CADAVERIC LOBAR LUNG TRANSPLANTATION IS A VIABLE OPTION TO SHORTEN DONOR WAITING TIME IN SMALL CYSTIC FIBROSIS PATIENTS

Dirk Van Raemdonck1,  Geert M Verleden2,  Lieven Dupont2,  Willy Coosemans1,  Herbert Decaluwé1,  Georges Decker1,  Paul De Leyn1,  Philippe Nafteux1,  Marc Decramer2,  Toni Lerut1

1Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
2Department of Pneumology, University Hospitals Leuven, Leuven, Belgium

Background: Small-sized cystic fibrosis (CF) patients are at risk for a long waiting time to find a suitable lung donor. Lobar lung transplantation (L-LTx) from oversized donors may help to reduce the waiting time comparable to size-matched donors (SM-LTx).

Methods: Out of 451 isolated lung transplants (01/07/1991-31/07/2009), 65 (14%) were performed for CF (63DL-2SL; 35M-30F; median age 27 [13-57] years; height 166 [144-192] cm; weight 50 [30-82] kg; waiting time 158 [3-1143] days) including 5 L-LTx (7.7%) with a follow-up of 12 [4-50] months.
L-LTx donors were comparable to SM-LTx in height (175 [160-185] vs 170 [155-190] cm) and weight (70 [60-80] vs 70 [40-100] kg), intubation period (58 [34-96] vs 44 [14-285] hours), and PO2/FiO2 (494 [261-601] vs 498 [258-668] mm Hg); NS.

Results: L-LTx recipients were younger (20 [13-25] vs 28 [14-57] yrs); p<0.05, shorter (151 [145-166] vs 168 [144-192] cm; p<0.05, lighter 43 [34-46] vs 51 [30-82] kg); p<0.01, and had comparable waiting time (135 [29-921] vs 158 [3-1143] days);NS.
R+L middle/lower lobes were implanted in 4 recipients versus R+L upper lobes in the remaining with need for ECMO support in 3/5. Implantation and ischemic times for the first and second lung were 55 [50-64] and 58 [39-66] min and 263 [240-471] and 426 [401-598] min, respectively. Total operating time was 467 [414-550] min. Primary graft dysfunction was present in 80% with postoperative need for vv-ECMO in 1 recipient. Hospital stay was 39 [30-67] days. Actuarial 4-year survival is 100%. Bronchial stenosis requiring laser/stenting was seen in 1/10 anastomoses. FEV1 and FVC improved significantly from preoperatively (26 [21-29] % and 42 [36-45] %) to the latest follow-up (73 [54-81] % and 74 [66-81] %); p< 0.01 and p< 0.05, respectively.

Conclusions: L-Ltx is a viable alternative to SM-LTx in small CF patients facing long waiting times. Long-term outcome is excellent despite a higher incidence of primary graft dysfunction. Peroperative use of ECMO should be considered prior to implanting the contralateral lobe.