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Antibody-mediated rejection (AMR) of cardiac allografts mediated by anti-HLA Donor Specific Antibodies (DSA) is one of the major barriers to successful transplantation for the treatment of end-stage heart failure. Therapeutic plasma exchange (TPE) is a first-line treatment for pre-transplant desensitization. However, indications for treatment regimens and treatment end-points have not been well established. In this study, we investigated how sera dilutions could guide TPE regimens for effective peri-operative desensitization and early AMR treatment. Our data show that 1:16 dilutions of EDTA-treated sera and 1.5 volume TPE reduce anti-HLA class I and class II antibody levels in the same manner and, therefore, allows to predict which antibodies would respond to peri-operative TPE. We successfully applied this approach to transplanting three highly sensitized cardiac recipients (CPRA 85-93%) with peri-operative desensitization based on a virtual crossmatch performed on 1:16 diluted serum. Furthermore, we have used sera dilutions to guide DSA treatment post-transplant. Although these findings have to be confirmed in a larger prospective study, our data suggest that serum dilutions can serve as a predictive biomarker to guide peri-operative desensitization and post-transplant immunologic management.

Purpose The number of elderly patients requiring a lung transplantation (LTx) continues to grow. However, there are concerns that the age distribution of LTx recipients may be unbalanced, at a detriment to elderly patients. In order to assess the relationship between LTx and recipient age, we investigated the survival outcomes of elderly primary single and double LTx patients through analysis of the UNOS database. Methods We analyzed the UNOS database (1987-2014), investigating single and double LTx recipients based on three separate age groups (≤69, 70-74, and ≥75 years old). Using variables such as age, gender, ethnicity, BMI, length of stay (LOS), ECMO, inhaled NO usage, blood group, and procedure type, the three groups were compared for any significance (p=0.05). Survival outcomes were compared between the groups (STATA Inc.) and data were presented as mean±standard deviation. Results During 1987 to 2014, 27,980 patients received LTx (n= 16,015 double LTx, and n=11,888 single LTx). Out of total LTx patients, 27,076 patients were ≤69, 729 patients were 70-74, and 98 patients were ≥75 years old. Demographic data showed 54% male, 86% white, 7% black, 5% Latino, and 2% other. Recipient mean age was 55±15 years, with BMI- 24±4 kg/m2, median LOS was 15 days, and blood groups: O-45%, A-40%, B-11%, AB-4%. UNOS showed lower data on ECMO-1% and inhaled NO-0.21% usage. Log-rank test for equality of survival demonstrated significance based on age for patients who received single and double LTx (p Conclusion Survival outcome of single LTx patients did not show any significant statistical difference when performed in elderly patients above 70 years of age. When double LTx were performed, younger patients below 69 years of age seemed to do better in survival compared to elderly patients above 70 years of age. The beneficial survival outcome for single LTx patients extends to an older age than double LTx patients.

Purpose There are controversies regarding which side of the lungs, under-perfused versus over-perfused to be replaced when performing single lung transplantation (LTx). Theoretically, under-perfused lung appears to be better replaced rather than over-perfused lung; however, occasionally over-perfused lung is chosen due to limited organ availability, size discrepancy between the sides, or anatomical complexity, and this is recognized as ‘side-mismatching’ in single LTx. This study aims at evaluating the impact of side-mismatching on transplant outcomes. Methods Graft side-mismatching was defined with a prospectively designed formula using baseline quantitative lung perfusion scan data, and the patients who underwent single LTx between January 2016 and June 2018 were stratified as either side-matched or side-mismatched. A retrospective review of the LTx database was used to obtain short- and mid-term outcomes as well as complications for those patients. Results Two hundred eighteen patients received single LTx between January 2016 and June 2018. Out of these, there were a total of 18 patients had a side-mismatched graft while those with a side-matched graft over the same time period were used as controls. There were no significant differences between the groups in their patients’ characteristics except more patients with age above 70 years old and less patients with secondary pulmonary hypertension noted in the side-mismatched group. While the size-mismatched group consisted of more patients who underwent right single than left single LTx and required more intraoperative cardiopulmonary support (25% vs. 8.2%, p Conclusion Our data suggest that there is no evident increased risk or compromised post-transplant outcomes in performing side-mismatched single LTx when appropriate lung graft as well as intraoperative cardiopulmonary support is chosen. This strategy could optimize organ utilization increasing effective organ supply and decreasing waitlist mortality. In addition, this may contribute to avoiding the surgical or anatomical complexity leading to improved transplant outcomes.

Purpose The numbers of lung transplantation (LTx) recipients are gradually increasing worldwide. That leads to the subsequent question whether offering a redo-LTx is a viable option in some of those patients, especially the older patients, who were once transplanted. We investigated the survival outcome of single or double redo-LTx in both younger and elderly recipients analyzing the UNOS database. Methods Patients receiving single or double redo-LTx (n=1092; UNOS data from 1987-2014) were divided into three different groups based on recipient age - ≤69, 70-74, and ≥75 years old. Survival outcome was compared among the three groups using Kaplan-Meier Curve. Variables such as age, gender, ethnicity, BMI, length of stay (LOS), ECMO and inhaled NO usage, blood groups and types of procedures were compared for significance (p Results 498 had single and 594 had lung redo-LTx. 1069 patients were ≤69, 20 patients were 70-74, and 3 patients were over ≥75 years old. Demographic data showed 52% male, 87% white, 6% black, 5% Latino, and 2% others. Patients had BMI- 24 ± 5 kg/m2, median LOS 15 days, and blood groups: O-46%, A-40%, B-10%, AB-4%. Although UNOS data showed ECMO-4% and inhaled NO-1.3% usage, many data were missing from UNOS database for ECMO and inhaled NO. Log-rank test for equality of survival between the three groups showed no difference in survival for single redo-LTx (p=0.89), but demonstrated significance between the age cohorts for double redo-LTx (p=0.004). There was no significant difference in individuals receiving single redo-LTx based on age: ≤69 vs. 70-74 years old (p=0.63), ≤69 vs. ≥ 75 years old (p=0.94), 70-74 vs. ≥75 years old (p=0.91). Conclusion Single lung redo-LTx had no survival difference in different age groups compared to double lung redo-LTx. Older patients had more single lung redo-LTx than younger patients. Single lung redo-LTx data whether contralateral side or the same side lung redo-LTx was performed, were missing in UNOS database.

Purpose Since we recently yielded and presented our results for concomitant lung transplantation (LTx) and coronary artery bypass grafting (CABG) (LTx/CABG) that showed a 100% 1-year survival, more patients with severe coronary artery disease (CAD) have been referred to us, which has driven us to establish our institution's decision-making algorithm for those with concurrent severe CAD in LTx. Methods Between September 2017 and September 2018, we prospectively evaluated 31 consecutive patients with concurrent severe CAD referred for LTx at our center. Severe CAD is defined as the one with at least one of the main coronary artery branches being angiographically significant (>70% stenosis) or when clinical or physiologic criteria are met. An experienced interventional cardiologist and two cardiac surgeons jointly reviewed the CAD severity of all these patients prior to listing and decided their treatment options following the algorithm below. Patients with clinically significant CAD and unstable clinical trajectories were listed for LTx/CABG (Figure). Results Following joint review, revascularization was deemed unnecessary in 5 patients (16%) who eventually underwent LTx alone. Two patients were scheduled for LTx/CABG but underwent LTx alone based on intraoperative judgement. Nine patients (30%) underwent concomitant LTx/CABG. Six were single and three were double LTx. One case was with ECMO bridged to LTx/CABG. All patients with severe CAD who proceeded to transplant were discharged and clinically stable at the end of the study period. Conclusion While multimorbidity in the elderly now constitutes the greatest present medical burden even in LTx, a well-designed selection algorithm contributes to their optimal treatment options leading to improved outcomes following LTx for those with severe CAD.

OBJECTIVES We attempted to determine if transplants of lungs from diabetic donors (DDs) is associated with increased mortality of recipients in the modern era of the lung allocation score (LAS). METHODS The United Network for Organ Sharing (UNOS) database was queried for all adult lung transplant recipients from 2006 to 2014. Patients receiving a lung from a DD were compared to those receiving a transplant from a non-DD. Multivariate Cox regression analysis using variables associated with mortality was used to examine survival. RESULTS A total of 13 159 adult lung transplants were performed between January 2006 and June 2014: 4278 (32.5%) were single-lung transplants (SLT) and 8881 (67.5%) were double-lung transplants (DLT). The log-rank test demonstrated a lower median survival in the DD group (5.6 vs 5.0 years, P = 0.003). We performed additional analysis by dividing this initial cohort into two cohorts by transplant type. On multivariate analysis, receiving an SLT from a DD was associated with increased mortality (HR 1.28, 95% CI 1.07–1.54, P = 0.011). Interestingly, multivariate analysis demonstrated no difference in mortality rates for patients receiving a DLT from a DD (HR 1.12, 95% CI 0.97–1.30, P = 0.14). CONCLUSIONS DLT with DDs can be performed safely without increased mortality, but SLT using DDs results in worse survival and post-transplant outcomes. Preference should be given to DLT when using lungs from donors with diabetes.

The Protek Duo is a novel dual lumen cannula that is inserted percutaneously via internal jugular (IJ) venous access. The proximal inflow lumen is positioned in the right atrium and the distal outflow lumen is positioned in the main pulmonary artery. These lumens are connected with the para

Aim Virtual crossmatch (VXM) has increased non-local organ utilization and improved clinical outcomes for sensitized lung patients. However, the concordance between VXM and cell-based crossmatch is not absolute because Single Antigen Bead (SAB) assay is prone to both false-negative and false-positive reactions. Since false-positive antibody specificities may unnecessarily deny an organ based on VXM, the goal of this study was to evaluate what additional testing may be warranted to recognize such reactions and to improve virtual crossmatch accuracy. Methods All sera were pre-treated with EDTA to inactivate complement in order to avoid prozon-like effect and were analyzed by SAB. A positive VXM was defined as the presence of donor specific antibodies based on SAB that would result in unacceptably positive Flow Crossmatch (FCXM). FCXM was done using 3-color analysis on a 1024 channel scale. All sera was retrospectively tested by FlowPRA Screen and LSPRA (phenotype bead) assays to rule out antibodies against denatured HLA epitopes detected by SAB. Results Of 58 consecutive VXM performed during July-December 2016 for lung candidates with CPRA > 10%, 28 had no DSAs or had acceptably weak DSAs and were predicted to result in negative or acceptably low positive FCXM. Other 30 VXM had one or more strong DSAs and were predicted to result in unacceptably positive FCXM and the organ offers were refused. Additional antibody testing showed that only 23 out of 30 VMXs should have been called positive. The other 7 VXM were called unacceptably positive due to the presence of antibody against denatured antigens. Three patients had antibodies against class I denatured antigens (MFI ranging 2500–3500) and four patients had antibodies against class II denatured antigens (MFI ranging 2000–14,000). After using LSPRA and FlowPRA Screen assays, the antibody against denatured antigens were removed from the list of UA and 5 out of 7 patients were successfully transplanted. Conclusions We found that at our center 12% VXM are false-positive due to the presence of antibodies against denatured antigens detected by SAB. Multiple antibody testing platforms, including SAB, LSPRA, and FlowPRA Screen, can be used for antibody characterization to avoid erroneous assignment of UA that may lead to an unnecessary organ offer refusal.