Purpose: Chronic Lung Allograft Dysfunction (CLAD) remains the leading cause of graft loss after lung transplantation (LTx). FEV1 has been used as a surrogate to classify CLAD, with %changes in individual FEV1 baselines being used to define CLAD. Reasoning behind individual baselines is historical, to facilitate comparisons between single-lung and heart-lung transplant recipients. Given shifts towards bilateral LTx as well as candidate demographics, the utility of % baseline and its impact on decision-making is unknown.

Introduction: In patients waiting for a combined heart and lung transplantation, pretransplant allosensitization to human leukocyte antigens (HLA) is common due to previous cardiac operations and increases waiting list time and mortality. Waiting until a crossmatch negative donor is found is not possible in most cases due to the compromised hemodynamic and respiratory conditions. In this report, we present a case of a successful heart and lung transplantation performed across preformed donor specific antibodies (pfDSA, positive virtual crossmatch) using a peritransplant desensitization protocol.

Purpose: Pretransplant sensitization to human leukocyte antigens (HLA) increases the recipient waiting list time and mortality in lung transplantation. Instead of awaiting crossmatch-negative donors, since 2013, recipients with preformed anti-HLA donor specific antibodies (pfDSA) have been managed peri-transplant at our institution with a combination of repeated IgA- and IgM-enriched intravenous immunoglobulin infusions (IgGAM, first infusion: 2gr/kg, then 0.5gr/kg every 4 weeks thereafter to a maximum of 6 months), preceded by repeated plasmapheresis (PE), and a single dose of anti-CD20 antibody (375mg/m2, Rituximab) after the first IgGAM infusion.

Purpose: Graft survival after lung transplantation is inferior to other forms of solid organ transplantation. Marginal improvements in long-term outcomes have occurred in the past 20 years, but chronic lung allograft dysfunction (CLAD) remains the leading cause of graft loss. CLAD encompasses different pathophysiological processes leading to accelerated decline in graft function. Treatment options are limited, with studies being characterized with unpredictable treatment responses and outcomes. This study stratifies clinical course in LTx, summarizes outcomes and explores the dynamics of graft failure.

Purpose: Patients with severe pulmonary hypertension (PH) refractory to medical therapy may benefit from lung transplantation (LTx). Compared to other indications, PH patients listed for LTx are usually younger and may show an initial stable period on the waiting list. However, the hemodynamic condition of PH patients may suddenly deteriorate, and patients require extracorporeal membrane oxygenation (ECMO) as a bridge to LTx. In this retrospective sigle-center study, we investigated factors predicting the need for ECMO bridging before transplantation and the impact of ECMO bridging on outcomes after LTx.

Purpose: Lung function monitoring early after bilateral lung transplantation is limited to spirometry, which depends strongly on patient compliance. Besides morphology, magnetic resonance imaging (MRI) acquires functional parameters by application of dedicated techniques, such as free breathing, contrast agent-free phase resolved functional lung (PREFUL) MRI. The aim of this study was to establish very early baseline standard ventilation values in clinically stable transplant patients compared to healthy controls using MRI.

Purpose: Pediatric lung transplantation poses unique challenges, from donor shortage to surgical access, intraoperative cardiopulmonary support and postoperative management. Moreover, experience with pediatric lung transplantation is scarce, especially in patients younger than 12 years old. In this study, we present our 18-year experience with lung transplantation in pediatric patients younger than 12 years old.

Purpose: Lung transplantation exposes the allograft to ischemia, and does not usually restore the pulmonary vasculature to normal. Beyond the perioperative phase, graft surveillance relies on spirometry, assessing mainly ventilation. Conventional V/Q scans have demonstrated abnormal perfusion in 49% of grafts at 3 months. Scintigraphy or MRI surveillance poses challenges. The Automatic Lung Parameter Estimator (ALPE) allows non-invasive estimation of ventilation and perfusion. This study assesses the utility of ALPE in understanding V/Q phenotypes post-transplant.

Purpose: Freedom from chronic lung allograft dysfunction (CLAD) is desirable after lung transplantation (LTx). To what extent patients are predestined for CLAD by hitherto unknown biological factors pre- or post-transplant or if the condition is due to external triggers is still unknown. The current study compares the proteomic profile of bronchiolar lavage fluid (BALF) from patients with more than 36 months of survival and pulmonary function stability (stable) with patients who develop CLAD within the first year post-transplant (eCLAD).

measures respiratory system mechanics and may provide insights into CLAD phenotype physiology.We hypothesise that oscillometry parameters (Total resistance = R rs5 , Distal small airways resistance = R rs5-19 ) may further elucidate obstructive physiology between phenotypes.Methods: A cross-sectional study was performed at 2 Australian centres (Sydney and Melbourne) including bilateral LTx recipients presenting to clinic between 2020-2021.Stable LTx recipients without CLAD and those with CLAD were included.Participants performed concurrent airway oscillometry and spirometry.CLAD phenotypes were adjudicated as per ISHLT 2019 criteria for bronchiolitis obliterans syndrome (BOS), restrictive allograft syndrome (RAS) and mixed patterns.Undefined/unclassified CLAD phenotypes were excluded.Patients were matched for CLAD severity based on the ratio of concurrent FEV 1 /baseline FEV 1 .Oscillometry parameters were compared between CLAD phenotypes and to those without CLAD using the Kruskal-Wallis test.Results: A total of 167 patients were included in this study with No CLAD (n=90), RAS (n=9), Mixed (n=5), BOS (n=63).There were no significant differences in CLAD severity between patients in each CLAD phenotype (p=0.37).Median (IQR) R rs5 Z-Scores were significantly higher in recipients with BOS 1.00 (2.64) compared to those with RAS -0.28 (1.83) and those without CLAD 0.11 (1.56) p<0.001.Median R rs5-19 values were significantly higher in those with BOS 1.10 (1.35) compared to those without CLAD 0.25 (0.57), but no different to those with RAS 0.78 (0.76) or Mixed phenotypes 0.63 (1.68) p<0.001. Conclusion:In CLAD recipients with matched severity, R rs5 Z-Score is significantly more abnormal in BOS phenotype compared with RAS, reflecting greater airflow abnormalities in medium and large airways in this phenotype.R rs5-19 values were not significantly different between CLAD phenotypes, indicating that increased distal small airways resistance (reflective of bronchiolitis obliterans lesions) may be uniformly present.Oscillometry appears to provide additional physiologic insights into ISHLT 2019 CLAD phenotypes.

recipient survival and CLAD-free survival.

analysis was to provide literature to help inform future analgesic guidelines.The Alfred Hospital is the single national centre for paediatric lung transplantation.With an increasing prevalence of thoracic transplants per year, there is a need to optimize analgesic regimes to aid post-operative recovery.Epidural analgesia provides a unique method of delivering titratable analgesia with relative low risk.Methods: All paediatric patients undergoing lung transplantation (2005-2021) at our tertiary hospital were identified.Data variables including indication for surgery, age, operation performed, Cardiopulmonary Bypass required, daily perioperative analgesia delivery, day 5 oral morphine equivalent (OME) requirement, total OME requirement, ICU and ventilatory outcomes, opioid/epidural/ketamine/general harm were all assessed as per CTCAE, pain outcomes, pain and opioids on discharge.Descriptive statistics were recorded.Average between groups were analyzed using a parametric unpaired t test with p values determined.Results: A total of 44 patients met our inclusion criteria.37/44 (84%) patients required epidural analgesia.Patients with epidurals post pulmonary transplantation required, on average, half (57%) less opioids post operatively in comparison to patients without epidurals (1.56 vs 3.63, unpaired t test, p < 0.005).Additionally, patients with an epidural required on average 70% less days intubated (3.84 vs 12.86, unpaired t test, p < 0.001).Patients with an epidural require on average 33% less days in hospital (24 vs 36, unpaired t test, p > 0.05).This was not statistically significant.The highest CTCAE graded epidural related harm was 3. Conclusion:The majority of our paediatric population undergoing lung transplantation utilise epidural analgesia.This locally completed audit suggests that epidural analgesia is associated with a reduction in the requirement for opioid related analgesia.In patients not receiving epidural analgesia there was an association with an increased length of stay and delayed extubation.Post-operative pathways in patients not receiving epidural analgesia differed significantly.Individualised analgesia management is recommended.

Background: Lung transplantation (LTx) has been demonstrated to be a feasible therapy in patients with irreversible lung injury due to SARS-CoV-2. Aim of this retrospective study was to present our experience with LTx in SARS-CoV-2 patients.

Background: Pretransplant sensitization to human leukocyte antigens (HLAs) increases the recipient waiting list time and mortality in lung transplantation. Instead of awaiting crossmatch-negative donors, since 2013, recipients with preformed anti-HLA donor-specific antibodies (pfDSA) have been managed peritransplant at our institution with a combination of repeated IgA- and IgM-enriched intravenous immunoglobulin infusions (IgGAM, first infusion: 2 g/kg, then 0.5 g/kg every 4 weeks thereafter to a maximum of 6 months), preceded by repeated plasmapheresis (PE), and a single dose of anti-CD20 antibody (375 mg/m2, rituximab) after the first IgGAM infusion. This study presents the 9-year results of this protocol in patients transplanted with pfDSA.