Since 1990, the Thoracic Surgery Directors Association (TSDA) has presented an award annually to an outstanding article presented by a resident at The Society of Thoracic Surgeons (STS) Annual Meeting. Established to encourage resident research in cardiothoracic surgery, the award was renamed in 2009 to honor Benson R. Wilcox, MD, who was instrumental in establishing TSDA and who served as the organization’s first secretary/treasurer and later as its president. Abstracts submitted to the STS Program Committee representing research performed by residents were forwarded to the TSDA to be considered for this award. The abstracts were reviewed and the winner selected by the TSDA Executive Committee. In 2013, the recipient of the TSDA Benson R. Wilcox Award was Bryan A. Whitson, MD, PhD, a resident of the Division of Cardiac Surgery at The Ohio State University Wexner Medical Center Department of Surgery.
Use of the Donor Lung After Asphyxiation or Drowning: Effect on Lung Transplant Recipients Bryan A. Whitson, MD, PhD, Marshall I. Hertz, MD, Rosemary F. Kelly, MD, Robert S. D. Higgins, MD, MSHA, Ahmet Kilic, MD, Sara J. Shumway, MD, and Jonathan D’Cunha, MD, PhD Departments of Surgery and Medicine, The University of Minnesota, Minneapolis, Minnesota; Department of Surgery, Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and Department of Cardiothoracic Surgery, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Background. With the relative paucity of acceptable donors for lung transplantation, criteria for extended donor consideration are being explored. We sought to evaluate the suitability of donors whose cause of death was asphyxiation or drowning (A/D) as a potential option to enlarge the donor pool. Methods. We queried the United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research registry for lung transplantation from 1987 to 2010 to assess associations between cause of death and recipient survival using the Kaplan-Meier method. To adjust for potential confounders, we used a Cox proportional hazards model and a logistic regression model to evaluate incidence of rejection within the first year. Results. There were 18,250 adult primary lung transplantations performed, with 309 A/D donors. There was no difference in survival between groups (log-rank, p [ 0.52). There were no differences in demographics, length of stay, airway dehiscence, lung allocation score (LAS), or ischemic time in univariate analysis (all p > 0.05). The
A/D lung recipients had fewer deaths from pulmonary causes (5.8% versus 9.5%; p [ 0.02). Proportional hazards analysis was significant for double lung transplantation (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.8– 0.9), height difference (HR, 1.002; 95% CI, 1.00–1.003), donor age greater than 50 years (HR, 0.89; 95% CI, 0.83– 0.96), and recipient age greater than 55 years (HR, 0.8; 95% CI, 0.76–0.84). A/D cause of death did not impact survival in multivariate analysis. Conclusions. A/D as a donor cause of death was not associated with poor long-term survival or incidence of rejection in the first year after transplantation. Donor cause of death by A/D, when carefully evaluated and selected, should not automatically exclude the organ from transplant consideration. These results provide important justification for potentially broadening the donor pool safely.
F
offers the potential of being both a life-saving and lifeenhancing therapy. Although this therapy is critically needed, there is a relatively inadequate supply of acceptable quality organs suited for transplantation, with only 17% of lungs offered for transplantation being able to be successfully transplanted [1]. In the modern era, there are novel approaches to enlarging the donor pool, such as extended criteria [2, 3], donation after cardiac death (DCD) [4–9], and ex vivo perfusion [5]. The lungs from donors who have either been asphyxiated or drowned are not routinely used as lung donors. We sought to evaluate the suitability of
or patients with end-stage lung disease, there are few viable long-term options. For the appropriate candidate with end-stage lung disease, lung transplantation Accepted for publication May 7, 2014. Presented at the Poster Session of the Forty-ninth Annual Meeting of The Society of Thoracic Surgeons, Los Angeles, CA, Jan 26–30, 2013. Winner of the Thoracic Surgery Directors Association Benson R. Wilcox Award. Address correspondence to Dr Whitson, Department of Surgery, Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, N825 Doan Hall, 410 W 10th Ave, Columbus, OH 43210; e-mail: bryan. [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2014;98:1145–51) Ó 2014 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.05.065
GENERAL THORACIC
TSDA BENSON R. WILCOX AWARD
GENERAL THORACIC
1146
TSDA WILCOX AWARD WHITSON ET AL DONOR LUNG USE AFTER ASPHYXIATION OR DROWNING
Table 1. Donor Mechanism of Death Donor Mechanism of Death Intracranial hemorrhage/stroke Blunt trauma Gunshot wound or stabbing Other Asphyxiation Drowning
Frequency
%
6,637 4,919 4,179 2,206 280 29
36.4 27 22.9 12.1 1.5 0.2
donors whose cause of death was asphyxiation or drowning (A/D) as a potential option to enlarge the donor pool using national data.
Material and Methods We used the United Network for Organ Sharing (UNOS)/ Organ Procurement and Transplantation Network (OPTN) Standard Transplant Analysis and Research (STAR) database. The STAR database is administrated through UNOS/OPTN as overseen by the US Department of Health and Human Services. The UNOS/OPTN STAR database maintains data elements reflecting donor characteristics (eg, donor mechanism of death, donor age, donor sex), pretransplantation recipient characteristics (eg, indication for transplantation, recipient age, recipient sex), and posttransplantation recipient characteristics and outcomes (ie, length of stay, recipient survival, development of postoperative complications) [10]. The STAR database contains data on solid organ transplantation performed in the United States and contains data on lung transplant recipients from 1987 to the present [11]. The data registry contains information from all 11 of the United States subdivided OPTN regions. This retrospective analysis of the UNOS/OPTN STAR database was approved by the Institutional Review Board at the University of Minnesota (1006E83853) and The Ohio State University (2012H0306) with a waiver of need for individual consent. We evaluated all adult (18 years of
Ann Thorac Surg 2014;98:1145–51
Table 2. Recipient Diagnosis as Indication for Lung Transplantation Diagnosis Chronic obstructive pulmonary disease Idiopathic pulmonary fibrosis Cystic fibrosis Other Alpha-1 Antitrypsin Deficiency Primary pulmonary hypertension Sarcoidosis
Frequency
%
6,763 4,232 2,456 2,251 1,270 727 538
37.1 23.2 13.5 12.3 7 4 3
age and older) lung transplant recipients in the United States whose transplantation procedures were performed between 1987 and 2010. We limited our analysis to single and bilateral lung transplant recipients from cadaveric donors only. Those patients undergoing repeated transplantation had their second or further lung transplants excluded, and their survival was censored at the time of repeated transplantation, if performed. The data were analyzed with SAS for Windows, version 9.3 (SAS Institute Inc, Cary, NC). For all statistical testing, we used a 2-sided significance level of 0.05. For betweengroup comparisons, we used a 2-sample t test for continuous variables and a c2 test for categorical variables. Unless otherwise stated, results are reported as mean standard deviation. The Kaplan-Meier method was used to compare unadjusted all-cause mortality [12, 13]. To adjust our survival analysis for potentially confounding patient factors, we used a Cox proportional hazards regression model to adjust for covariates associated with survival and a logistic regression model for covariates associated with treatment for rejection.
Results Study Cohort There were 19,115 lung transplant procedures performed during the study period. Of those recipients, 18,250 met
Table 3. Univariate Analysis Associated With Donor Cause of Death Donor Cause of Death Variable Lung allocation score Single/double Donor M/F Recipient M/F Treated for rejection in first year Length of stay (d) Airway dehiscence Ischemic time (h) Posttransplantation dialysis Posttransplantation stroke Donor smoking Recipient age 55 y Donor age 50 y
Asphyxiation/Drowning
Other
p Value
44 15.4 41.8%/58.2% 66%/34% 46%/54% 50.8% 27.3 35.9 1.5% 4.9 1.8 5.4% 0.7% 14.2% 50.8% 1.9%
43.6 14.8 49.5%/50.5% 63%/38% 53%/47% 47.4% 26.5 71 1.4% 4.7 1.7 5.2% 2.1% 22.6% 49.1% 13.7%
0.47
Use of the Donor Lung After Asphyxiation or Drowning: Effect on Lung Transplant Recipients Bryan A. Whitson, MD, PhD, Marshall I. Hertz, MD, Rosemary F. Kelly, MD, Robert S. D. Higgins, MD, MSHA, Ahmet Kilic, MD, Sara J. Shumway, MD, and Jonathan D’Cunha, MD, PhD Departments of Surgery and Medicine, The University of Minnesota, Minneapolis, Minnesota; Department of Surgery, Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and Department of Cardiothoracic Surgery, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Background. With the relative paucity of acceptable donors for lung transplantation, criteria for extended donor consideration are being explored. We sought to evaluate the suitability of donors whose cause of death was asphyxiation or drowning (A/D) as a potential option to enlarge the donor pool. Methods. We queried the United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research registry for lung transplantation from 1987 to 2010 to assess associations between cause of death and recipient survival using the Kaplan-Meier method. To adjust for potential confounders, we used a Cox proportional hazards model and a logistic regression model to evaluate incidence of rejection within the first year. Results. There were 18,250 adult primary lung transplantations performed, with 309 A/D donors. There was no difference in survival between groups (log-rank, p [ 0.52). There were no differences in demographics, length of stay, airway dehiscence, lung allocation score (LAS), or ischemic time in univariate analysis (all p > 0.05). The
A/D lung recipients had fewer deaths from pulmonary causes (5.8% versus 9.5%; p [ 0.02). Proportional hazards analysis was significant for double lung transplantation (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.8– 0.9), height difference (HR, 1.002; 95% CI, 1.00–1.003), donor age greater than 50 years (HR, 0.89; 95% CI, 0.83– 0.96), and recipient age greater than 55 years (HR, 0.8; 95% CI, 0.76–0.84). A/D cause of death did not impact survival in multivariate analysis. Conclusions. A/D as a donor cause of death was not associated with poor long-term survival or incidence of rejection in the first year after transplantation. Donor cause of death by A/D, when carefully evaluated and selected, should not automatically exclude the organ from transplant consideration. These results provide important justification for potentially broadening the donor pool safely.
F
offers the potential of being both a life-saving and lifeenhancing therapy. Although this therapy is critically needed, there is a relatively inadequate supply of acceptable quality organs suited for transplantation, with only 17% of lungs offered for transplantation being able to be successfully transplanted [1]. In the modern era, there are novel approaches to enlarging the donor pool, such as extended criteria [2, 3], donation after cardiac death (DCD) [4–9], and ex vivo perfusion [5]. The lungs from donors who have either been asphyxiated or drowned are not routinely used as lung donors. We sought to evaluate the suitability of
or patients with end-stage lung disease, there are few viable long-term options. For the appropriate candidate with end-stage lung disease, lung transplantation Accepted for publication May 7, 2014. Presented at the Poster Session of the Forty-ninth Annual Meeting of The Society of Thoracic Surgeons, Los Angeles, CA, Jan 26–30, 2013. Winner of the Thoracic Surgery Directors Association Benson R. Wilcox Award. Address correspondence to Dr Whitson, Department of Surgery, Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, N825 Doan Hall, 410 W 10th Ave, Columbus, OH 43210; e-mail: bryan. [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2014;98:1145–51) Ó 2014 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.05.065
GENERAL THORACIC
TSDA BENSON R. WILCOX AWARD
GENERAL THORACIC
1146
TSDA WILCOX AWARD WHITSON ET AL DONOR LUNG USE AFTER ASPHYXIATION OR DROWNING
Table 1. Donor Mechanism of Death Donor Mechanism of Death Intracranial hemorrhage/stroke Blunt trauma Gunshot wound or stabbing Other Asphyxiation Drowning
Frequency
%
6,637 4,919 4,179 2,206 280 29
36.4 27 22.9 12.1 1.5 0.2
donors whose cause of death was asphyxiation or drowning (A/D) as a potential option to enlarge the donor pool using national data.
Material and Methods We used the United Network for Organ Sharing (UNOS)/ Organ Procurement and Transplantation Network (OPTN) Standard Transplant Analysis and Research (STAR) database. The STAR database is administrated through UNOS/OPTN as overseen by the US Department of Health and Human Services. The UNOS/OPTN STAR database maintains data elements reflecting donor characteristics (eg, donor mechanism of death, donor age, donor sex), pretransplantation recipient characteristics (eg, indication for transplantation, recipient age, recipient sex), and posttransplantation recipient characteristics and outcomes (ie, length of stay, recipient survival, development of postoperative complications) [10]. The STAR database contains data on solid organ transplantation performed in the United States and contains data on lung transplant recipients from 1987 to the present [11]. The data registry contains information from all 11 of the United States subdivided OPTN regions. This retrospective analysis of the UNOS/OPTN STAR database was approved by the Institutional Review Board at the University of Minnesota (1006E83853) and The Ohio State University (2012H0306) with a waiver of need for individual consent. We evaluated all adult (18 years of
Ann Thorac Surg 2014;98:1145–51
Table 2. Recipient Diagnosis as Indication for Lung Transplantation Diagnosis Chronic obstructive pulmonary disease Idiopathic pulmonary fibrosis Cystic fibrosis Other Alpha-1 Antitrypsin Deficiency Primary pulmonary hypertension Sarcoidosis
Frequency
%
6,763 4,232 2,456 2,251 1,270 727 538
37.1 23.2 13.5 12.3 7 4 3
age and older) lung transplant recipients in the United States whose transplantation procedures were performed between 1987 and 2010. We limited our analysis to single and bilateral lung transplant recipients from cadaveric donors only. Those patients undergoing repeated transplantation had their second or further lung transplants excluded, and their survival was censored at the time of repeated transplantation, if performed. The data were analyzed with SAS for Windows, version 9.3 (SAS Institute Inc, Cary, NC). For all statistical testing, we used a 2-sided significance level of 0.05. For betweengroup comparisons, we used a 2-sample t test for continuous variables and a c2 test for categorical variables. Unless otherwise stated, results are reported as mean standard deviation. The Kaplan-Meier method was used to compare unadjusted all-cause mortality [12, 13]. To adjust our survival analysis for potentially confounding patient factors, we used a Cox proportional hazards regression model to adjust for covariates associated with survival and a logistic regression model for covariates associated with treatment for rejection.
Results Study Cohort There were 19,115 lung transplant procedures performed during the study period. Of those recipients, 18,250 met
Table 3. Univariate Analysis Associated With Donor Cause of Death Donor Cause of Death Variable Lung allocation score Single/double Donor M/F Recipient M/F Treated for rejection in first year Length of stay (d) Airway dehiscence Ischemic time (h) Posttransplantation dialysis Posttransplantation stroke Donor smoking Recipient age 55 y Donor age 50 y
Asphyxiation/Drowning
Other
p Value
44 15.4 41.8%/58.2% 66%/34% 46%/54% 50.8% 27.3 35.9 1.5% 4.9 1.8 5.4% 0.7% 14.2% 50.8% 1.9%
43.6 14.8 49.5%/50.5% 63%/38% 53%/47% 47.4% 26.5 71 1.4% 4.7 1.7 5.2% 2.1% 22.6% 49.1% 13.7%
0.47
