Dr. Deborah Jo Levine with Stanford University, in Stanford, California, reports on lung transplantation indications and candidate selection and ESC/ERS PH criteria for lung transplant listing.
Hey, thank you so much. Listen, Mike. Uh And I wanna thank you and Amy for inviting me again. This is always one of my favorites. We have so much fun and we learn a lot and I love, um I really love hanging out with the faculty and let me tell you fellows, you, we, we have to give you another round of applause because I can't do it except, but you guys did awesome. All of those cases should be presented at a meeting and maybe as a uh an unknown or something like that, it would be super fun and they could probably all be published. So think about it. They're great topics and keep going with ph in your career. Thank you. Um So I um thank you also because I'm, I'm going to be, we switched a little bit so I can make my plane. But I really want to talk about my two passions and how they're interactive. Um And I really, I always was told as I was going into my career that I can't do both, but I could never give up one. So it was um they say you, you'll just never do well in either one. But you know what? I loved them both and they really do. Um, hook up together in so many ways. When I started this talk, I had 100 and 27 slides. I don't have that anymore, but there's so many things you can talk about in this and I picked one topic or one way that I think everyone will like. And that's really to talk about the overview. And when you look at this article, um from back in 82 lung transplant and Pah have been really hooked up together associated since then. The first heart lung transplant was done at Stanford uh in 1981. And that was the first heart lung, it was done for Pah. And the first lung transplant for PAH was 1983. And actually, when I was in San Antonio, well, before I got there, they did the first single lung transplant for Pah, which isn't really done anymore. But there is just a very long history between um patients with um ph and lung transplantation. So I just want to talk to you a little bit about what's happening in the world of transplant. And this is a slide from the International Society of Heart Lung Transplant. It shows you as you progress over the years that really you can see an exponential increase in, I don't know where the pointer is but an exponential increase in the numbers of lung transplants being done internationally. You can see that really. Um um, both here and I mean, both it abroad. That's international and here's us. Uh The numbers are still as, as high. You can see there's a little bit of a dip. We did take a dip during COVID. Uh believe it or not, probably you believe it more than not. Um, but the numbers are coming up. In fact, this year, there's gonna be a record number of lung transplants being performed in the United States. Um Up to 3000, we're already at 3000 and it's basically only November. Um So really, we are all getting to be more successful in the numbers of lung transplants being performed all over the world. This is a little bit over older slide, a couple of years old, but this is just showing us what are the lung diseases in the US that we transplant for? You can see interstitial lung disease COPD. Um The green is, and the bottom green is PAHCF is pink and other is brown. And really the thing I want you to see is that over time, you can see that ILD just exponentially jumped up crazily. Um uh Since uh this is when a new allocation system was formed in 2005, looking at transplanting patients who are sicker IOD patients, they're very sick, they get sick very quickly and that's why the number went up so high after that. Um New So in introduction of what's called the las uh was as was introduced in 2005, really didn't change a lot for others. And you can see the baseline of pulmonary hypertension patients is relatively stable over the years. We don't do a lot. Um but we'll see how many we do do. Um So even with this increase in numbers, the success we have in introducing how many more we're doing. Um We, we're not that great. We still have a lot of work left to do on survival. And this is a uh a nice Captain Meyer curve that really shows us over time with what, why uh survival on the Y axis and uh years on the X axis that really in the last three eras, we don't, haven't really changed much in terms of our survival um benefit. So at all, all comers, all diseases about five and 6.5, 7 years for median survival. And that's all comers. Now, when you break that down, uh it looks a little bit different and some um some disease states are a little bit um that uh perform a little bit better with lung transplant. And some don't, you can see the light blue line is pulmonary arterial hypertension and it really comes down right under CF and those are really the two disease states that really have very good outcomes. Um And that's likely because many of them are younger, they don't have as many comorbidities. Um And this, this is probably one of the major reasons I wanna take, I want you to take a look at this because even with this, you can see the median survival in the light blue, which is pah is still only about 7.5 years. It's a little bit better than the median, but it's not that much better. But take a look at this. If the patient lives one year he lives. So she lives one year, then you see these numbers getting a lot, lot better. In fact, that blue line goes from 7.5 years to almost 11 years. So conditional on one year survival, I lived a year after a transplant. I am going to live a lot longer. So why is that? Does anybody know anybody know for the PH patients? And maybe we, I, I won't wait too long because we don't have that much time. But if anyone, if anyone knows and tell me, ok, well, I'm gonna show you then look at that box. I, I brought it up at the very beginning but I didn't really make it that, you know, relevant. You can see that right within that first year and really per operatively. I'm, where's that little pointer is that you can see this little curve here. Can you see what I'm talking about where a lot of patients died really quickly? Right? You don't get that with those other diseases. Why? Because per operatively pulmonary hypertension patients have a very difficult time. They're always very sick. They're in right heart failure, whether they're on ECMO or not, which they all are now. But, um, but back then, you know, many of them weren't, they weren't done all, all, all on pump and there was a lot of perioperative mortality. So that is why if you lived really after the first couple of months, you probably did well. But it is that period of time, unlike any other disease state that has this, who else has this? Can anyone figure out who else may have this kind of kind of issue? Well, it's probably patients with group three, right patients with Ilco um Phildphcobd who still have a relative association of right heart dysfunction, right heart failure, they still have the same kind of issues that a patient with Pah would have. So once you get through that perioperative as a Ph patient, you do relatively well. So these patients after transplant, I'm gonna talk a teeny bit about why patients die after transplant. Just to make sure you understand, you know, the difficulty and the challenges of making these hard decisions, both you the patient and the transplant center because um most of the patients, why do we have these um decreased um survival now is after a year after transplant. The most common reason for a patient to die is what's called chronic lung allograft dysfunction or clad So clad really affects up to 50% of patients at five years. And if you have clad, you have a very high chance of progressing to death. So it affects a lot of patients and it means that our patients have this risk of death, even if they undergo lung transplant and do fine. Um what chronic lung allograft dysfunction really is. It's this irreversible change and you know, PFTs, you know, this uh this spirometry looks like a terrible COPD or he has like almost no um flow left. And so it's an obstructive disease that has a very, very uh irreversible progressive decline in the FEB one. Um How do you get clad? Multiple risk factors throughout your whole life after transplant would be um a uh would be how it you progress to clad. So, a lot of stuff happening after transplant that makes you wonder, should I even undergo this? It's a big deal, right? And I'm only gonna live five years and most patients do progress over time uh with risk factors of all immune, immune injury as well as non immune injury leading to it. So it's a very important point to think about when you are going to go to CLAD and once you get clad, guess what looks like there's a ton of therapies for it. Right. Well, really, you look at this, the only therapy that's really known to work is retransplant. So, what about indications in candidate selection when we know we're gonna want to talk about ph, but when you look at all comers and this is a great uh document. This is the ISHLT consensus document on an understanding when to refer and list candidates for lung transplant. And it really in general of this, I just want, it also talks about heart lung transplants, which we'll talk a little bit about later. And really in general, heart lung transplant is really reserved for patients who have both advanced heart disease and advanced lung disease that they wouldn't get through the transplant with either one. It used to be that as you can tell a lot more heart lungs were done. Look at this way back in the early eighties, all transplants were heart lung, they weren't lung at all. And so over time and this is um green, is North America yellow is um is North Ameri, uh green, is North America yellow, is Europe. Europe obviously had a lot more heart lungs than we did. Um And over time, everybody decreased. And that's why that's because we found out because most patients who were getting heart lungs were pah patients. But we knew now over time that the right ventricle probably remodels and, and you will do fine with just bilateral lungs once you get those really high pressures um out of the system, which is from the lungs. And they were right right now, there's probably only about 25 per year in the US. Um, as opposed to all these 203 100 ones that were done previously, generally, and then we won't go through this too much, but generally to get a lung transplant or to be a good candidate, you have to have a really high percent of risk of death from dying from a lung disease within two years. Um, and if you don't, it's probably not worth it, but you also have to have a very high likelihood that you'll live at least five years. Um There are absolute contraindications. We won't go through those, but we will talk a little bit about them when I put you to work at the end with questions. So pulmonary hypertension is common, right? It's huge. Everybody has pulmonary hypertension. 1% of of patients, uh people in the whole world have it and 10% of patients over 10% over 10% over 65 have Ph. So are all patients that have PH candidates for lung transplant? Yes or no. I see a lot of head shaking. No, you're right. Not all Ph patients are candidate, potential candidates. Remember PH is a very multidisciplinary disease. It's really when you look at it, the diagnostic groups depend on, on them, on the uh clinical hemodynamic and pat pathological characteristics. So those five groups are really helping us decide um what therapies um are available and, and you know, lung transplant is really a therapy. So when you look at it. The diagnosis really drives the treatment of the individual patients when you really make that diagnosis. And that's probably the most important thing we can do is make sure your patient is fitting it into the right here box or the right treat uh the right diagnosis. So pah obviously group one rare but probably the most common reason we do ph patients and lung transplant. Group three, we know that many patients with. There's been multiple studies done looking at how many patients post transplant in their explant when they had ILD or COPD, they had lesions exactly like those of patients who had PAH. So that's the next most common. And then patients who have CTF but can't undergo an endarterectomy or they aren't um medically manageable for some reason or another. They are also candidates for um in some cases, a lung transplant. But look at the ones that we talked about pulmonary arterial hypertension, rare CTF, even rarer uh lung disease, rare, but not as rare as the other two. So they're not the most common of all the PHS. So yes, not all patients are going to be lung transplant candidates. And the ones that are are in the rarer categories. Today, we're gonna be talking a lot about um pah. So group one, but uh an interesting group is also group three. And if we have time questions can come from that. So when you look at all the ph people remember they're not all the same either. So you have to decide, you know, is there something about each group that would make them a better or worse candidate for lung transplant? 50% of our patients with PH are idiopathic, about 49%. So idiopathic inheritable, which is about 7% of all idiopathic, they are gonna be the normal run of the mill pah patients that really may not have a lot of comorbidities. They're on therapy, they're on triple drugs and now they're progressing. They need to get transplanted. But the other 50% are having associated diseases and you have to look at each one of those associated diseases to make sure that that's not gonna be worsened after a transplant. Remember, you're transplanting the lungs, not the whole body and in a system you have to think about all of that. So let's look at a few of them. Not a lot. But let's look at a few of these. What about uh group, 1.3 drugs and toxins? We've already talked about methamphetamines. It's a huge issue in many areas of the country. Um, some more than other. When I moved up to California, it's up to a third of our patients. And uh it's, it's a very difficult disease because not only are you dealing with Pah, but you're dealing with the idea that it's a very addictive drug that is hard to get off. It's almost impossible. And people from all social statuses, all races, all either gender, it can affect anyone and it's a very sad and difficult situation. These patients have a very high rate of relapse going back to their drugs. I've seen it in the very short time. I've been up uh in my new center with a couple of patients who are post transplant. You know, it's a coping mechanism and if things get hard in life, it's easy to fall back on things that make us comfortable. And lung transplant is at least the most um stressful situation a person can go through whether it be pain, family situations, doctor everything, rejection, infection, all of these things can really be difficult challenges socially and psychologically on these patients. So, relapse, post transplant is very common and they don't work well together. Um And, and so that has to it, it really is a absolute contraindication unless this person is completely cleared. Now, with all these things going on at looking at disparities and things like that. Everyone's always trying to figure out how do we get these patients to undergo the the treatment they need fast enough to get transplanted because it is a devastating disease and their ph is nothing to laugh at. It's very, it's very most of the time, very severe. So that's one challenge in 1.3. Um uh pah 1.54 is just as challenging. These are patients who have connective tissue disease and autoimmune disease, connective tissue disease. What is it? It's a systemic disease. It is not something that you get the lungs out and you're gonna be fine. Oops, sorry, don't look at that. We're not ready for that. Um, it, it's not, so it's not something that you're gonna be one and done with transplants, done. I'm done. These patients have uh a lot of problems whether it be esophageal kidney, heart lung, I mean heart uh skin um and uh ab uh a abdominal and including liver. So most patients with um most patients who have scleroderma are the patients who have the most difficult journey. That's whether they're scleroderma, ILD, scleroderma, phild or scleroderma pah. They happen to be the most common um patients we see with Ph as well. So these patients in many, many centers still are have a contraindication to lung transplant. Why is that patients with scleroderma have a very difficult problem with esophageal dissimilate. Who cares? Right. I'll tell you what, I'll tell you why we care reflux disease or GERD is one of the most highly associated situations for chronic rejection or clad. Why? Because even micro aspiration can turn into rejection. And those patients um have a a lot of ed and after a lung transplant, oftentimes your swallowing mechanism, your um even your motility is dec is decreased. So many situations around the country and the world used to and some still do make scleroderma ph a contraindication to lung transplant now, most people are looking at things they can do. Like you can have a peg GJ tube placed and never eat again and make sure that that's something that's done. But these are things that are very difficult and telling someone they're never gonna eat again. Um First of all, they laugh because like I'm gonna go home and eat. That's what they do. But you have contracts and things like that. But esophageal dis motility can be very, very difficult. Remember with scleroderma, you have that like steel pipe. This was from medical school. All you fellows remember the steel pipe, um esophagus, it doesn't work, it's just a pipe, it doesn't have any motility. This is how they get these problems. Esophageal dysmotility, scleroderma makes it hard but they have other things. Scleroderma has a lot of renal insufficiency and any and other and uh organ damage. So connective tissue disease is a difficult one. In fact, the IC HLT just did a whole two part um series on connective tissue disease and all the issues. There's a lot of heart stuff, there's a lot of stuff that we have to be looking at HIV. Remember 0.5% of all patients with HIV have PH and sometimes the ph is more difficult to control than their HIV. In fact, most of the times there are definitely HIV patients that can get transplanted. Very few. But you look at donor recipient matching and if you do have an HIV donor. You can put these lungs uh into an HIV um uh uh recipient. But again, very high infection rate you have now, not only the HIV, but also transplant and a lot of the drug drug interactions with some of the HIV meds uh can be difficult with some of our immunosuppressants, congenital heart disease. Obviously. Um These can be from very little um to very, not little um Eisen minors and those like that require a heart lung transplant um because it is not going to work without it. And some of them can get a bilateral if it's very mild uh PV OD. Um So pulmonary renal accles disease or pulmonary capital he hemangiomatosis, very important and challenging in the fact that these patients do not do well with our medications. They have a lot, they're very sensitive to the vasodilation and oftentimes um d don't are very rapid in terms of their progression and those patients have to be referred right away uh to uh a um to a lung transplant center. However, oftentimes they, these patients look feel and uh we think are just regular oph. So they're really kind of behind the eight ball getting referred. So this is uh one of the things that makes it very, very challenging. Ok. Now it's time for you guys to help. I'm, I'm tired, I'm gonna let you do all the work. So how common is a lung transplant for patients with Paha a large proportion of patients. Um are, it's a large proportion of patients get lung transplant because the outcomes are so much better than with other disease states. That's a b very small proportion because there are therapies that cure this. These diseases. C it's proportional with other diseases. Il DC OPD or D, none of the above. Can I just have a hand raise for a B C or D? Well, the DS have it. None of the above. And I'm gonna tell you why. Now this is a slide from the ISHLT. That's very interesting. It's one of my favorite slides in the whole wide world. And what does it show? It shows that over time um from the early 19 nineties before, you know IPO prosol was even in our use um uh we had and so what it is is on the, on the Y axis is the percent of transplants by the different colors, which is different disease states over time. So over time, look at white, that's Idiopathic Pulmonary arterial hypertension. Back then, this was called PPH or Primary Pulmonary hypertension. And as you see, over time, this was about 1520 percent of all of our lung transplants being done were done for PAH over time, that white line gets skinnier and skinnier and skinnier and skinnier to. Now, at this point, about 2, 2017, 2018, it was less than 2% of our, less than 2.5% of all of our transplants being done. Why is that? Well, let's see. Could it be uh oh, this is just what happened over those 20 years? Well, could it be the fact that we got a lot of drugs, all of these drugs were um implemented, um approved and used over time. And if you look at this next slide, it kind of gives you the timeline of when they were proved and how that white line got skinnier. So it looks like when Op Prostin all was started, even though it wasn't the greatest therapy in the world. I mean, it is the greatest therapy in the world, not the easiest in 1995. You can see that this white line went from 20% maybe down to 10. And I'll tell you it makes back before then. I wasn't obviously practicing back then. But back then you only had one decision to make. I would see a patient I guess say, oh you have ph you're getting a transplant. Super easy. Nothing else to do. Get a transplant right. Then. Iops and all came on bo sent and Remodulin. Everything came on. All of those are fantastic, right? We have so many, but now it's making all of our jobs more difficult because we'll see why one thing these drugs did do is that this is the most recent IC HLT iteration. Even only 2018. They don't put this graph up anymore. But I love it. The, the most, the most recent iteration doesn't even put PAH on them. They put retransplant on there but they don't put pah, that shows you that we're done. Right. Mike. No more transplants for Pah. We're done. We've cured it. Correct. Right. You're gonna finish this talk because you're right. It did not. II, I guess II, I should keep going. Right. Reality check. Whoever that was. They know they, they have the reality check that yes, even though these drugs have helped us decrease the progression to death, we still have um progression, the disease, even though we have great therapies and some more coming on board, we still have a substantial risk for patients to deteriorate while they're on this great therapies that we have. So we're not done. We have to do a few more slides. Um And then we'll, we'll go to lunch. So the best thing is, yes, it's a pro, we have so many therapeutic options. That's great. But the con or the consideration is create, it creates a lot of challenges for the physi referring physician to the transplant team and the patient. So these are some questions that I thought up about, you know, what, what makes it so complicated for the referring position is, should I refer them? They're not gonna do well anyways or who do I refer? When do I refer then for us as a transplant team? Who should we list, when should we list them? And how should we list them? What kind of transplant should they get? And the patient do I wanna go through this freaking transplant? It seems like it's gonna be really hard. How do I know if I want one? I don't even know if I want one. And then are there any other options? Right. So there's a lot of things now that come up with all of these great therapies we have. So, what is the best time for Ph providers to start the transplant conversation with a Ph patient? Is it when the patient has a PV R A? Ok. A when a patient has a PV R greater than five wood units, B when a patient is admitted to the IC U with right heart failure, C early on in a patient's diagnosis as a possibility or d when patients are placed on IV therapy, A hands, B hands C and D. Ok. We have a little split in the room. I'm gonna say early on in the patient's diagnosis as a possibility. The reason I say that and you're gonna see this question again, come up for all the people who didn't get it, right? Because you would have gotten the next one, right? I tricked you. I said, when is the best time to have a conversation? Not a best time to refer. When should you start saying to this patient? This possibly could be in your future. It's not a big deal right now. But I, I'm telling you all the therapies. So this is why I tricked you. And I'm sorry, that wasn't nice to do on a Saturday afternoon. This was just when the diagnosis, when the, when you're gonna have a little bit of a conversation. Another thing I wanna point out here is, it's not the ph doctor's responsibility. It's not the referring physician's response ability to talk about transplant. I feel as a transplant doctor even to have that conversation, it's a good referral that patient may never get a transplant and be the worst candidate in the world and they don't even want one. But I think, and we see this from the CF world. Is that having the ability to say, think that patient to say, OK, I looked at everything I don't want one having that referral is never bad. So I think any patient should be with Ph who's not, you know, doing perfectly could, could be a possible referral. What is a contraindication for transplant referral? A, the patient is not severe enough for transplant B? The patient has too high of A BM IC. The patient has really bad kidney injury. D none of the above A's bees, CS and D. OK? And I, I agree with de and I'll tell you why. The reason is if you looked, I had one slide I took out because I have too many. The, the slide that I really liked was to show this progression of the guidelines or the consensus from the IC HLT from 19. Um I guess it was like in the eighties all the way up every seven or eight years, they do another one. This one was just done in 2021. The reason I put, what is a contraindication to referral is number one, nothing should be a contraindication to referral if a patient wants to look at it, send them if you don't know, send them. But also contraindications have changed over time. It used to be that patients who were intubated were not transplant candidates or you can be intubated for a week. And then we're gonna take you off the list. Patients with a BM I greater than 30 used to be a contraindication. Now, patients are coming to us with 35. You know what it does is there's no contraindication to um to, to referral. If a patient has a BM I of 40 they come see us, guess what it gives us time to say. You have to get them on a weight loss program. Do this, do that? It gives you the time to say what they would need to do to become a candidate. ECMO used to be a contra indication to transplantation. Now, this is an old slide. It's even higher. Now, now how many consults do we get? We get a million consults for um patients who are on ECMO to go to lung transplant or even we put them on ECMO to get a lung transplant and they're on ECMO for weeks or months. So, contraindications to referral does not exist. When should patients be referred for transplant? If they're ph Well, a when a patient has a PV R greater than five, I told you, you'd see this again when a patient is admitted to the IC U with right heart failure. C when a patient is in a high risk group, D when patients are placed on IV therapy or EC and D A B C D, I made this a little easy. E Yeah, there they go. OK. So, right. And I'm just gonna show you a couple, there's just a couple of slides left. Um This is a um this is the ES ce RJ 22 crate. Uh There's every society has their own criteria to referral to lung transplant. So the ESC has one, the WSPH the ISHLT, everybody has their own, even your heart journals do that. So they all have it, they all say the same thing but they all want to act different. So they all say them differently. But you're right. There's a lot of reasons of when to refer. And the need for IV or sub Q therapy is a good reason to refer. And then if these patients have the known high risk variants such as PB OD or PC H as we talked about or even sclero uh systemic sclerosis, there's other things as well, but I think those are the only two I put on the question. Um They really use the reveal risk score. So when, as you're seeing patients go through, if you have a scar score greater than seven, at least from the ESC, they say that's a reason to refer. Um Now let's take a look at the, is att guidelines again, the same thing, they have a lot of different things um need for IV or sub acute therapy and known or suspected variants of PB OD and PC H. The correct answer is none of those. Actually, even though I said C and D was correct. Really, the best answer is just refer early timing is everything. Why? Because first of all, how long does it take to get along a long time? Our patients are very unpredictable. I'm gonna tell you a very short story about a patient that I will never understand what we did and I was still a fellow. So I can't, it wasn't really my decision. But anyways, this was a patient and I can see you, you'll see this is a patient that everyone knew and loved. She, we were taking care of her in a PH clinic for years and years. And then it came time that hey, you're ready to be uh evaluated, referring and enlisted for transplant. So she did and she was on all the therapy, she's on three drug therapy. And basically what happened was she came, she got, she got an offer, came to the hospital. I was on call that night and she was walking around the floor, around and around and around. She looked great. She looked so good. She had just gone to a birthday party and she was perfect. And I called up my attending and I'm like, hey, you might wanna come in here. I don't understand. Do we wanna transplant her? She's on like one or 2 L and she's walking around the room and she looks fantastic. And so he um came in, we had a big discussion, talked to the surgeons, talked to everybody, our whole team. And we're like, you know, Mary, you look really good and you know, there's this short time after transplant, we wanna give you the most life you have before transplant because we know after transplant, you may only get five years, maybe seven, maybe 10. But so we, we said we're gonna give you the option. Well, we can call someone in n for this, these lungs. And so she said, no, I don't want to do it. I wanna have life beforehand. So she went home. She had a great life three months later, I know because I was on a trip, I think it was a chest or something. And I got a phone call from one of my fellow colleagues. And she, he's like, oh, Mary is getting transplant and I'm like, oh, that's so great by the time she was there, three months later, she had gone into such severe right heart failure that she was one of those patients with that little box. I showed you that she was too sick for transplant. And this is why we have to refer early because since our patients are unpredictable, they can be good one day and three months later, they can be terribly so refer early, refer um you know, all the time. And you can always be said, hey, we're just gonna watch and the transplant center will just watch. They don't have to transplant them right away. Also, when you refer someone early, if we do find something in the work up, maybe they have renal insufficient, we have to fix it. Maybe they have some kind of, maybe they're smoking and they have to stop. It gives time to make those modifiable changes to make that patient, either a candidate or if there are a candidate, a better candidate. So remember, um timing is everything and this is actually a picture from Prague in the IHLT. I don't know if you guys are, I know you're gonna go is in Prague this year. So it should be fun. The other thing I want you to really remember is that it's not like we're doing this all by ourselves. We can figure this out. We have the tools now. Uh J and uh I think, yeah, Jean and Mike went through both all of our risk assessment tool. And there's even more we can kinda see how patients are doing. So, don't think we're all doing it by ourselves. We do have tools to help. One more question. How do we list patients for lung transplant? What type of surgery? A single transplant? B um uh bilateral lung transplant, C, heart lung D, multiorgan um A B see, you can have more than one, see uh D and, and OK, good. And so this is really important. So, yes, uh most, most patients, probably 98% of patients either have B through D and maybe 1 to 2% in, have tried to do a single lung transplant. Actually, the single lung transplant that we did in, in um early, I wasn't there yet but I, the patient lived 25 years and that's how I knew the patient but she had a single lung for ph. So that was kind of weird anyways, bilateral lung transplant most of the time, 95% of the times um you do have that right heart remodeling and you can get um patients transplanted with bilateral lung um heart lung transplant if you have a very bad right ventricle, that's not coming back. Um On pressors are not doing well. They, they oftentimes can get a heart lung multiorgan. There's an um in UNOS we just had a big um change in our UNOS classification, multi organ donors. So patients who had very severe ph who ended up having hepatopathy or really bad renal dysfunction. Um, they can now be, uh, increased on the list by getting a multiorgan. They used to not be candidates but now getting a heart with a, a lung kidney or what we just did was a heart lung kidney. Uh, that's not uncommon with really bad ph, your kidneys have kind of failed over time. Uh, you can, you can do this and there something else called the safety net that if you're not available to get a uh a uh kidney right away, you can be listed for um a heart, a lung or a heart lung. And um if you don't get the kidney, then a kidney, um you can be top of the list in within the first year or 365 days after your transplant, you can get a kidney uh instead of waiting seven years on the list like everybody else. So these are the types of surgeries we do again, most of them are, are, are number B and one of the things is so we already talked about when to refer, when do we list for lung transplant? And I think this was the most important thing is the, the red line that says patient, this is from the ESC. But I think all of the them say this is the, the patient has been fully evaluated, adjudicated and prepared for transplantation. Patients who come in right heart failure, they get on ECMO and they're very, very sick. And then we get called and say, uh you know, when this patient's on ECMO, she needs to have a lung transplant. First of all, is she awake? Is he awake? Aware that he's getting a lung transplant? This happened all the time in COVID. The people up in Toronto, the University of Toronto group, they did a uh kind of a criteria of who should get transplanted off ECMO. And that was based on, on COVID data. And there are nine different criteria. One of them, they have to be awake and say, yeah, I want it number two, they, but you can use the same thing for patients who have rapid decline or just crash on the ECMO. You know, these are really important things that hey, you're gonna wake up and you're gonna have two new organs or three new organs. So patient has been fully evaluated enough to know all these tests can't be done on ECMO. I'm in a much bigger ECMO Center now than I ever was. And it, it there's a lot of patients on ECMO and they, it's hard to get our full work up done that we need um even a right heart cath, you can't really get a right heart Cath for a lot of things when you're on ECMO, right? That's, that would be counterintuitive. And then all these other things that we kind of talked about already. So really, I'm done and it's really, where are we going from here? Um The consensus on listing and transplanting, which I didn't show you that great slide. But it really is ever changing both for Ph, but for any other lung disease and we're getting better and better and every time we do a new iteration of that um guideline, we use the experience of the years before that and they're always better. There's hardly any contraindications anymore, you know, different diseases, different infections, they're all kind of relative contraindications. Someone's gonna try it. Um But I think that's good. If we don't push our envelope, we're not gonna move forward. And that's in Ph and that's in transplant. The seventh World Symposium, Barcelona, June 2024. Be there. It will likely bring a new set of criteria or will it? I don't know. We're gonna find out. Uh not like we have enough, not like we don't have enough new um guidelines, right? We just had two new ones pop up. Um What won't change? The need to identify patients early, refer them early, have them on the right therapies while they're waiting and being followed very carefully. The slide I took it out. I had the same slide J uh J did about following patients and how often they should be followed. These patients need to be followed so carefully and, and um oftentimes with monthly echoes to see where they are and if we need to get them exception points with pulmonary hypertension. I just wanna let you know they are not benefited by the new allocation system. We just had a new allocation system put out in March 2024 and we are not benefited by that. And so what the munos has done is allowed us to have exception points. We call up the pulmonary thoracic board and say this patient is super sick and we need them to be higher on the list because most of the that you get for being sick on a transplant list are based on lung disease. It's not a lung disease. They're gonna have a great fev one. They're not always on oxygen, so they're very, very sick, but they're not sick the way the las or the CAS shows. So, starting all of these things early and making sure that we are watching them carefully. Progressively is important, start treatment early and education patients, ed educate all the patients early on all the management ta um issues whether it be going from orals to sub Q to IV, to newer therapies that maybe we aren't even using it all the way to transplant is important. They need to know what the options are. So they have time to make an educated decision and I think that's it. Thank you so much.
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