PRÉLEVEMENT À CŒUR ARRÊTÉ & POUMON MYTHE OU RÉALITÉ ? R. SOUILAMAS Hôpital Européen Georges Pompidou. Paris HEGP Lung Transplant Group

DONNEUR IDÉAL Age < 55 ans Radiographie Pulmonaire Normale PaO2>300 à FiO2=1 sous PEEP 5 cm Faible durée de ventilation Tabac < 20PA Absence de trauma thoracique Absence d’inhalation Absence d’infection bronchique Absence de chirurgie cardio-pulmonaire

Bilan des prélèvements d’organes en France (Agence de la Biomédecine) Donneurs prélevés d’au moins un organe autre que Poumon ou C/P Donneurs prélevés d’un ou 2 poumons ou d’un C/P

Quelle est La Morale de l’Histoire !

SOLUTIONS DONNEUR VIVANT Éthique Logistique DONNEUR MARGINAL Subjectivité Limites DÉCÉDÉ PAR ARRÊT CARDIAQUE

Donneur Cœur Arrêté en France "Le ministre de la santé et des solidarités, Vu les articles L. 1232-1 et L. 1232-6 (1°) du code de la santé publique ; Vu le décret n° 2005-949 du 2 août 2005 relatif aux conditions de prélèvement des organes, des tissus et des cellules et modifiant le livre II de la première partie du code de la santé publique (dispositions réglementaires), Arrête : Art. 1er. − Les organes qui peuvent être prélevés sur une personne décédée présentant un arrêt cardiaque et respiratoire persistant sont le rein et le foie. Art. 2. − Le directeur de l’hospitalisation et de l’organisation des soins et le directeur général de la santé sont chargés, chacun en ce qui le concerne, de l’exécution du présent arrêté, qui sera publié au Journal officiel de la République française

CONTROVERSE SUR LE DONNEUR À CŒUR ARRÊTÉ Irréversibilité de la mort Définitions de la mort Gestes techniques sur personne décédée Ambulance bicéphale Consentement des proches « en urgence »

DONNEUR À CŒUR ARRÊTÉ Warm ischemia tolerance in collapsed pulmonary graft is limited to 1 hour. Van Raemdonck DEM, Jannis NCP, De Leyn PRJ, Flameng WJ, Lerut TE.. Ann Surg 1998; 228: 788-96

NHBD kidney, liver and lung donor program The third essential basement of the programm is the large experience with NHBD, firstable for kidneys and livers and lately for lungs, of another hospital in Madrid (Hospital Clínico San Carlos). 5th International Meeting TRANSPLANTATION CYSTIC FIBROSIS & EXVIVO Paris 10-11 March 2010 Gomez de Antonio D, Thoracic Surgery HUPHM Madrid. Spain

Protocol -Cardiac arrest -Transport to HSC. -Death certif. Preservation time (4h max.) Warm ischemic time (2h max.) Cold ischemic time -Cardiac arrest -Transport to HSC. -Death certif. -XR, serology -1st judge permission (preservation) -Topical cooling -Heparinization 2nd judge and family perm. (harvest) -FB -Flush perfusion (300cc donor´s blood + 5-6 l Perfadex®) -Harvest. -Transport to HUPHM. -EXVIVO evaluation. -Implantation. This is the sequential events during the process of NHB donation. After cardiac arrest, that obviously has to be witnessed, the estrahospital advanced support units take the potential donor to HCSC, where ER staff certifies death. Immediately, permission for preservation is requested from the Judge on duty while X Ray and serologic tests are performed. After permission, topical cooling with Perfadex is initiated through 2 chest tubes in each side (the donor is also heparinized and put on ECMO and deep hypothermia to preserve intraabdominal organs). Judge and family consent, this time for donation, is requested and fiberoptic examination is performed as is done in BD donors. The next step is to go on with organ retrieval, excluding pulmonary vasculature as soon as possible and performing in situ evaluation of the grafts after flush perfusion with Perfadex. (300 ml of donor´s blood are passed through the pulmonary artery and gas analysis of the effluent in the left atrium is made. If PO2/FiO2 is higher than 300, corrected by temperature, lungs are considered valid. Then, grafts are taken to HUPHM for implantation. Recently we have included in this algorithm XVIVO evaluation of these grafts.

Arrest

ECMO (abdominal organs)

Topical cooling

Flush perfusion

Bronchoscopy

Clinical Phase Age 41,44(SD 11,1) Gender 29 male Cause of death -Ethics committee aproval -Specific informed consent 29 NHBD uncontrolled (2002-2009) Age 41,44(SD 11,1) Gender 29 male Cause of death Aortic dissection (3) Sudden arrest (23) CET (1) Electrocution (2) PaO2/FiO2 480 (SD 92 ) Since 2002, we have performed 30 uncontrolled NHBD lung transplants (29 of them are included in this report, the last one was done less than 2 months before and was not included here). Donors were 41 years old of mean age, all male, the most frequent cause of death was sudden arrest, followed by 3 aortic dissections, 2 electrocutions, and 1 cranioencephalic traumatism. PaO2/FiO2 ratio, corrected by temperature, has always been above 300.

MATERIAL AND METHODS 10h 12h Warm ischemic time (min) 114 (SD 36) Preservation time (min) 185 (SD 44.7) Cold ischemic time (min) 1st: 294 (SD 79) 2nd: 455 (SD 121) Total ischemic time (min) 1st: 576 (SD 115) 2nd: 701 (SD 111) Mean warm ischemic time was of 2h, mean preservation time was 3h, cold ischemic time for the first lung was near 5 hours and more than 7h for the second graft. All together, represents a total ischemic time for the first lung of almost 10 hours, and for the second lung above 12 hours. 10h 12h

RESULTS.- PGD G 3 G 2 G 1 G 0 Incidence Duration Recovering In this figure you can see the incidence of Primary Graft Disfunction,, the duration of each grade, the average of patients that finally recovered from this situation and the hospital mortality rate associated with each grade of PGD. 5 patients suffered grade 1 PGD (in blue), with a duration of 48 hours till final recover and one of them died in multiorganic failure after a pneumonia. Five patients developed gade 2 PGD (in red) with a mean duration of 7 days and one of them died just before discharge after the withdrawal of a central venous catheter. 11 patients presented grade 3 PGD (in green), with a long duration as well, and 3 died (one died due to intestinal ischemia, another was transplanted in septic situation and another died after an episode of ventricular fibrilation. G 0 Incidence Duration Recovering 30 days mortality rate

RESULTS.- Survival 3 months: 78% 1 year: 68% 3 years: 57% 5 years: 51% 84 72 60 48 36 24 12 months 1,0 0,8 0,6 0,4 0,2 0,0 Cumulative Survival 3 months: 78% 1 year: 68% 3 years: 57% 5 years: 51% In terms of survival, three months survival rate was 78%(those 5 hospital deaths described before) , the first year survival rate was 68%, third year survival rate was 57% and 5 year SV rate 51%.

RESULTS.- BOS 1st year: 11% 3 years: 35% 5 years: 45% 84 72 60 48 36 24 12 months 1,0 0,8 0,6 0,4 0,2 0,0 Free of BOS 1st year: 11% 3 years: 35% 5 years: 45% Attending Bronchiolitis Obliterans Syndrome, 11% the first year, 35% at 3 years and 55% at 5 years.

Ex Vivo Évaluation

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