Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
Marcelo Cypel MD MSc FRCSCCanada Research Chair in Lung TransplantationSurgical Director ECLS Lung Program UHNAssociate Professor of Surgery Division of Thoracic SurgeryDepartment of SurgeryUniversity of Toronto
The Toronto Experience & Current Status
Disclosure
• Founding Partner:• Perfusix Canada Inc.
• Perfusix USA Inc. (Lung Bioengineering /UT)
• XOR Labs Toronto Inc.
• XVIVO Perfusion – Research support and clinical trial• United Therapeutics – Consultant • Xenios/Fresenius – Research support and investor in XOR• Gilead Sciences – Research Support
Van Raemdonck et al. Transplant Int 2014 Mar 15. doi: 10.1111/tri.12317
Commercial Devices for Ex Vivo Lung Perfusion
TORONTO EVLP
Perfusion : 40% CO, LAP 5mmHg, PAP 10-12mmHgVentilation: 7cc/kg, 7BPM, PEEP 5, FiO2 = 21%
Cypel/Keshavjee J Heart Lung Transplant 2008; 27(12):1319-25.
5
Concept Development & Study Design
Equipment Troubleshooting
1st Animal Experiment
Human Trial Design:Researchers,Ethics board, patients
1st Human Transplant
Completion of Trial and Health Canada Application
Approved for clinical use
Reimbursement
2005
20072008
20102012
2012
20052006
Toronto EVLP Timeline of Development
1st Patient transplanted with Toronto EVLP system
Health Canada• FDA (Aug 2014)
OHTAC MOH
6April 14th 2011, vol. 364, no. 15, pp. 1431-1440.
Early outcomes were similar in the 2 groups
NEJM, April 14th 2011
EVLP for high risk donor lungs is safe
8
Yeung, J. JHLT 2016
0 1 2 3 4 5 6 7 8 9 10
0
10
20
30
40
50
60
70
80
90
100
Time (Years)
Surv
ival
pro
babi
lity
(%)
Number at riskEVLP: No
133 100 73 51 34 23 14 12 5 2 0EVLP: Yes
133 89 55 40 26 14 10 0 0 0 0
EVLPNoYes
133 EVLPs vs. 133 matched controls
Early Outcomes
9
Category No EVLP (n=133) EVLP (n=133) p
Hospital LOS (Median, IQR) 23 (16.5-43) 21 (16-34) 0.21
ICU LOS (Median, IQR) 4 (2-14.5) 4 (2-10.5) 0.83
ISHLT PGD at 72h 0.02
0 82 (61.7%) 92 (69.2%)1 8 (6.0%) 18 (13.5%)2 30 (22.6%) 14 (10.5%)3 12 (9.0%) 9 (6.8%)
Yeung. J, JHLT 2016
Indications for EVLP at TGH(n=397 cases)
1) High-risk BDD: 55%2) Standard DCD: 11%3) High-risk DCD: 29%4) Logistics or retrieval by another team: 5%
Results EVLP by indications: AATS Annual Meeting 2018
Clinical EVLP Experience at TGH = 397 cases
Total utilization rate= 69%
EVLP & Lung Transplant Activity / Year 1983 - 2017
0
20
40
60
80
100
120
140
160
180
83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 '07
'08
'09
'10
'11
'12
'13
'14
'15 16 17
No
of T
x /
yr
Year
EVLP-LTXLTx only
Total EVLP performed to-date(N=252)
Toronto Lung Transplant Program Annual Growth 1991- 2017
27 27 25 2432 30 31 33 38
5042
59 5464 68
87
100
86
102
84
102104
133
115
128
145
170
0
50
100
150
200
91 92 93 94 95 96 97 98 99 '00
'01
'02
'03
'04
'05
'06
'07
'08
'09
'10
'11
'12
'13
'14
'15
'16 17
Num
ber o
f LTx
YearLTx/Year
2006-2011Plateau
mean 93.52000-2006~100% increase
ECD era
2012-201670% increase
EVLP era
14
Operative (30d) Mortality Rate(Avg 3% past 5 yr)
0%
25%
50%
75%
100%
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
Rate %: # death within 30-d post-op / # Tx within Calendar year
•DCD
•Extending Lung Preservation
•Implementation Process
EVLP
•DCD
•Extending Lung Preservation
•Implementation Process
EVLP
• SRTR data: DNDD utilization rate in USA is 21%• DCDD utilization rate in USA is 2.1%• DCDD rate in Canada and Australia and Europe 28%
DCD Lung Transplantation: Standard of Care
15-30% of transplants from DCDs
Cypel at al. J Heart Lung Transplant 2015 Oct;34(10):1278-82
Should All DCD Lungs be Treated with EVLP? Avoid surprises…
DCD, rapid arrest after WLST, “no concerns” straight to transplant
Machuca TN, et al. Am J Transplant. 2015;15:993-1002
•DCD
•Extending Lung Preservation
•Implementation Process
EVLP
Combining Cold and Warm Preservation in Large Animal Model can substantially prolong preservation time
Hsin et al. J Heart Lung Transplant 2016 Jan;35(1):130-6.
Towards Elective Lung Transplantation: Outcome of Transplantation of Lungs Preserved More Than 12h
90-day Mortality
P re s e rv a t io n T im e (H o u rs )
Ca
se
s
1 2 1 4 1 6 1 8 2 0 2 2
M e d ia n
Yeung J, Krueger, Yasufuku K, de Perrot M, Pierre A, Waddell T, Singer L, Keshavjee S, Cypel M. Nov 17, 2016
p=0.6
TGH Practice
•We routinely transplant lungs over 12h preservation time•Patients can remain at home – further distances•Don’t need to call in patient until donor assessment is complete (even more important in DCD as 40-50% don’t arrest)
•No need to rush in difficult cases worrying about ischemic time•More transplants can occur in the daytime – teams can sleep better performance, lower costs, allow program volume escalation without team burnout
Dr. X
Dr. MC
•DCD
•Extending Lung Preservation
•Implementation Process
EVLP
Transplant Center - Centric Model
Organ Repair Hub Model
Toronto Lung TransplantEVLP Process
Donor offers in Canada
Donor offers in US
UHN Organ repair center
Lung Bioengineering
(Maryland)
TGH transplant
Early days of EVLP at TGH
31
Concept Development & Study Design
Equipment Troubleshooting
1st Animal Experiment
Human Trial Design:Researchers,Ethics board, patients
1st Human Transplant
Completion of Trial and Health Canada Application
Approved for clinical use
Reimbursement
2005
20072008
20102012
2012
20052006
Staff surgeon- fellows- OPS
OPS • 3 EVLP teams (pairs): 1 full time OPS + 1 research fellow doing lab EVLP projects.
OPS Call Schedule has first and second call
34
Conclusions
• ~ 30-40% of our lung transplant activities come from EVLP lungs
• EVLP is a very effective method to test quality and improve function in DCDs and NDDs
• Combining cold static preservation and EVLP allows us to bring lung transplantation to a semi-elective procedure.