Ex-Vivo Lung Perfusion for lung transplant
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Franco Valenza 35°Corso Nazionale TPM Imola, 18-21 novembre 2014
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Ex-Vivo Lung Perfusion for lung transplant
- 1. Franco Valenza Department of Pathophysiology and Transplantation Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico Ex-Vivo Lung Perfusion for lung transplant.
- 2. No conflict of interest Ex-Vivo Lung Perfusion for lung transplant.
- 3. Donation process Ex-Vivo Lung Perfusion Evaluation, Reconditioning, Repair Economic consideration Ex-Vivo Lung Perfusion for lung transplant.
- 4. Recipient Cause of death History Functional Microbiology Diagnosis Functional status Clinical, Instrumental Visual inspection Biopsy Organ Multi-organ donor Ideal Extended criteria Unacceptable
- 5. Van Raemndonck, Proc Am Thor Soc (2009);6:28
- 7. Van Raemndonck, Proc Am Thor Soc (2009);6:28
- 8. Pierre, J Thor Cardiovasc Surg (2002);123:421
- 9. pz in lista d'attesa trapianti effettuati numero 0 20 40 60 80 100 120 Waitlist Lung Tx death … to safely increase the number of organs
- 10. Recipient Cause of death History Functional Microbiology Diagnosis Functional status Procedure Clinical, Instrumental Visual inspection Biopsy Organ Multi-organ donor Donor treatment
- 11. Porro, Transpl Proc (2012); 44:1830
- 12. 123 89103 20 27 9 Autonomic Brain Storm Diagnosis of Brain Death Procurement 12 9 OR ICU
- 14. Autonomic Brain Storm Brain Death diagnosis Operating Room First P/F 0 100 200 300 400 500 Second Third * * RM 2 way Anova; *P<0.05 vs Autonomic Brain Storm
- 15. Mascia, JAMA 2010; 304(23):2620
- 16. Vt (ml/kg) 2 3 4 5 6 7 8 9 10 11 12 13 14 Pazienti(N) 0 10 20 30 40 50 60 70
- 17. PEEP (cmH2 O) 1 2 3 4 5 6 7 8 9 10 11 12 13 Pazienti(N) 0 10 20 30 40 50 60 70
- 18. Singbarlt, Am J Transpl (2011); 11:1517
- 19. Recipient Cause of death History Functional Microbiology Diagnosis Functional status Procedure Clinical, Instrumental Visual inspection Biopsy Organ Multi-organ donor Donor treatment
- 20. "Successive transition from one paradigm to another via revolution is the usual developmental pattern of mature science." The Structure of Scientific Revolutions (1962)
- 21. Recipient Cause of death History Functional Microbiology Diagnosis Functional status Procedure Clinical, Instrumental Visual inspection Biopsy Organ Multi-organ donorEx-Vivo Lung Perfusion
- 22. Jirsch DW, Fisk RL, Couves CM. Ex vivo evaluation of stored lungs. Ann Thorac Surg 1970;10:163-168. Fisk RL, Symes JF, Aldridge LL, Couves CM. The pathophysiology and experimental therapy of acid pneumonitis in ex vivo lungs. Chest 1970;57:364-370. Ex-Vivo Lung Perfusion
- 24. Steen, Ann Thor Surg (2003);76:244 EX-VIVO LUNG PERFUSION (EVLP): UNA POSSIBILE STRATEGIA PER AUMENTARE IL NUMERO DI POLMONI DISPONIBILI PER TRAPIANTO.
- 25. Steen, Ann Thor Surg (2003);76:244 EX-VIVO LUNG PERFUSION (EVLP): UNA POSSIBILE STRATEGIA PER AUMENTARE IL NUMERO DI POLMONI DISPONIBILI PER TRAPIANTO.
- 26. Ingemansson, Ann Thor Surgl(2009);87:255
- 28. Valenza, Transpl Proc (2011) 43:993
- 29. Valenza, Transpl Proc (2012) 44:1826
- 32. PaO2/FiO2 158 mmHg Lung “Evaluation”
- 35. Lung “Reconditioning” PaO2/FiO2 180 mmHg
- 36. Brain storm Observation Retrival Time (hours) Fluidbalance(mL) CVP
- 37. Brain storm Observation Retrival Time (hours)
- 39. Brain storm Observation Retrival Time (hours)
- 46. Extended criteria EVLP Lungs available for transplantation Non guidelines recipients
- 47. Is EVLP challenging the dogma?
- 50. Ischemia Reperfusion EVLP Thrombi, mediators Ischemia reperfusion injury Preservation Treatments (genes, drugs) Baseline
- 51. Cypel, J Heart Lung Transplant (2008);27:1319
- 52. Martins, Gene Therapy (2004);11:1786
- 53. Eaton, Annu Rev Physiol (2009);71:403
- 54. Valenza, Transpl Proc (2011);43:993
- 55. PAPm(mmHg) 0 5 10 15 20 25 30 REC 0 REC 60 REC 240 0 1 2 3 4 * * * Control Beta-agonist Valenza, J Heart Lung Transpl (2012); 31:524 Beta agonist reconditioning of donor lungs
- 56. Extended criteria LUNG EDEMA EVLP Lungs available for transplantation Lung “Reconditioning” Unacceptable AB-INGESTIS SECRETIONS Lung “Repair”
- 57. Extended criteria LUNG EDEMA EVLP Lungs available for transplantation Lung “Reconditioning” Unacceptable INHALATION SECRETIONS Lung “Repair”
- 58. Prospective observational investigation 123 subjects, 15 ICU
- 59. Time Brain death Cold storage REPERFUSION Lung transplantation Valenza, Intensive Care Med exp (2014)
- 60. Valenza, Intensive Care Med exp (2014)
- 63. Time (min) 0 60 120 180 240 300 360 420 480 540 600 ICP(mmHg) 0 20 40 60 80 100 120 140 160 180 Time (min) 0 60 120 180 240 300 360 420 480 540 600 CPP(mmHg) -150 -100 -50 0 50 100 TREATMENTINDUCTION
- 65. Time Brain death Cold storage REPERFUSION Lung transplantation AB-INGESTIS Donor treatment
- 66. High vs. Low PEEP donor treatment
- 67. Time Brain death Cold storage REPERFUSION Lung transplantation AB-INGESTIS Donor treatment EVLP “repair”
- 69. Valenza, Organs Tissue & Cells (2012)
- 72. Economic considerations Timing of the transplantation
- 73. Van Raemdonk, Transpl Int. 2014 Mar 15. doi:10.1111/tri.12317
- 74. Recipient Organ Multi-organ donor Anesthestist Perfusionist Surgeon Nurse 2 Students 2 Surgeons Anesthestist 2 Nurses Know how Clinical- preclinical EVLP team Procurement team
- 76. EVLP pre-conditioning of the lung?
- 77. pz in lista d'attesa trapianti effettuati numero 0 20 40 60 80 100 120 Waitlist Lung Tx death … in conclusion
- 78. Recipient Cause of death History Functional Microbiology Diagnosis Functional status Clinical, Instrumental Visual inspection Biopsy Organ Multi-organ donor Ex-Vivo Lung Perfusion Donor treatment
- 79. pz in lista d'attesa trapianti effettuati numero 0 20 40 60 80 100 120 decessi Donor EVLP Waitlist Lung Tx death … in conclusion
- 80. U.O. Anestesia e Rianimazione U.O. Chirurgia Generale ad Orientamento Toracico Infermieri Camera Opreatoria Zonda Centro di Ricerche Chirurgiche Precliniche Direzione Scientifica , Generale Fondazione Ca’ Granda Sponsors of the project Regione Lombardia Centro Nazionale Trapianti Lega Lombarda Fibrosi Cistica Uknowledgments Silvia, Sara, Jacopo, Alessandro, Giulia, Grazia, Stefano, Katia, Patrizia, Andrea, Daniele… Research Team
- 81. … to you for your attention! Uknowledgments
- 82. Department of Pathophysiology and Transplantation, Univeristy of Milan Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico franco.valenza@unimi.it
- 85. Percorso “DCD-donor” ACC sul territorio Trasferimento in PS Diagnosi di morte Percorso di donazione “polmone” Strategia di preservazione nel cadavere Valutazione qualità organo – ricondizionamento
- 86. “Open lung strategy” Collasso Inflazione Ossigenzione
- 88. “Ex-vivo Lung Perfusion - EVLP”
- 89. EVLP Trapianto 11.30 15.30 19.30 23.30 4.30 19.30 Decesso Consenso Prelievo Percorso “DCD-donor” 1 novembre 2014
- 90. Strategia di preservazione nel cadavere semplice esportabile a basso costo Ex-Vivo Lung Perfusion valutare ricondizionare migliorare Percorso “DCD-donor” ... It is feasible!
- 91. 12 Potenziali DCD / anno AREU-118 Milano, Monza-Brianza (aprile-giugno 2014) 1113 Arresto Cardiocircolatorio 783 Trattamento Arresto 234 Trasferimento in Pronto soccorso 30 Età, HIV-HCV, neoplasia …. sopravvivenza 50% …. rate idoneità EVLP 20%
- 92. ?????? 12 Potenziali DCD / anno
- 93. Milano 12 Potenziali DCD / anno