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Ann Thorac Surg 2000;70:1678
© 2000 The Society of Thoracic Surgeons
Discussion
DR AXEL HAVERICH (Hannover, Germany): You were a bit cautious in your conclusions whether or not to accept patients who were acutely ill on a ventilator, especially those with retransplantation after initial graft failure. Do you generally not accept those candidates for transplantation today, or would you think there are instances where even those can undergo retransplantation?
DR MEYERS: I do think there are instances when the strategy of an acute retransplantation might be appropriate. If you have a patient with extreme graft dysfunction immediately after transplant who is not infected, who is conscious without neurologic defect, and who has no evidence of infection, I think that I and my colleagues would consider retransplantation. I would say that such a situation is exceedingly rare, and the last time it occurred in our program was in the summer of 1996. That patient was one of the survivors in our group of five acute retransplants. Since then we have done 200 transplants, including some patients that have developed severe graft dysfunction. Some have been supported with extracorporeal membrane oxygenation but none have been retransplanted.
DR JOSEPH E. BAVARIA (Philadelphia, PA): Most transplant centers are probably not transplanting ventilated patients but some, like ours, will transplant a stable ventilated patient, but we usually put a time limit on it, for example, a week.
My question is, regarding your 16 stable ventilated patients, how long were they on the ventilator? What was the mean time they were on the ventilator? Did the patients that were on the ventilator shorter do better than the ones that were on longer? Thank you. This was a fine presentation.
DR MEYERS: The median time that the stable patients were on the ventilator was 45 days prior to transplant. The median time they had been listed prior to intubation was 7 months. It was such a disparate group of patients that the mean values really did a poor job of describing them. I think the mean was much higher, but there was 1 patient from Europe who had been intubated with a tracheostomy for 1,500 days at the time of his transplant. That skewed the results, but the median length of intubation was 45 days.
DR SHAFIQUE H. KESHAVJEE (Toronto, Ontario, Canada): Dr Meyers, I really enjoyed your presentation. It was very well delivered with outstanding results, as we have come to expect from your program. I wonder how you manage patients that are on your list that get intubated? Do you get them transferred to your hospital to look after them prior to the transplant? And secondly, given your experience, would you now wait for a period of time to see if patients will stabilize prior to truly considering them for a transplant?
DR MEYERS: When patients get close to the top of the waiting list, they move to St. Louis. If they were to have a decompensation while in the top rungs of the waiting list, then they would probably already be in St. Louis. If they were to decompensate and get intubated elsewhere, it is unlikely that they would be near the top and therefore it is unlikely that this strategy would help them.
The patients that we are transplanting right now have been on the waiting list for 600 days, and unless patients were in the range of that target, it would be unfair and unethical to jump them to the top of the list. I don’t think that we have been in the habit of transferring patients after they have decompensated on our waiting list.
Regarding your second question, I believe the terms "stable" and "unstable" are arbitrary. By my definition, unstable patients are the acute posttransplant patients. Some of the patients that we transplanted as part of the so-called "stable group" were actually in the ICU on paralysis or heavy sedation because they were poorly tolerating being intubated. In some people’s viewpoint they would be fairly unstable, but for the definition of this talk, if they weren’t immediateley posttransplant and they had a decompensation, they would fall into our stable category. If they were near the top of the waiting list, we would be looking for potential donors for them.
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