Department of Thoracic and Cardiovascular Surgery, Lerner Research Institute, Cleveland, Ohio; Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio; Transplant Center, Cleveland Clinic, Cleveland, Ohio.
Department of Thoracic and Cardiovascular Surgery, Lerner Research Institute, Cleveland, Ohio.
Ann Thorac Surg. 2020 Jun;109(6):1663-1669. doi: 10.1016/j.athoracsur.2019.12.072. Epub 2020 Feb 15.
Lungs of donors with high body mass index (BMI) have more atelectasis and a lower PaO/FiO (P/F) ratio than those with normal BMI. This study prospectively evaluated outcomes of a new approach for these lungs in our lung transplant program.
From February 2016 to December 2018, 336 lung transplants were performed at Cleveland Clinic. Of these, 58 met criteria for our aggressive approach to donors with a P/F ratio of less than 300 mm Hg at offer and BMI of 25 kg/m or greater. In the donor operating room, lung recruitment was performed by positive end-respiratory pressure of 25 to 30 cmHO for 30 seconds and lungs were converted to either straight transplantation or ex vivo lung perfusion (EVLP). Postoperative outcomes of the low P/F-high BMI group were compared with those of recipients receiving lungs meeting standard criteria.
Of the 58 donors, 33 were converted to straight lung transplantation because they demonstrated significant improvement in the P/F ratio after lung recruitment compared with the P/F ratio at lung offer (median, 278 versus 420 mm Hg; P < .01). Seventeen lungs with a persistently low P/F ratio underwent EVLP, 8 of which were transplanted. There was no significant difference in primary graft dysfunction grade 3 at 72 hours (n = 3 of 41 [7.5%] versus 31 of 247 [13%]; P = .79) or in 30-day survival (100% versus 97%; P = .60) between low P/F-high BMI and standard groups.
These data suggest that atelectasis in high-BMI donors contributes to P/F ratios less than 300 mm Hg and that intraoperative lung recruitment or EVLP can allow the use of lungs from these donors with good outcomes.
与正常 BMI 相比，体重指数（BMI）较高的供体的肺更容易出现肺不张，且 PaO/FiO（P/F）比值更低。本研究前瞻性评估了我们肺移植项目中一种新方法对这些肺的效果。
2016 年 2 月至 2018 年 12 月，克利夫兰诊所共进行了 336 例肺移植。其中，58 例符合我们的激进方法标准，这些供体的 P/F 比值在供肺时小于 300mmHg，BMI 大于等于 25kg/m2。在供体手术室中，通过施加 25 至 30cmHO 的正呼气末压力来进行肺复张 30 秒，并将肺转换为直接移植或体外肺灌注（EVLP）。比较低 P/F-高 BMI 组的术后结果与符合标准的受体接受肺的结果。
58 例供体中，33 例因肺复张后 P/F 比值较供肺时明显改善（中位数 278 对 420mmHg；P＜0.01）而直接进行肺移植。17 例 P/F 比值持续较低的肺进行 EVLP，其中 8 例进行了移植。在 72 小时时的原发性移植物功能障碍 3 级（n=41[7.5%]与 247[13%]；P=0.79）或 30 天存活率（100%与 97%；P=0.60）方面，低 P/F-高 BMI 组与标准组之间无显著差异。
这些数据表明，高 BMI 供体的肺不张导致 P/F 比值低于 300mmHg，术中肺复张或 EVLP 可使这些供体的肺得到有效利用，并取得良好的效果。
