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Central Surgical Association

49th Annual Meeting

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The Effects of Prolonged Allograft Ischemic Times on Outcomes in Bilateral Lung Transplantation
Alfred J. Casillan1, Alice L. Zhou1, Eric W. Etchill1, Jinny S. Ha1, Pali Shah2, Christian A. Merlo2, *Errol L. Bush1
1Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States, 2Medicine, Johns Hopkins Hospital, Baltimore, Maryland, United States

Objective: Historically, there has been a 6-hr ischemic time limit for lung allografts. New lung allocation rules broaden geographic sharing and will make prolonged ischemic times more commonplace. Despite this, few studies report the outcomes of ischemic periods >6 hrs, and it is not known whether extending ischemic times further, potentially to ≥10 hrs, is appropriate. This study examined the collective U.S. experience with extending ischemic times, including ≥10 hrs, during bilateral lung transplantation (LTX).

Methods: Adult bilateral LTX cases since 2005 were retrospectively examined in the United Network for Organ Sharing database. Multiorgan transplants, redo lung transplants, and ex vivo lung perfusion cases were excluded. Cases were grouped as having standard (<6 hrs), moderate (6-10 hrs), or long (≥10 hrs) ischemic times. Primary outcomes included mortality, intubation at 72 hrs after surgery, and the need for extracorporeal membrane oxygenation (ECMO) in the first 72 hrs after surgery. Secondary outcomes included acute rejection, postoperative dialysis, and hospital length of stay. Pairwise analysis using Bonferroni-adjusted comparisons and multivariable logistic regressions were used to assess the primary outcomes.

Results: Among the 19,624 bilateral LTXs performed, 62.6% of the allografts had standard ischemic times (SIT), 35.9% had moderate ischemic times (MIT), and 1.5% had long ischemic times (LIT). Increased baseline ventilator support (p<0.001) and ECMO support (p<0.001) were seen in the MIT and LIT groups prior to transplantation. MIT and LIT recipients also experienced fewer days on the waiting list (p<0.001). Compared to the standard group, MIT recipients had higher 30-day mortality (3.6% vs 2.6%, p<0.001), 1-year mortality (13.0% vs 10.9%, p<0.001), intubation 72 hrs after surgery (39.8% vs 29.7%, pp<0.001), and need for ECMO within 72 hrs following transplantation (10.0% vs 5.3%, p<0.001). Similarly, LIT recipients demonstrated higher rates of 30-day mortality (7.0% vs 2.6%, p<0.001), 1-year mortality (19.9% vs 10.9%, p<0.001), and intubation (53.3% vs 29.7%, pp<0.001) or ECMO (18.8% vs 5.3%, p<0.001) at 72 hrs compared to SIT recipients. These outcomes persisted even after adjusting for baseline characteristics. Both MIT and LIT cohorts also demonstrated increases in acute rejection, postoperative dialysis, and hospital length of stay (p<0.001 for all secondary outcomes).

Conclusions: New allocation rules will increase allograft ischemic times. While this practice may shorten waiting times and more equitably distribute organs for critically ill recipients, prolonged ischemia results in increased mortality and diminished allograft function, as evidenced by an increased need for intubation and ECMO. The potential risks and benefits of using lung allografts with prolonged ischemic times must be carefully considered prior to their use.

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