Ann Thorac Surg 1997;64:203-206
© 1997 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Retrieval by Other Procurement Teams Provides Favorable Lung Transplantation Outcome
Yuji Shiraishi, MD,
Laura Ochoa, RN,
Greg Richardson, RN,
Janice R. Semenkovich, MD,
Elbert P. Trulock, MD,
Sudhir Sundaresan, MD,
Joel D. Cooper, MD,
G. Alexander Patterson, MD
Division of Cardiothoracic Surgery, Department of Surgery; Mallinckrodt Institute of Radiology; and Respiratory and Critical Care Division, Department of Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
Accepted for publication January 8, 1997.
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Abstract
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Background. During the last 4 years, we have increasingly used lungs retrieved by other procurement teams. We therefore investigated whether the use of those lungs affected the outcome of lung transplantation.
Methods. We analyzed the results of 159 consecutive lung transplantations performed at our institution between July 1, 1992, and December 31, 1995. The transplants were divided into three groups: distant donor lungs retrieved by our team (DB group, n = 68); distant donor lungs retrieved by other teams (DX group, n = 46); and local donor lungs retrieved by our team (LB group, n = 44). One transplantation with a local donor lung retrieved by another team was excluded from the analysis.
Results. No significant differences were noted between the three groups in alveolar-arterial oxygen gradient immediately after transplantation (DB group, 359 ± 18 mm Hg; DX group, 329 ± 23 mm Hg; LB group, 327 ± 20 mm Hg) and at 24 hours; days on ventilator; days in the intensive care unit; length of hospital stay; 30-day mortality; and actuarial 1-year survival (DB group, 81%; DX group, 87%; LB group, 89%).
Conclusions. The use of donor lungs retrieved by other teams achieves an equivalently satisfactory outcome after lung transplantation as lungs retrieved by our team.
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Introduction
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Since successful isolated lung transplantation was first achieved by the Toronto group in 1983, many centers throughout the world have started lung transplant programs [1]. As more centers participate in lung transplantation, more thoracic surgeons have learned the technique of lung transplantation, including lung retrieval and implantation. The majority of centers send their own teams to the donor hospital for lung retrieval. The strategy of other-team harvesting is standard for renal transplantation and is commonly employed for liver transplantation. There is an established program of regional retrieval of thoracic organs in the United Kingdom (results are not available). Because a simple and reliable technique of lung procurement has been established [2], a retrieval team from another institution should be able to successfully evaluate and retrieve donor lungs. In most cases, a cardiac surgeon with lung harvest experience is at the donor site.
During the last 4 years, we have used donor lungs retrieved by other teams when either the lung retrieval team from another center or the heart retrieval team was comfortable in performing the lung retrieval for us. This study was aimed at investigating whether the use of donor lungs retrieved by other teams affected the outcome of lung transplantation in our center.
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Patients and Methods
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We analyzed the results of 159 consecutive lung transplantations performed at Barnes-Jewish Hospital between July 1, 1992, and December 31, 1995. Lung transplants were divided into three groups: lungs from distant donors that our team retrieved (DB group, n = 68); lungs from distant donors that other teams retrieved and sent to us (DX group, n = 46); and lungs from local donors that our team retrieved (LB group, n = 44). One transplantation using a local donor lung retrieved by another team was excluded from the analysis. Donor lungs retrieved in the donor hospitals located outside the service area of our organ procurement organization (Mid-America Transplant Services) were defined as the distant donors. Follow-up was completed on July 1, 1996, or at the time of the recipient's death, thus giving a minimum follow-up of 6 months for all surviving recipients.
Donor Selection
Donor lung suitability was evaluated by our previously published criteria [3]. However, because we have found that a satisfactory outcome can be achieved with lungs from a marginal donor, we have liberalized the criteria and used marginal donor lungs for select recipients [4]. Radiographic assessment was initially made by personnel at the donor hospital and relayed to us (as part of the initial donor data) before our team was sent to retrieve the organ. This preliminary radiographic assessment was confirmed by our retrieval team on arrival at the donor hospital. If another retrieval team in the donor hospital was comfortable with the lung retrieval, our team was not sent. Flexible bronchoscopy was routinely performed by the lung retrieval team to rule out aspiration or pus in the airway.
Donor lung suitability including age, arterial oxygen tension, duration of mechanical ventilation, and number of marginal donor lungs was compared between the three groups. Donor arterial oxygen tension was determined during mechanical ventilation at an inspired oxygen fraction of 1.0 and a positive end-expiratory pressure of 5 cm H2O. The last arterial oxygen tension measurement before cross-clamping the aorta was used as the donor value for this variable. Marginal status was defined on the basis of the chest radiograph when infiltrates or evidence of trauma (contusion or pneumothorax) was present in either lung (unsatisfactory chest radiograph). Donors older than 55 years or donors having a confirmed smoking history of greater than 20 pack-years were also judged marginal.
Characterization of Clinical Features
Lung transplantation candidates were selected according to our previously reported guidelines [5]. Clinical data used for analysis included age, sex, diagnosis, type of transplantation, time of ischemia, and use of cardiopulmonary bypass. The ischemic time of the second lung was used as the ischemic time in bilateral sequential transplantation. Unilateral and bilateral sequential lung transplantations were performed by our previously described techniques [6, 7].
Recipient Outcome
Variables used to evaluate early outcome included the following: alveolar-arterial oxygen gradient immediately on return to the intensive care unit after transplantation and at 24 hours after operation; number of days of mechanical ventilation; number of days in the intensive care unit; length of hospital stay; and death within 30 days. Actuarial survival was calculated by the Kaplan-Meier method.
Statistical Analysis
Values are expressed as the mean ± the standard error. Statistical analysis of values between the three groups was performed by analysis of variance and Scheffé Ftest, 
2test, or log-rank test. A significant difference was considered to exist when the pvalue was less than 0.05.
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Results
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Donor Lung Suitability
Age, arterial oxygen tension, and duration of mechanical ventilation of lung donors were equivalent for the three groups. The frequency of marginal donor lungs was not significantly different between the three groups. Most marginal donor lungs were defined as such on the basis of chest radiographs (Table 1
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Recipient Profile
There were no significant differences in age, sex, and diagnosis of recipients between the three groups. In terms of the type of transplantation, more single-lung transplantations were performed in the DX group than in the DB group (p< 0.05) (Table 2).
Ischemic Time and Use of Cardiopulmonary Bypass During Implantation
The LB group had the shortest ischemic time of the three groups. There was no significant difference in this variable between the DB group and the DX group. Cardiopulmonary bypass was used in an obligatory fashion for all lung transplantations for pulmonary hypertension (Table 3). When the transplant operations for pulmonary hypertension were excluded, cardiopulmonary bypass was required during bilateral sequential transplantation in 9 patients in the DB group, 2 patients in the DX group, and 3 patients in the LB group.
Early Recipient Outcome
There was no significant difference in alveolar-arterial oxygen gradient between the three groups. The LB group had a shorter requirement of mechanical ventilation, fewer days in the intensive care unit, and a shorter hospital stay compared with the DB and DX groups. However, these differences did not achieve significance. No significant differences were detected in days ventilated, days in the intensive care unit, and length of hospital stay between the DB group and the DX group. The 30-day mortality rates showed no significant differences between the three groups (Table 4). The causes of the seven deaths within 30 days were coma and multiple-organ failure in the DB group, two graft failures in the DX group, and dehiscence, graft failure, and sepsis in the LB group.
Survival
Actuarial 1-year and 3-year survival rates were 81% and 68%, respectively, in the DB group, 87% and 71% in the DX group, and 89% and 76% in the LB group (Fig 1).
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Fig 1. . Actuarial survival curve for the three groups receiving a lung transplant between July 1, 1992, and December 31, 1995. (DB =distant donor lungs retrieved by us;DX = distant donor lungs retrieved by other teams;LB =local donor lungs retrieved by us;Tx =transplantation.)
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Comment
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In recent years, lung transplantation has become an effective therapy for patients with end-stage pulmonary disease. As the technique of lung preservation has improved, distant retrieval has become standard. Usually each lung transplant center sends its own team to the donor hospital for lung retrieval. However, this is often unnecessary, as other thoracic donor organ harvest teams are usually present and capable of harvesting donor lungs. Standardization of techniques of lung procurement at the same time as heart procurement [8, 9] makes this situation feasible. In most retrievals conducted by other teams, a coordinator from our organ procurement organization traveled by air to the donor hospital to assist with lung harvest and transport. Occasionally lungs are sent without such assistance from our organ procurement organization. In either case, air travel was the same, ie, recipient center and back or donor center and back. Therefore, there may be limited cost-effectiveness in reducing already high organ fees. Nonetheless, certainly there is greater efficiency and less duplication of surgical staff.
The absence of a significant difference in the frequency of marginal donor lungs between the three groups revealed that our decision to allow other teams to perform lung retrieval was not confined to cases in which the donor lungs completely satisfied rigorous donor-assessment criteria. We also did not make this decision on the basis of recipient profile, ie, age, sex, and diagnosis. The decision was based solely on the willingness of the team in the donor hospital to do the retrieval. Single-lung transplantations were more frequently performed using distant donor lungs retrieved by other teams than with distant donor lungs retrieved by us. Often the other retrieval team was from a lung program harvesting one lung and sending the contralateral lung to our program.
Lung transplantations using local donors tended to show better early outcome than those using distant donors. However, these differences did not achieve significance. It was of importance that no significant difference in early outcome was detected between lung transplantations using distant donor lungs retrieved by our team and lung transplantations using distant donor lungs retrieved by other teams. There were no significant differences in 30-day mortality and actuarial survival between the three groups. This study demonstrated that the outcome of our lung transplant procedures was not affected by the team used for retrieval.
In summary, as the technique of lung procurement has been standardized, we have used donor lungs retrieved by other teams and have achieved equivalently satisfactory outcomes for lung transplantation. This strategy, which avoids duplication of surgical manpower and may prove cost-effective, recommends the development of a national program for regional harvest teams, as has been accomplished in the United Kingdom.
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Acknowledgments
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We gratefully acknowledge the help of Richard B. Schuessler, PhD, with the statistical analysis and Mary Ann Kelly in the preparation of the manuscript.
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Footnotes
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Address reprint requests to Dr Patterson, Division of Cardiothoracic Surgery, Washington University School of Medicine, Suite 3108 Queeny Tower, One Barnes Hospital Plaza, St. Louis, MO 63110.
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References
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- Pohl MS, Cooper JD. Results of the international registry. In: Patterson GA, Couraud L, eds. Current topics in general thoracic surgery: lung transplantation. Amsterdam: Elsevier, 1995:455–65.
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- Sundaresan S, Trachiotis GD, Aoe M, Patterson GA, Cooper JD. Donor lung procurement: assessment and operative technique. Ann Thorac Surg1993;56:1409–13.
- Sundaresan S, Semenkovich J, Ochoa L, et al. Successful outcome of lung transplantation is not compromised by the use of marginal donor lungs. J Thorac Cardiovasc Surg1995;109:1075–80.
- Trulock EP. Recipient selection. Chest Surg Clin North Am1993;3:1–18.
- Patterson GA, Cooper JD. Lung transplantation for emphysema. Chest Surg Clin North Am1995;5:851–68.[Medline]
- Pasque MK, Cooper JD, Kaiser LR, Haydock DA, Triantafillou A, Trulock EP. Improved technique for bilateral lung transplantation: rationale and initial clinical experience. Ann Thorac Surg1990;49:785–91.[Abstract]
- Todd TR, Goldberg M, Koshal A, et al. Separate extraction of cardiac and pulmonary grafts from a single organ donor. Ann Thorac Surg1988;46:356–9.[Abstract]
- Wahlers T, Schafers HJ, Cremer J, Hirt S, Haverich A. Technique and results of organ sharing for heart and isolated single or double-lung transplantation. Transplant Proc1991;23:2675.[Medline]
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Abstract
Introduction
