Objective: Lung transplantation (LTx) is a life-saving treatment for patients with end-stage pulmonary disease refractory to medical therapy. Primary graft dysfunction (PGD), characterized by lung edema, severe hypoxemia and diffuse pulmonary infiltrates within 72 hours remains an important risk factor for early morbidity and mortality after LTx.
Methods: The records of LTx recipients (n = 131) between April 2001 and December 2005 were reviewed. Lung preservation with Perfadex ® solution was identical in all donors. PGD was graded (0-3) according to the recommendations of the ISHLT [1] considering the PaO 2 /FiO 2 ratio and findings on chest X-ray and the incidence was compared at different time (hrs) points (T0, T24, T48 and T72) after LTx. Three patients were excluded from the study (intra-operative deaths n=2, missing notes n=1).
Results: Forty-seven single LTx and 81 bilateral LTx were performed in 75 male and 53 female patients. PGD 1-3 was observed in 46 patients (36%) at T0, in 40 (31%) at T24, in 35 (27%) at T48 and in 35 (27%) at T72. PGD 3 decreased from 29% at T0 to 10% at T24 [Table]. Institution of ECMO within 24 hours after LTx was necessary in 3 patients with PGD 3 with successful weaning in all. No direct mortality related to PGD was observed.
| PDG grad | T0 | T24 | T48 | T72 |
| Grade 0 | 82 (64 %) | 88 (69 %) | 93 (73 %) |
93 (73 %) |
| Grade 1 | 3 (2 %) | 14 (11 %) | 12 (9 %) | 10 (7 %) |
| Grade 2 | 6 (5 %) | 13 (10 %) | 12 (9 %) | 11 (9 %) |
| Grade 3 | 37 (29 %) | 13 (10 %) | 11 (9 %) | 14 (11 %) |
There was no significant difference in donor oxygenation capacity (PaO 2 /FiO 2 ) as well as in type of operation (single versus bilateral) between PGD grades. Graft ischemic times were longer in PGD 1-3 compared to PGD 0 at T0 (380±16 minutes versus 317±11minutes, p<0.05). The use of CPB (38/128) during LTx was associated with a higher risk for PGD 1-3 at T0 (p<0.05, 0R: 3.781, CI: 1.706 – 8.380) and at T24 (p<0.05, OR: 2.782, CI: 1.252 – 6.179). In patients with PGD 3 at T0, CPB had been used in 3/11 (27%) emphysema patients versus 15/26 (58%) non-emphysema patients (p=0.09). Patients with emphysema had a lower risk to develop PGD 1-3 at T0 (p<0.05, OR: 0.3424, CI: 0.1594 – 0.7357) and at T24 (p<0.05, OR: 0.4012, CI: 0.1833 – 0.8785). The duration of mechanical ventilation was significantly longer in patients who developed PGD 1-3 versus PGD 0 at all time points (p<0.05). Patients with PGD 1-3 at T24, T48, T72 had a longer ICU stay and a longer hospital stay than patients with PGD 0 (p<0.05).
Conclusion: Primary graft dysfunction plays an important role in the early morbidity after lung transplantation with longer mechanical ventilation and longer ICU and hospital stay. Longer graft ischemic time and the use of CPB was related to an increased the risk to develop PGD but this may be well result from specific recipient characteristics (eg. pulmonary hypertension).
[1] Christie JD, Carby M, Bag R et al. Report of the ISHLT working group on primary lung graft dysfunction part II: definition. A consensus statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2005; 24: 1454 - 9