The first lung transplant at the Alfred was performed in 1990 when Professor Trevor Williams joined the cardiothoracic team led by Professor Esmore. Professor Greg Snell now heads the lung transplantation team.
They have progressively striven to increase transplant numbers by the use marginal donors, thus offering donation to families and patients where this would be considered impossible in other countries. In close cooperation with the ICU, this has lead to the largest lung transplant service in the Southern Hemisphere and survival figures well above international comparisons. Outside of Australia this has been considered truly ground breaking, especially the use of “Donation After Cardiac Death” lungs with 100% 1-year survival.
From 1990 to end 2011 there were 251 single lung transplants and 562 bilateral lung transplants at the Alfred. In addition there have been 64 heart lung transplants and 22 domino transplants performed at the Alfred. (A domino transplant involves transplanting a heart lung block into a patient with lung disease e.g. cystic fibrosis for technical reasons and then transplanting their healthy heart into another recipient)
Paediatric Lung Transplantation
The Alfred Hospital has the only dedicated paediatric lung transplant service in Australia and to date has transplanted children from most states and New Zealand with advanced lung disease with excellent results.
In 2005, the Victorian Department of Health announced the establishment of a Paediatric Lung Transplant Program, which operates under the umbrella of the adult lung transplant program and consists of a large multidisciplinary team. The multi-disciplinary paediatric lung transplant team at The Alfred and Royal Children's Hospital Melbourne (RCHM) has been established to provide safe and efficacious lung transplantation to children from the age of 5 years, to those weighing greater than 20kg. In July 2011, Alfred Health was chosen to host the new Nationally Funded Centre (NFC) Program for Paediatric Lung and Heart-Lung Transplantation.
With a limited supply of paediatric organ donors, the Alfred has pioneered strategies to ensure that children awaiting lung transplantation are not selectively disadvantaged by the scarcity of potential paediatric donors. These include the use of donation after cardiac death (DCD) lungs, using marginal donor lungs and down-sizing adult donor lungs so as to perform lobar transplants. Unfortunately, some children continue to deteriorate whilst on the waiting list for lung transplantation, and the Alfred/RCHM team has used a number of strategies to manage these patients, including inhaled nitric oxide, ventilation on ICU and extracorporeal membrane oxygenation (ECMO) to bridge children to transplantation.
EMO technologies are rapidly evolving and their use as a bridge to transplant is likely to increase in the future. The Alfred/RCHM are developing protocols that will allow patients to be established on ambulatory ECMO as a bridge to lung transplant.
The lung transplant operation is performed by senior surgeons from the Alfred’s Cardiothoracic Surgical Department, with attendance by RCHM cardiothoracic surgeons as required. Depending on the underlying lung disease and the size of the donor lungs the following operations will be considered; double lung transplant, single lung transplant, heart-lung transplant and bi-lateral lobar transplant using lungs down-sized from an adult donor. After the operation, patients are transferred to the Cardiothoracic Intensive Care Unit (ICU). To date, mean ICU length of stay for children undergoing lung transplantation in the Alfred’s paediatric lung transplant program is 14 days (range 2 – 39 days) and mean total hospital length of stay is 24 days (range 9 – 51 days).
Despite the challenges of looking after patients outside of the usual adult hospital population this initiative has been very successful with lots of multidisciplinary input and interhospital support from the Royal Children’s Hospital. To date in August 2012 there have been 21 paediatric lung transplants including four patients transplanted from ECMO (extracorporeal membrane oxygenation support) and two heart lung transplants. Our outcomes in this group have been very favourable.