American Association for

Thoracic Surgery

71ST ANNUAL MEETING

Washington Hilton Hotel, Washington, DC

MAY 6-8, 1991

Program Outline

MONDAY MORNING, May 6, 1991

8:30 a.m. BUSINESS SESSION (Limited to Members)

8:45 a.m. SCIENTIFIC SESSION - International Ballroom

1. Pulmonary Transplantation: Early and Late Results

G. ALEXANDER PATTERSON, ALBERTO L. DeHOYAS*,

JUAN C. RAMIREZ*, JANET R. MAURER*

and TIMOTHY L. WINTON*

Toronto, Ontario, Canada

Isolated lung transplantation has been successfully applied in an increasing number of centres. A variety of end-stage lung diseases have been treated by isolated lung transplantation. Between November 1983 and October 1990, our centre performed 47 single (SLT) and 30 bilateral (BLT) lung transplants in 72 patients. Underlying diseases of patients receiving SLT included 22 idiopathic fibrosing alveolitis, 8 emphysema, 6 pulmonary vascular disease, 3 eosinophilic granuloma, 1 lymphangiomyomatosis, 1 extrinsic allergic alveolitis, 1 fibrosing mediastinitis. Five patients have undergone retransplan-tation; 3 of these were done early because of donor airway dehiscence and 2 performed late (one airway stricture and one bronchiolitis obliterans). Underlying diseases of BLT included 13 cystic fibrosis, 9 emphysema, 4 bronchiectasis, 1 each eosinophilic granuloma, bronchiolitis obliterans, primary pulmonary hypertension and 1 re-transplant for primary pulmonary hypertension. Eight SLT recipients (19%) died perioperatively and 8 (19%) died from 4 months to 6 years following transplantation. 28 of 44 SLT recipients (64%) are alive (2 weeks to 5 years). Eight BLT recipients (26%) died perioperatively and 1 (3%) died late. 21 of 30 BLT recipients (70%) are alive (4 weeks to 4 years). Airway dehiscence (2 SLT, 3 BLT) and infection (4 SLT, 5 BLT) have been the commonest cause of operative mortality. Late deaths have most commonly been due to chronic rejection complicated by infection (5 SLT, 1 BLT). One late death was due to renal failure. Of surviving SLT recipients, 2 of 28 (7%) are functionally limited by bronchiolitis obliterans. 2 of 21 BLT recipients (9%) have bronchiolitis obliterans but are not significantly impaired. 2 of 21 surviving BLT recipients (9%) have airway stenosis and infection ± rejection which provides significant functional impairment. Actuarial survival for SLT is 64% and 58%, and for BLT, 64% and 64% at 1 and 3 years respectively. Overall 47 of 49 surviving lung transplant recipients (67%) are surviving without functional disability.

*By Invitation

2. Cystic Fibrosis: Target Population for Lung Transplantation in North America in the 1990's

VAUGHN A. STARNES*, NORMANLEWISTON*,

JAMES THEODORE*, CHRISTOPHER STOEHR*,

EDWARD STINSON, NORMANE. SHUMWAY

and PHILIPS. OVER

Stanford, California

It is anticipated that about 3.5% of the 20,000 individuals with cystic fibrosis (CF) in North America will die each year of end-stage lung disease. Although this genetic disorder affects a number of organs, most of the mortality stems from a severe endobronchitis resulting from the basic molecular defect. Transplanted lungs do not have this defect and do not develop the pulmonary findings characteristic of this disease. Some 150 CF patients have received heart-lung or lung transplantation to date in North America and Europe, where it is now the single most common diagnosis for lung transplantation. We have evaluated 42 CF patients at our center, accepting 27 as transplant candidates. Thirty-three percent (9/27) have died while on the waiting list. Thirteen have received transplantion (12 HLT, one double lung) with a 77% survival. All survivors are NYHA Class I for activity. As we have found with other patients with pulmonary parenchymal disease, the incidence of obliterative bronchiolitis is much less than for patients with pulmonary vascular disease (none so far for CF, 30% for all PVD survivors).

CF patients present a number of challenges which are becoming less important with increased experience. The problem of pleural adhesions and/or previous limited surgical pleuradesis has largely been mastered with the use of the "clam shell" incision, a bilateral lateral thoracotomy with a bridging transverse sternal incision for better pleural exposure. Insulin-dependent diabetes mellitus and low dosage corticosteroid therapy are no longer considered absolute contraindications. Although both septic lungs must be removed, either an HLT with a "domino" donation of the heart or a double lung transplantation are appropriate for most candidates. This ability substantially expands the available donor pool. These data support the notion that lung transplantation has proven efficacy for selected CF patients.

*By invitation

3. Bilateral Lung Transplantation for Cystic Fibrosis

TIMOTHY L. WINTON*. JUAN C. RAMIREZ*,

ALBERTO L. DeHOYAS*, JANETR. MAURER*,

MASINA SCA VUZZO* and G. ALEXANDER PA TTERSON

Toronto, Ontario, Canada

Heart/lung transplant has been advocated as the preferred procedure for end-stage cystic fibrosis. Adequate cardiac function in these patients has permitted the use of the recipient's heart for a cardiac allograft (Domino procedure). Since 1988 our centre has performed 13 bilateral lung transplants in patients with cystic fibrosis including 8 male (mean age, 27.6 years) and 5 female (mean age, 26.6 years). Mean room air PaO₂ was 53.6 ± 5.9 mmHg; FVC, 1.7 ± 0.64 L; FeV₁, 0.85 ± 0.4 L and 6 minute walk, 511.7 ± 114.9 M. En bloc bilateral lung transplantation was performed in three patients. Ten patients underwent sequential bilateral single lung transplantation. Two patients underwent median sternotomy and the most recent eleven patients had transverse bilateral thoracotomy and sternotomy. Nine patients required cardiopulmonary bypass with a mean time of 3.8 hours for the en bloc procedure and 2.4 hours for the sequential operation. Mean allograft ischemic times for en bloc procedures was 4.6 hours. For the sequential procedure, mean allograft ischemic time was 2.9 hours for the first implanted lung and 4.2hours for the second lung. Post operative cardiac function was adequate in all patients. There were 4 post operative deaths. One patient died of disseminated sepsis, 2 patients of bilateral gram negative pneumonia and 1 patient of cyclosporin neurotoxicity. Among 9 surviving patients, the most frequent complication was spesis; bilateral pneumonia 2, CMV pneumonia 1, empyema 2, lung abscess 1, mediastinal abscess 1, sepsis 1 and disseminated herpes 1. Airway stenosis requiring stent insertion occurred in 3 patients. Among operative survivors, 3 month follow up mean room air PaO₂ was 88.57 ± 5.94 mmHg (P<0.0001); FVC 2.85 ± 0.7 L (P<0.0002); FeV₁, 2.69 ± 0.76 L (P<0.0001) and 6 minute walk, 656.6 ± 114.5 M (P<0.02). Despite significant morbidity and mortality in this challenging group of young patients, bilateral pulmonary transplantation is an effective surgical option associated with significant post operative functional improvement.

9:45 a.m. INTERMISSION - VISIT EXHIBITS

10:30 a.m. SCIENTIFIC SESSION - International Ballroom

4. Single Lung Transplantation for Primary Pulmonary Hypertension

MICHAEL K. PASQUE*, LARRYR. KAISER*,

CAROLYN DRESLER*, ELBERT TRULOCK*,

ANASTASIOS N. TRIANTAFILLOU* and

JOEL D. COOPER

St. Louis, Missouri

Shorter waiting times, relative technical simplicity, and satisfactory application to a broad spectrum of patients has made single lung transplantation (SLT) a viable option in the treatment of patients with end-stage primary pulmonary hypertension (PPH). Seven patients with PPH underwent SLT on cardiopulmonary bypass. Two associated atrial septal defects were closed at the time of SLT. Despite severely compromised pre-transplant right ventricular function in all patients, there has been no early or late mortality. Right ventricular functional recovery has been nearly uniform and is characterized by the following hemodynamic data (mean: 13 weeks post-transplant):

Echocardiography documented early recovery of right ventricular function and geometry. Radionuclide ventriculography (mean: 17 weeks post-transplant) documented a significant (p=.006) increase in right ventricular ejection fraction from 22% (± 15; S.D.) to 51% (± 11; S.D.). Left ventricular ejection fraction did not change significantly post-transplant. Pulmonary ventilation/perfusion scans (mean: 17 weeks post-transplant) documented a predominance of flow to the transplanted lung with a slight, but significant, decrease in ventilation of the transplanted side:

Exercise tolerance has been excellent in all recipients. These early data cautiously support SLT as a transplant option in PPH although long-term follow-up of the functional and hemodynamic results is required before widespread application.

*By Invitation

5. Surgical Lessons Learned in Heart Transplantation for Complex Congenital Heart Disease

ROBERTE. MICHLER*. CRAIG R. SMITH*,

JAN M. QUAEGEBEUR * and ERIC A. ROSE

New York, New York

Cardiac transplantation provides an excellent therapeutic option to high-risk reparative surgery in the pediatric patient with complex congenital heart disease. Since many of these patients will have had prior corrective or palliative procedures, the surgeon must be prepared to manage the potentially distorting anatomical effects of these prior operations, as well as the underlying complex congenital anatomy. We have performed 54 cardiac transplants in 52 pediatric patients. Nineteen patients (37%) with congenital heart disease carried the following diagnoses: corrected transposition of the great arteries (4); single ventricle variants (6) including one with visceroartrial situs inversus; hypoplastic left heart syndrome (2); Ebstein's anomaly (1); VSD (2); Tetralogy of Fallot (1); A-V canal (1); and coarctation of the aorta with left ventricular outflow tract obstruction (2). There were 11 males and 8 females ranging in age from 5 days to 17.7 years (mean 9.4 ± 6.6 yrs) with a mean weight of 31.8 ± 25.3 (range 2.3-100 kg). The mean duration of illness pre-transplant was 17.8 ± 32.9 months. Fifteen patients (79%) had undergone 30 prior operations (14 palliative and 16 corrective). The mean interval between prior surgery and transplantation was 4.7 ± 5.9 yrs (range 2.6 mos-17.7 yrs). The mean ischemic time was 182 + 58 min (range 68-270 min).

No deaths were related to surgical technique. The most frequently encountered technical problem was distortion of the pulmonary artery (PA) secondary to bands, shunts, conduits, and Fontan connections. Stenoses were patched, dilated PA's were partially oversewn and the main orifice transferred leftward in patients with malposition of the great arteries. Discrepancies in size of the donor and recipient right atria were amenable to suture plication or cephalad extension of the recipient right atrium, and enlargement of the donor right atrium by incision through the SVC posterior to the SA node. Visceroatrial situs inversus was successfully corrected by creating autologous tissue tunnels for SVC and IVC return. Heart transplantation for congenital heart disease can be performed with excellent results provided careful attention is paid to restoring functional anatomy.

11:15 a.m. PRESIDENTIAL ADDRESS

Discovery in Surgery: Reflections on a Golden Age

Keith Reemtsma, M.D., New York, New York

*By Invitation