 was comparable. However, more lungs were transplantedin the prone group (14 of 27 donors, 52%) compared to 23% in the controlgroup, an effect persisting after adjusting for baseline PFR (OR 3.0, 95%CI: 1.2-7.8, p=0.02).Conclusion: Prone ventilation acutely improved oxygenation in hypox-emic BD organ donors with basilar atelectasis relative to those managed inthe supine position and resulted in more lungs transplanted.(942)Disparities in the Lung Allocation Score Due to Geography Have NotChanged Since November 2017L. Benvenuto, M. Aversa, M. Anderson, L. Shah, J. Costa, B.P. Stanifer,H. Robbins, F. D'Ovidio, J. Sonett and S.M. Arcasoy Columbia UniversityMedical Center, New York, NY.Purpose: Differences in geographic donor lung availability affect waitlist out-comes. We hypothesized that the lung allocation score (LAS) at transplant andwaitlist time would vary based on local donor lung availability and that broadergeographic sharing since November 2017 would improve these disparities.Methods: Using UNOS data, we conducted a retrospective cohort study of23,414 lung transplant recipients from January 1, 2006 - December 31,2018. Local lung availability was defined as the ratio of donor lungs towaitlist candidates in the local donation service area. We calculated thelocal lung availability for candidates prior to November 25, 2017. We usedmixed multivariable linear regression and Poisson regression, adjusting fortime dependent LAS changes, to examine the relationship between locallung availability, LAS at transplant and waitlist time. We used Wilcoxonrank-sum to compare LAS at transplant before and after November 2017.Results: Compared to recipients in the top quartile with greatest local lungavailability, recipients in the lowest quartile were transplanted with a LAS6.2 points higher (95% CI: 5.6-6.9, p <0.001) and waited significantly lon-ger, 186 days (95% CI: 178-194) compared with 93 days (95%CI: 88-97),p <0.001. This difference varied by transplant type, with single lungsrecipients transplanted with a LAS 2.0 points higher in the lowest quartile(95%CI: 0.9-3.0, p < 0.001) compared with the top and double lung recipi-ents transplanted with a LAS 8.8 points higher (95% CI: 8.0-9.6, p<0.001)in the lowest quartile compared with the top. At centers in the lowest quar-tile of local lung availability, the LAS at transplant did not meaningfullychange after November 2017 (44.1 § 15.2, compared to 45.7§ 16.3,p=0.042), however the waitlist time did decrease from 206 days (95%CI:192-222) to 155 days, (95% CI: 133-176), p <0.001. The LAS at transplantand waitlist time for recipients did not change at high local lung availabil-ity centers (50.7 § 19.6 compared to 51.3 § 19.6, p=0.38, and 74 days(95%CI: 66-81) compared to 61 days (95%CI: 52-70), p=0.66).Conclusion: Prior to November 2017, low local lung availability was associ-ated with longer waitlist times and higher LAS at transplant that were muchmore pronounced for double lung recipients. Since expanding allocation to 250miles, meaningful differences in LAS at transplant have not yet been observed.(943)Exceptional LAS Requests in Eurotransplant: Analysis of an 8-yearEffort to Improve Lung Allocation for Precarious PatientsR. Vos,1 J.M. Smits,2 R. Hoek,3 D. Green,2 P. Evrard,4 C. Knoop,5G.M. Verleden,1 B. Rondelet,6 J.M. Kwakkel-vanErp,7 L. Seghers,8D.A. van Kessel,9 B. Luijk,9 E.A. Verschuuren,10 G. Lang,11 K.Hoetzenecker,11 G. Laufer,11 D. Hoefer,12 F. Langer,13 R. Schramm,14T. Deuse,15 R. Buhl,16 C. Witt,17 and J. Gottlieb.18 1University HospitalsLeuven, Leuven, Belgium; 2Eurotransplant International Foundation,S376 The Journal of Heart and Lung Transplantation, Vol 39, No 4S, April 2020Leiden, Netherlands; 3Erasmus University Medical Center, Rotterdam,Netherlands; 4Centre Hospitalier Universitaire Universite Catholique deLouvain, Namur Godinne, Belgium; 5Universite Libre de Bruxelles, HôpitalErasme, Bruxelles, Belgium; 6Universite Catholique de Louvain, CHUMont-Godinne, Namur, Godinne, Belgium; 7University Antwerp, UZA,Antwerp, Belgium; 8Erasmus MC, Rotterdam, Netherlands; 9UniversityMedical Center, Utrecht, Utrecht, Netherlands; 10University of Groningen,Groningen, Netherlands; 11Medical University of Vienna, Vienna, Austria;12Medical University Innsbruck, Innsbruck, Austria; 13Saarland UniversityMedical Center, Homburg/Saar, Homburg/Saar, Germany; 14RuhrUniversity of Bochum, Bad Oeynhausen, Germany; 15University HospitalEppendorf, Hamburg, Germany; 16Medizinische Klinik und Poliklinik derUniversit€atsmedizin Mainz, Main, Germany; 17Charite -Universit€atsmedizin Berlin, Berlin, Germany; and the 18Hannover MedicalSchool, Hannover, Germany.Purpose: Following introduction of the lung allocation score (LAS) in 2011,Eurotransplant member centers can apply for an exceptional LAS (eLAS) ifthe calculated LAS insufficiently reflects the perceived transplant benefit for apatient, specifically in case of primary pulmonary hypertension group 1 and 4;combined lung+nonrenal transplantation; rare diseases; or extracorporealsupport. Each eLAS proposal is evaluated by a LAS Review Board, consistingof ≥3 lung transplant experts, which subsequently declines or approves theeLAS request in consensus of ≥3 votes. In case of a lower than accepted score,predefined business rules to assign LAS percentiles are used.Methods: A retrospective analysis of all eLAS requests in Eurotransplantfrom December 2011 until September 2019.Results: Overall, 5183 lung transplants (deceased donors) were performedand 420 eLAS requests were made (Germany 52%, Netherlands 18%, Aus-tria 18%, Belgium 13%), of which 116 (28%) were approved. Most eLASrequests concerned group B/Pulmonary vascular disease (44%), followedby group C/Cystic fibrosis or immunodeficiency disorder (28%), thengroup D/Restrictive lung disease (15%) and finally group A/Obstructivelung disease (11%); whereas 10 patients (2%) were not classified. The pro-portion of accepted eLAS requests significantly differed between countries(Germany 25%, Netherlands 37%, Austria 20%, Belgium 36%) (p=0.042).eLAS requests decreased in the Netherlands following its LAS introduc-tion in 2014 (2011-2014 mean 13/yr vs. 2015-2019 mean 4.6/yr; p=0.060).However, since 2015 an overall annual increasing number of eLASrequests is seen, with doubling of the eLAS requests in 2018 vs. 2015, butno difference in acceptance rate (2015-2018: 22.4%) (Figure). Acceptancerates were 38% for Group B, 21% for Group C, 20% for Group D and 11%for Group A.Conclusion: The observed variations require further investigation to opti-mize lung allocation for specific patient populations in Eurotransplant.(944)Lung Transplantation from Controlled and Uncontrolled Donation afterCirculatory Death Donors. Single Centre ExperienceA. Palleschi,1 V. Musso,1 R. Lorenzo,1 D. Tosi,1 I. Righi,1P. Mendogni,1 V. Rossetti,2 A. Zanella,3 and M. Nosotti.1 1ThoracicSurgery and Lung Transplantation Unit, Fondazione IRCCS Ca’Granda - Ospedale Maggiore Policlinico, Milan, Italy; 2Pneumology Unit,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico,Milan, Italy; and the 3Anesthesia, Critical Care and Emergency,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan,Italy.Purpose: We started our uncontrolled donation after circulatory death(DCD) experience in 2014 with the first successful lung transplantation(LT). After a long period of local logistical reassessment, in 2017 weresumed the process managing both uncontrolled and controlled DCD.This cohort study reviews early outcome of our initial series of LT fromDCD donors and matches it with the outcome of patients transplanted withgraft from donation after brain death (DBD) donors in the same period.Methods: This is a single-institution, retrospective study on data collectedprospectively from adult patients who underwent bilateral LT at our Centrebetween 10/2017 and 07/2019. Our DCD procurement protocol consists of:1) an in situ graft preservation with open-lung approach (cPAP); 2) non-rapid normothermic lung procurement isolated (only-lung uncontrolledsetting) or during abdominal normothermic regional perfusion, namelywithout pleural topical cooling before the start of PA flushing (multiorgancontrolled setting); 3) ex-situ assessment/evaluation with machine perfu-sion (EVLP or OCS) before LT.Results: In the study period 51 subjects respected inclusion criteria(Table). Ten of these were from DCD donors (19.6%; 6 cDCD and 4uDCD). The flow-chart shows the DCD experience (Image).Conclusion: Our DCD program increased the LT number with an adequateearly-intermediate outcome, despite extended periods of warm ischemia.Our results suggest that LT from DCD donors is feasible in controlled anduncontrolled setting, in isolated and combined organs procurement.Variables DCD group DBD groupNumber of lung transplantations 10 41DonorGender, male 9 (90%) 28 (68.3%)Age, years, median (95% CI) 54 (47.3 to 60.1) 50 (37.7 to 53.0)cDCD ISHLT-interval 1, minutes,median (95% CI)12 (5 to 25) NAcDCD ISHLT-interval 3, minutes,median (95% CI)176 (122 to 191) NATime from PA flush to 1st lung reperfusion(without machine perfusion time),minutes, mean (95% CI)640 (505 to 775) 435 (386 to 483)RecipientsGender, male 23 (56%) 5 (50%)Age, years, median (95% CI) 42 (24.9 to 51.5) 37 (31.7 to 48.4)Disease: CF, COPD, IPF 7; 2; 1 (70%; 20%;10%)27; 4; 10 (66%;10%; 24%)LAS, median (95% CI) 40 (34.9 to 49.3) 40.5 (38.4 to 45.5)Machine perfusion rate 100% 17.6%Intraoperative ECMO 6 (60%) 20 (50%)Postop. MV, days, median (95% CI) 2 (1 to 4) 1 (1 to 1)30-day mortality rate 0% 0%1-year mortality rate 0% 2%Best FEV1, mean (95% CI) 82.7 (69.3 to 96.0) 90.1 (84.2 to 95.9)Airway complication 2 (20%) 3 (7.3%)

NARCIS 

Exceptional LAS Requests in Eurotransplant: Analysis of an 8-year Effort to Improve Lung Allocation for Precarious Patients

   University of GroningenExceptional LAS Requests in EurotransplantVos, R.; Smits, J. M.; Hoek, R.; Green, D.; Evrard, P.; Knoop, C.; Verleden, G. M.; Rondelet,B.; Kwakkel-vanErp, J. M.; Seghers, L.Published in:Journal of Heart and Lung TransplantationIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2020Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Vos, R., Smits, J. M., Hoek, R., Green, D., Evrard, P., Knoop, C., Verleden, G. M., Rondelet, B., Kwakkel-vanErp, J. M., Seghers, L., van Kessel, D. A., Luijk, B., Verschuuren, E. A., Lang, G., Hoetzenecker, K.,Laufer, G., Hoefer, D., Langer, F., Schramm, R., ... Gottlieb, J. (2020). Exceptional LAS Requests inEurotransplant: Analysis of an 8-year Effort to Improve Lung Allocation for Precarious Patients. Journal ofHeart and Lung Transplantation, 39(4), S375-S376. http://10.1016/j.healun.2020.01.475CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 04-06-2022Abstracts S375Purpose: A total of 180 lung transplantations (LTx) were performed at asingle center in Saudi Arabia. 92% of our donors were marginal. The crite-ria of deceased brain dead donors represent unique differences that bringunique challenges. This report highlights the challenges, managementstrategies and outcomes.Methods: The LTx Program at King Faisal specialist hospital was estab-lished in 2000. Over the last 9 years the program has witnessed rapidgrowth. Retrospective review of 180 patients and their donors that under-went LTx at our center between January 2010 and September 2019.Results: The most common indication for LTx was pulmonary fibrosis(40%), followed by cystic fibrosis (CF)-related bronchiectasis (24%), non-CF-related bronchiectasis (21%), chronic obstructive pulmonary disease(4%), sarcoidosis (3%), Microtithiasis (3%).Regarding Lung donors (LDs)92% of our lungs were marginal. 10% age >55 years, 16% PO2 <300mmhg, 32% abnormal CXR, 22% Purulent secretions on bronchoscopy,83% Prolonged ventilation more than 5 days with a mean duration ofmechanical ventilation (MV) of 9+/-7 (days). Bacterial colonization wasnoted in 74% of LDs, including multidrug-resistant bacteria such as acine-tobacter (31%), klibsiellae (24%) and pseudomonas (12%). Over the last5 years extracorporeal membrane oxygenation (ECMO), was used in21.5% of our LTx as a rescue strategy for grade 3 primary graft dysfunc-tion with 30 days survival of 92% and 1 year survival 88%. Ex vivo lungperfusion was used to expand our pool of LDs, 9 successful cases from 20attempts were performed over the last 5 years. In spite of the liberal utiliza-tion of marginal donors and prolonged post lung transplantation mechani-cal ventilation {Median (range)} 11 (1-145 days), length of ICU stay 14(3-145) and length of hospital stay 36 (12-168), our 30 days, 90 days, 1year, 3 years and 5 years survival rates were 94.3%, 89%, 87.5%, 76% and62.5% respectively which is comparable to the international standards.Conclusion: Shortage of good donors forced us to use extended criteria totransplant moderate and high risk patients. The selective use of Ex vivoand ECMO helped to achieve comparable results. Marginal donors evenwith bacterial colonization can be successfully utilized for LTx.(941)Prone Ventilation in Brain-Dead Organ Donors Acutely IncreasesOxygenation and Results in More Lungs TransplantedG.F. Marklin,1 C. O'Sullivan,1 and R. Dhar.2 1Mid-America Transplant,St Louis, MO; and the 2Neurology, Washington University in St. LouisSchool of Medicine, St Louis, MO.Purpose: A PaO2/FiO2 ratio (PFR) above 300 is a primary donor criterionfor lung transplantation. Absence of cough and respiratory drive in thebrain-dead (BD) donor results in basilar atelectasis, contributing to V/Qmismatching and hypoxemia. We hypothesized that ventilating BD donorsin the prone position would result in better V/Q matching, increased PFR,and more lungs transplanted.Methods: All BD donors at our OPO are treated with a lung-protectiveventilation strategy, recruitment maneuvers and repeated fiberopticbronchoscopy (FOB). Since June 2018, a prone ventilation protocolwas instituted for donors meeting the eligibility criteria: 12-70 yearsold, basilar atelectasis on X-ray or CT, and a PFR <300 after the firstFOB. Eligible donors were placed in the prone position for at least12 hours with all routine treatments continued. PFR was measured atfour, eight, and twelve hours, as well as prior to procurement, andchange calculated from baseline (ΔPO2). The control group consistedof 81 hypoxemic donors treated with routine care in the supine posi-tion in the two years prior.Results: In 14 months, 27 donors met eligibility criteria and were enrolled.Median baseline PFR was 222 mm Hg (IQR 181-270) compared to 187(116-250) in controls (p=0.06). PFR increased more after four hours ofprone ventilation (102 vs. 54 mm Hg, p=0.01), to 348 mm Hg (269-409)versus 264 (156-339) with supine ventilation. At 12-hours, there was atrend for PFR to remain higher: 351 (260-434) vs. 280 (157-358, p=0.13).Final PFR was 385 mm Hg (328-424) vs. 289 mm Hg (219-440, p=0.09)although ΔPO2 was comparable. However, more lungs were transplantedin the prone group (14 of 27 donors, 52%) compared to 23% in the controlgroup, an effect persisting after adjusting for baseline PFR (OR 3.0, 95%CI: 1.2-7.8, p=0.02).Conclusion: Prone ventilation acutely improved oxygenation in hypox-emic BD organ donors with basilar atelectasis relative to those managed inthe supine position and resulted in more lungs transplanted.(942)Disparities in the Lung Allocation Score Due to Geography Have NotChanged Since November 2017L. Benvenuto, M. Aversa, M. Anderson, L. Shah, J. Costa, B.P. Stanifer,H. Robbins, F. D'Ovidio, J. Sonett and S.M. Arcasoy Columbia UniversityMedical Center, New York, NY.Purpose: Differences in geographic donor lung availability affect waitlist out-comes. We hypothesized that the lung allocation score (LAS) at transplant andwaitlist time would vary based on local donor lung availability and that broadergeographic sharing since November 2017 would improve these disparities.Methods: Using UNOS data, we conducted a retrospective cohort study of23,414 lung transplant recipients from January 1, 2006 - December 31,2018. Local lung availability was defined as the ratio of donor lungs towaitlist candidates in the local donation service area. We calculated thelocal lung availability for candidates prior to November 25, 2017. We usedmixed multivariable linear regression and Poisson regression, adjusting fortime dependent LAS changes, to examine the relationship between locallung availability, LAS at transplant and waitlist time. We used Wilcoxonrank-sum to compare LAS at transplant before and after November 2017.Results: Compared to recipients in the top quartile with greatest local lungavailability, recipients in the lowest quartile were transplanted with a LAS6.2 points higher (95% CI: 5.6-6.9, p <0.001) and waited significantly lon-ger, 186 days (95% CI: 178-194) compared with 93 days (95%CI: 88-97),p <0.001. This difference varied by transplant type, with single lungsrecipients transplanted with a LAS 2.0 points higher in the lowest quartile(95%CI: 0.9-3.0, p < 0.001) compared with the top and double lung recipi-ents transplanted with a LAS 8.8 points higher (95% CI: 8.0-9.6, p<0.001)in the lowest quartile compared with the top. At centers in the lowest quar-tile of local lung availability, the LAS at transplant did not meaningfullychange after November 2017 (44.1 § 15.2, compared to 45.7§ 16.3,p=0.042), however the waitlist time did decrease from 206 days (95%CI:192-222) to 155 days, (95% CI: 133-176), p <0.001. The LAS at transplantand waitlist time for recipients did not change at high local lung availabil-ity centers (50.7 § 19.6 compared to 51.3 § 19.6, p=0.38, and 74 days(95%CI: 66-81) compared to 61 days (95%CI: 52-70), p=0.66).Conclusion: Prior to November 2017, low local lung availability was associ-ated with longer waitlist times and higher LAS at transplant that were muchmore pronounced for double lung recipients. Since expanding allocation to 250miles, meaningful differences in LAS at transplant have not yet been observed.(943)Exceptional LAS Requests in Eurotransplant: Analysis of an 8-yearEffort to Improve Lung Allocation for Precarious PatientsR. Vos,1 J.M. Smits,2 R. Hoek,3 D. Green,2 P. Evrard,4 C. Knoop,5G.M. Verleden,1 B. Rondelet,6 J.M. Kwakkel-vanErp,7 L. Seghers,8D.A. van Kessel,9 B. Luijk,9 E.A. Verschuuren,10 G. Lang,11 K.Hoetzenecker,11 G. Laufer,11 D. Hoefer,12 F. Langer,13 R. Schramm,14T. Deuse,15 R. Buhl,16 C. Witt,17 and J. Gottlieb.18 1University HospitalsLeuven, Leuven, Belgium; 2Eurotransplant International Foundation,S376 The Journal of Heart and Lung Transplantation, Vol 39, No 4S, April 2020Leiden, Netherlands; 3Erasmus University Medical Center, Rotterdam,Netherlands; 4Centre Hospitalier Universitaire Universite Catholique deLouvain, Namur Godinne, Belgium; 5Universite Libre de Bruxelles, HôpitalErasme, Bruxelles, Belgium; 6Universite Catholique de Louvain, CHUMont-Godinne, Namur, Godinne, Belgium; 7University Antwerp, UZA,Antwerp, Belgium; 8Erasmus MC, Rotterdam, Netherlands; 9UniversityMedical Center, Utrecht, Utrecht, Netherlands; 10University of Groningen,Groningen, Netherlands; 11Medical University of Vienna, Vienna, Austria;12Medical University Innsbruck, Innsbruck, Austria; 13Saarland UniversityMedical Center, Homburg/Saar, Homburg/Saar, Germany; 14RuhrUniversity of Bochum, Bad Oeynhausen, Germany; 15University HospitalEppendorf, Hamburg, Germany; 16Medizinische Klinik und Poliklinik derUniversit€atsmedizin Mainz, Main, Germany; 17Charite -Universit€atsmedizin Berlin, Berlin, Germany; and the 18Hannover MedicalSchool, Hannover, Germany.Purpose: Following introduction of the lung allocation score (LAS) in 2011,Eurotransplant member centers can apply for an exceptional LAS (eLAS) ifthe calculated LAS insufficiently reflects the perceived transplant benefit for apatient, specifically in case of primary pulmonary hypertension group 1 and 4;combined lung+nonrenal transplantation; rare diseases; or extracorporealsupport. Each eLAS proposal is evaluated by a LAS Review Board, consistingof ≥3 lung transplant experts, which subsequently declines or approves theeLAS request in consensus of ≥3 votes. In case of a lower than accepted score,predefined business rules to assign LAS percentiles are used.Methods: A retrospective analysis of all eLAS requests in Eurotransplantfrom December 2011 until September 2019.Results: Overall, 5183 lung transplants (deceased donors) were performedand 420 eLAS requests were made (Germany 52%, Netherlands 18%, Aus-tria 18%, Belgium 13%), of which 116 (28%) were approved. Most eLASrequests concerned group B/Pulmonary vascular disease (44%), followedby group C/Cystic fibrosis or immunodeficiency disorder (28%), thengroup D/Restrictive lung disease (15%) and finally group A/Obstructivelung disease (11%); whereas 10 patients (2%) were not classified. The pro-portion of accepted eLAS requests significantly differed between countries(Germany 25%, Netherlands 37%, Austria 20%, Belgium 36%) (p=0.042).eLAS requests decreased in the Netherlands following its LAS introduc-tion in 2014 (2011-2014 mean 13/yr vs. 2015-2019 mean 4.6/yr; p=0.060).However, since 2015 an overall annual increasing number of eLASrequests is seen, with doubling of the eLAS requests in 2018 vs. 2015, butno difference in acceptance rate (2015-2018: 22.4%) (Figure). Acceptancerates were 38% for Group B, 21% for Group C, 20% for Group D and 11%for Group A.Conclusion: The observed variations require further investigation to opti-mize lung allocation for specific patient populations in Eurotransplant.(944)Lung Transplantation from Controlled and Uncontrolled Donation afterCirculatory Death Donors. Single Centre ExperienceA. Palleschi,1 V. Musso,1 R. Lorenzo,1 D. Tosi,1 I. Righi,1P. Mendogni,1 V. Rossetti,2 A. Zanella,3 and M. Nosotti.1 1ThoracicSurgery and Lung Transplantation Unit, Fondazione IRCCS Ca’Granda - Ospedale Maggiore Policlinico, Milan, Italy; 2Pneumology Unit,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico,Milan, Italy; and the 3Anesthesia, Critical Care and Emergency,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan,Italy.Purpose: We started our uncontrolled donation after circulatory death(DCD) experience in 2014 with the first successful lung transplantation(LT). After a long period of local logistical reassessment, in 2017 weresumed the process managing both uncontrolled and controlled DCD.This cohort study reviews early outcome of our initial series of LT fromDCD donors and matches it with the outcome of patients transplanted withgraft from donation after brain death (DBD) donors in the same period.Methods: This is a single-institution, retrospective study on data collectedprospectively from adult patients who underwent bilateral LT at our Centrebetween 10/2017 and 07/2019. Our DCD procurement protocol consists of:1) an in situ graft preservation with open-lung approach (cPAP); 2) non-rapid normothermic lung procurement isolated (only-lung uncontrolledsetting) or during abdominal normothermic regional perfusion, namelywithout pleural topical cooling before the start of PA flushing (multiorgancontrolled setting); 3) ex-situ assessment/evaluation with machine perfu-sion (EVLP or OCS) before LT.Results: In the study period 51 subjects respected inclusion criteria(Table). Ten of these were from DCD donors (19.6%; 6 cDCD and 4uDCD). The flow-chart shows the DCD experience (Image).Conclusion: Our DCD program increased the LT number with an adequateearly-intermediate outcome, despite extended periods of warm ischemia.Our results suggest that LT from DCD donors is feasible in controlled anduncontrolled setting, in isolated and combined organs procurement.Variables DCD group DBD groupNumber of lung transplantations 10 41DonorGender, male 9 (90%) 28 (68.3%)Age, years, median (95% CI) 54 (47.3 to 60.1) 50 (37.7 to 53.0)cDCD ISHLT-interval 1, minutes,median (95% CI)12 (5 to 25) NAcDCD ISHLT-interval 3, minutes,median (95% CI)176 (122 to 191) NATime from PA flush to 1st lung reperfusion(without machine perfusion time),minutes, mean (95% CI)640 (505 to 775) 435 (386 to 483)RecipientsGender, male 23 (56%) 5 (50%)Age, years, median (95% CI) 42 (24.9 to 51.5) 37 (31.7 to 48.4)Disease: CF, COPD, IPF 7; 2; 1 (70%; 20%;10%)27; 4; 10 (66%;10%; 24%)LAS, median (95% CI) 40 (34.9 to 49.3) 40.5 (38.4 to 45.5)Machine perfusion rate 100% 17.6%Intraoperative ECMO 6 (60%) 20 (50%)Postop. MV, days, median (95% CI) 2 (1 to 4) 1 (1 to 1)30-day mortality rate 0% 0%1-year mortality rate 0% 2%Best FEV1, mean (95% CI) 82.7 (69.3 to 96.0) 90.1 (84.2 to 95.9)Airway complication 2 (20%) 3 (7.3%)

   University of GroningenExceptional LAS Requests in EurotransplantVos, R.; Smits, J. M.; Hoek, R.; Green, D.; Evrard, P.; Knoop, C.; Verleden, G. M.; Rondelet,B.; Kwakkel-vanErp, J. M.; Seghers, L.Published in:Journal of Heart and Lung TransplantationIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2020Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Vos, R., Smits, J. M., Hoek, R., Green, D., Evrard, P., Knoop, C., Verleden, G. M., Rondelet, B., Kwakkel-vanErp, J. M., Seghers, L., van Kessel, D. A., Luijk, B., Verschuuren, E. A., Lang, G., Hoetzenecker, K.,Laufer, G., Hoefer, D., Langer, F., Schramm, R., ... Gottlieb, J. (2020). Exceptional LAS Requests inEurotransplant: Analysis of an 8-year Effort to Improve Lung Allocation for Precarious Patients. Journal ofHeart and Lung Transplantation, 39(4), S375-S376. http://10.1016/j.healun.2020.01.475CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 31-10-2023Abstracts S375Purpose: A total of 180 lung transplantations (LTx) were performed at asingle center in Saudi Arabia. 92% of our donors were marginal. The crite-ria of deceased brain dead donors represent unique differences that bringunique challenges. This report highlights the challenges, managementstrategies and outcomes.Methods: The LTx Program at King Faisal specialist hospital was estab-lished in 2000. Over the last 9 years the program has witnessed rapidgrowth. Retrospective review of 180 patients and their donors that under-went LTx at our center between January 2010 and September 2019.Results: The most common indication for LTx was pulmonary fibrosis(40%), followed by cystic fibrosis (CF)-related bronchiectasis (24%), non-CF-related bronchiectasis (21%), chronic obstructive pulmonary disease(4%), sarcoidosis (3%), Microtithiasis (3%).Regarding Lung donors (LDs)92% of our lungs were marginal. 10% age >55 years, 16% PO2 <300mmhg, 32% abnormal CXR, 22% Purulent secretions on bronchoscopy,83% Prolonged ventilation more than 5 days with a mean duration ofmechanical ventilation (MV) of 9+/-7 (days). Bacterial colonization wasnoted in 74% of LDs, including multidrug-resistant bacteria such as acine-tobacter (31%), klibsiellae (24%) and pseudomonas (12%). Over the last5 years extracorporeal membrane oxygenation (ECMO), was used in21.5% of our LTx as a rescue strategy for grade 3 primary graft dysfunc-tion with 30 days survival of 92% and 1 year survival 88%. Ex vivo lungperfusion was used to expand our pool of LDs, 9 successful cases from 20attempts were performed over the last 5 years. In spite of the liberal utiliza-tion of marginal donors and prolonged post lung transplantation mechani-cal ventilation {Median (range)} 11 (1-145 days), length of ICU stay 14(3-145) and length of hospital stay 36 (12-168), our 30 days, 90 days, 1year, 3 years and 5 years survival rates were 94.3%, 89%, 87.5%, 76% and62.5% respectively which is comparable to the international standards.Conclusion: Shortage of good donors forced us to use extended criteria totransplant moderate and high risk patients. The selective use of Ex vivoand ECMO helped to achieve comparable results. Marginal donors evenwith bacterial colonization can be successfully utilized for LTx.(941)Prone Ventilation in Brain-Dead Organ Donors Acutely IncreasesOxygenation and Results in More Lungs TransplantedG.F. Marklin,1 C. O'Sullivan,1 and R. Dhar.2 1Mid-America Transplant,St Louis, MO; and the 2Neurology, Washington University in St. LouisSchool of Medicine, St Louis, MO.Purpose: A PaO2/FiO2 ratio (PFR) above 300 is a primary donor criterionfor lung transplantation. Absence of cough and respiratory drive in thebrain-dead (BD) donor results in basilar atelectasis, contributing to V/Qmismatching and hypoxemia. We hypothesized that ventilating BD donorsin the prone position would result in better V/Q matching, increased PFR,and more lungs transplanted.Methods: All BD donors at our OPO are treated with a lung-protectiveventilation strategy, recruitment maneuvers and repeated fiberopticbronchoscopy (FOB). Since June 2018, a prone ventilation protocolwas instituted for donors meeting the eligibility criteria: 12-70 yearsold, basilar atelectasis on X-ray or CT, and a PFR <300 after the firstFOB. Eligible donors were placed in the prone position for at least12 hours with all routine treatments continued. PFR was measured atfour, eight, and twelve hours, as well as prior to procurement, andchange calculated from baseline (ΔPO2). The control group consistedof 81 hypoxemic donors treated with routine care in the supine posi-tion in the two years prior.Results: In 14 months, 27 donors met eligibility criteria and were enrolled.Median baseline PFR was 222 mm Hg (IQR 181-270) compared to 187(116-250) in controls (p=0.06). PFR increased more after four hours ofprone ventilation (102 vs. 54 mm Hg, p=0.01), to 348 mm Hg (269-409)versus 264 (156-339) with supine ventilation. At 12-hours, there was atrend for PFR to remain higher: 351 (260-434) vs. 280 (157-358, p=0.13).Final PFR was 385 mm Hg (328-424) vs. 289 mm Hg (219-440, p=0.09)although ΔPO2 was comparable. However, more lungs were transplantedin the prone group (14 of 27 donors, 52%) compared to 23% in the controlgroup, an effect persisting after adjusting for baseline PFR (OR 3.0, 95%CI: 1.2-7.8, p=0.02).Conclusion: Prone ventilation acutely improved oxygenation in hypox-emic BD organ donors with basilar atelectasis relative to those managed inthe supine position and resulted in more lungs transplanted.(942)Disparities in the Lung Allocation Score Due to Geography Have NotChanged Since November 2017L. Benvenuto, M. Aversa, M. Anderson, L. Shah, J. Costa, B.P. Stanifer,H. Robbins, F. D'Ovidio, J. Sonett and S.M. Arcasoy Columbia UniversityMedical Center, New York, NY.Purpose: Differences in geographic donor lung availability affect waitlist out-comes. We hypothesized that the lung allocation score (LAS) at transplant andwaitlist time would vary based on local donor lung availability and that broadergeographic sharing since November 2017 would improve these disparities.Methods: Using UNOS data, we conducted a retrospective cohort study of23,414 lung transplant recipients from January 1, 2006 - December 31,2018. Local lung availability was defined as the ratio of donor lungs towaitlist candidates in the local donation service area. We calculated thelocal lung availability for candidates prior to November 25, 2017. We usedmixed multivariable linear regression and Poisson regression, adjusting fortime dependent LAS changes, to examine the relationship between locallung availability, LAS at transplant and waitlist time. We used Wilcoxonrank-sum to compare LAS at transplant before and after November 2017.Results: Compared to recipients in the top quartile with greatest local lungavailability, recipients in the lowest quartile were transplanted with a LAS6.2 points higher (95% CI: 5.6-6.9, p <0.001) and waited significantly lon-ger, 186 days (95% CI: 178-194) compared with 93 days (95%CI: 88-97),p <0.001. This difference varied by transplant type, with single lungsrecipients transplanted with a LAS 2.0 points higher in the lowest quartile(95%CI: 0.9-3.0, p < 0.001) compared with the top and double lung recipi-ents transplanted with a LAS 8.8 points higher (95% CI: 8.0-9.6, p<0.001)in the lowest quartile compared with the top. At centers in the lowest quar-tile of local lung availability, the LAS at transplant did not meaningfullychange after November 2017 (44.1 § 15.2, compared to 45.7§ 16.3,p=0.042), however the waitlist time did decrease from 206 days (95%CI:192-222) to 155 days, (95% CI: 133-176), p <0.001. The LAS at transplantand waitlist time for recipients did not change at high local lung availabil-ity centers (50.7 § 19.6 compared to 51.3 § 19.6, p=0.38, and 74 days(95%CI: 66-81) compared to 61 days (95%CI: 52-70), p=0.66).Conclusion: Prior to November 2017, low local lung availability was associ-ated with longer waitlist times and higher LAS at transplant that were muchmore pronounced for double lung recipients. Since expanding allocation to 250miles, meaningful differences in LAS at transplant have not yet been observed.(943)Exceptional LAS Requests in Eurotransplant: Analysis of an 8-yearEffort to Improve Lung Allocation for Precarious PatientsR. Vos,1 J.M. Smits,2 R. Hoek,3 D. Green,2 P. Evrard,4 C. Knoop,5G.M. Verleden,1 B. Rondelet,6 J.M. Kwakkel-vanErp,7 L. Seghers,8D.A. van Kessel,9 B. Luijk,9 E.A. Verschuuren,10 G. Lang,11 K.Hoetzenecker,11 G. Laufer,11 D. Hoefer,12 F. Langer,13 R. Schramm,14T. Deuse,15 R. Buhl,16 C. Witt,17 and J. Gottlieb.18 1University HospitalsLeuven, Leuven, Belgium; 2Eurotransplant International Foundation,S376 The Journal of Heart and Lung Transplantation, Vol 39, No 4S, April 2020Leiden, Netherlands; 3Erasmus University Medical Center, Rotterdam,Netherlands; 4Centre Hospitalier Universitaire Universite Catholique deLouvain, Namur Godinne, Belgium; 5Universite Libre de Bruxelles, HôpitalErasme, Bruxelles, Belgium; 6Universite Catholique de Louvain, CHUMont-Godinne, Namur, Godinne, Belgium; 7University Antwerp, UZA,Antwerp, Belgium; 8Erasmus MC, Rotterdam, Netherlands; 9UniversityMedical Center, Utrecht, Utrecht, Netherlands; 10University of Groningen,Groningen, Netherlands; 11Medical University of Vienna, Vienna, Austria;12Medical University Innsbruck, Innsbruck, Austria; 13Saarland UniversityMedical Center, Homburg/Saar, Homburg/Saar, Germany; 14RuhrUniversity of Bochum, Bad Oeynhausen, Germany; 15University HospitalEppendorf, Hamburg, Germany; 16Medizinische Klinik und Poliklinik derUniversit€atsmedizin Mainz, Main, Germany; 17Charite -Universit€atsmedizin Berlin, Berlin, Germany; and the 18Hannover MedicalSchool, Hannover, Germany.Purpose: Following introduction of the lung allocation score (LAS) in 2011,Eurotransplant member centers can apply for an exceptional LAS (eLAS) ifthe calculated LAS insufficiently reflects the perceived transplant benefit for apatient, specifically in case of primary pulmonary hypertension group 1 and 4;combined lung+nonrenal transplantation; rare diseases; or extracorporealsupport. Each eLAS proposal is evaluated by a LAS Review Board, consistingof ≥3 lung transplant experts, which subsequently declines or approves theeLAS request in consensus of ≥3 votes. In case of a lower than accepted score,predefined business rules to assign LAS percentiles are used.Methods: A retrospective analysis of all eLAS requests in Eurotransplantfrom December 2011 until September 2019.Results: Overall, 5183 lung transplants (deceased donors) were performedand 420 eLAS requests were made (Germany 52%, Netherlands 18%, Aus-tria 18%, Belgium 13%), of which 116 (28%) were approved. Most eLASrequests concerned group B/Pulmonary vascular disease (44%), followedby group C/Cystic fibrosis or immunodeficiency disorder (28%), thengroup D/Restrictive lung disease (15%) and finally group A/Obstructivelung disease (11%); whereas 10 patients (2%) were not classified. The pro-portion of accepted eLAS requests significantly differed between countries(Germany 25%, Netherlands 37%, Austria 20%, Belgium 36%) (p=0.042).eLAS requests decreased in the Netherlands following its LAS introduc-tion in 2014 (2011-2014 mean 13/yr vs. 2015-2019 mean 4.6/yr; p=0.060).However, since 2015 an overall annual increasing number of eLASrequests is seen, with doubling of the eLAS requests in 2018 vs. 2015, butno difference in acceptance rate (2015-2018: 22.4%) (Figure). Acceptancerates were 38% for Group B, 21% for Group C, 20% for Group D and 11%for Group A.Conclusion: The observed variations require further investigation to opti-mize lung allocation for specific patient populations in Eurotransplant.(944)Lung Transplantation from Controlled and Uncontrolled Donation afterCirculatory Death Donors. Single Centre ExperienceA. Palleschi,1 V. Musso,1 R. Lorenzo,1 D. Tosi,1 I. Righi,1P. Mendogni,1 V. Rossetti,2 A. Zanella,3 and M. Nosotti.1 1ThoracicSurgery and Lung Transplantation Unit, Fondazione IRCCS Ca’Granda - Ospedale Maggiore Policlinico, Milan, Italy; 2Pneumology Unit,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico,Milan, Italy; and the 3Anesthesia, Critical Care and Emergency,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan,Italy.Purpose: We started our uncontrolled donation after circulatory death(DCD) experience in 2014 with the first successful lung transplantation(LT). After a long period of local logistical reassessment, in 2017 weresumed the process managing both uncontrolled and controlled DCD.This cohort study reviews early outcome of our initial series of LT fromDCD donors and matches it with the outcome of patients transplanted withgraft from donation after brain death (DBD) donors in the same period.Methods: This is a single-institution, retrospective study on data collectedprospectively from adult patients who underwent bilateral LT at our Centrebetween 10/2017 and 07/2019. Our DCD procurement protocol consists of:1) an in situ graft preservation with open-lung approach (cPAP); 2) non-rapid normothermic lung procurement isolated (only-lung uncontrolledsetting) or during abdominal normothermic regional perfusion, namelywithout pleural topical cooling before the start of PA flushing (multiorgancontrolled setting); 3) ex-situ assessment/evaluation with machine perfu-sion (EVLP or OCS) before LT.Results: In the study period 51 subjects respected inclusion criteria(Table). Ten of these were from DCD donors (19.6%; 6 cDCD and 4uDCD). The flow-chart shows the DCD experience (Image).Conclusion: Our DCD program increased the LT number with an adequateearly-intermediate outcome, despite extended periods of warm ischemia.Our results suggest that LT from DCD donors is feasible in controlled anduncontrolled setting, in isolated and combined organs procurement.Variables DCD group DBD groupNumber of lung transplantations 10 41DonorGender, male 9 (90%) 28 (68.3%)Age, years, median (95% CI) 54 (47.3 to 60.1) 50 (37.7 to 53.0)cDCD ISHLT-interval 1, minutes,median (95% CI)12 (5 to 25) NAcDCD ISHLT-interval 3, minutes,median (95% CI)176 (122 to 191) NATime from PA flush to 1st lung reperfusion(without machine perfusion time),minutes, mean (95% CI)640 (505 to 775) 435 (386 to 483)RecipientsGender, male 23 (56%) 5 (50%)Age, years, median (95% CI) 42 (24.9 to 51.5) 37 (31.7 to 48.4)Disease: CF, COPD, IPF 7; 2; 1 (70%; 20%;10%)27; 4; 10 (66%;10%; 24%)LAS, median (95% CI) 40 (34.9 to 49.3) 40.5 (38.4 to 45.5)Machine perfusion rate 100% 17.6%Intraoperative ECMO 6 (60%) 20 (50%)Postop. MV, days, median (95% CI) 2 (1 to 4) 1 (1 to 1)30-day mortality rate 0% 0%1-year mortality rate 0% 2%Best FEV1, mean (95% CI) 82.7 (69.3 to 96.0) 90.1 (84.2 to 95.9)Airway complication 2 (20%) 3 (7.3%)

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Exceptional LAS Requests in Eurotransplant:Analysis of an 8-year Effort to Improve Lung Allocation for Precarious Patients

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