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The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
2( 11)
High Donor Sequence Number Grafts Can Be Safely Transplanted into
Select Patients
J.J. Squiers ,1 G. Saracino,2 T. Chamogeorgakis,3 J.C. MacHannaford,3
A.E. Rafael,3 G.V. Gonzalez-Stawinski,3 S.A. Hall,4 J.M. DiMaio,1
B. Lima.3  1Baylor Research Institute, Baylor Scott & White Health, Dallas,
TX; 2Simmons Transplant Institute, Baylor University Medical Center,
Dallas, TX; 3Cardiac and Thoracic Surgery, Baylor University Medical
Center, Dallas, TX; 4Cardiology, Baylor University Medical Center,
Dallas, TX.
Purpose: Donor sequence number (DSN) represents the number of potential
recipients to whom a heart graft has been offered and subsequently declined.
The feasibility of transplanting high DSN grafts has not been previously
investigated.
Methods: Donor and recipient medical records of 191 consecutive isolated
adult cardiac transplantations performed between 11/2012 and 3/2015 were
retrospectively reviewed. Grafts were grouped into Standard (Std; 0-75%ile),
Intermediate (75-90%ile), and High (90-100%ile) DSN groups. Intermediate
DSN grafts were excluded from comparisons. Associations of risk factors for
mortality were assessed with univariate and multivariate Cox proportional
hazards analyses. Cumulative survival was calculated with the Kaplan-Meier
method.
Results: A total of 191 patients underwent transplantation: 143 Std DSN
(range 1-80), 28 Intermediate DSN (range 81-299), and 20 High DSN (range
300-1479). As expected, High DSN grafts were harvested at greater mean
distance (miles: High DSN 862 ± 436 vs Std DSN 335 ± 362; p <  0.001)
with increased mean cold ischemia time (min: High DSN 276 ± 54 vs Std
DSN 213 ± 56; p <  0.001). Patients receiving High DSN grafts had lower
priority UNOS status (1A: High DSN 20% vs Std DSN 45%; p =  0.02) and
decreased mean PVR (Woods units: High DSN 1.3 ± 1.5 vs Std DSN 2.1 ±
1.8; p = 0.04). After adjusting for other factors, High DSN was not associated
with increased risk for mortality (HR 1.5, 95% CI 0.5-4.8, p =  0.32). There
were no differences in 30-day/in-hospital or 1-year mortality, or incidence
of primary graft dysfunction or severe graft rejection up to 1-year between
the Std and High DSN groups.
Conclusion: High DSN grafts (> 300) can be safely transplanted into select
patients. In this cohort, High DSN recipients had lower priority UNOS status
and decreased mean PVR. Despite increased recipient-donor distance and
cold ischemia time, patient and graft outcomes in the High DSN group were
no different than Standard DSN.
2( 12)
Too Much Information: Interaction of Donor Sequence and Acceptance
in the UNOS Database
D.A. Baran , K. Liaquat, J. Pieretti, C. Gidea, M. Munagala, M. Camacho,
C. Patel, M. Divita, M.J. Zucker.  Transplant Center, Newark Beth Israel
Med Ctr, Newark, NJ.
Purpose: In 2006 UNOS introduced an electronic notification system known
as DonorNet. It allowed electronic transmission of donor offers allowing
detailed information about each potential donor to be viewed quickly by
transplant centers, including their place on the allocation list (donor sequence
number). We sought to examine the utilization of donors based on sequence
number and also to assess if higher sequence number resulted in inferior
long term survival compared to donors taken more readily at lower sequence
number.
Methods: A custom data request was made of UNOS to provide the data on
transplants since the advent of DonorNet along with sequence number for
accepted hearts. Demographics were compared with descriptive statistics and
survival post transplant examined with Kaplan-Meier curves.
Results: From 5/1/2007 - 3/31/2014 there were 13481 adult heart transplants
reported to UNOS with donor sequence numbers available. Transplant recipi-
ents consisted of 10037 males (74 %) with the majority having Type O or A
hearts (38 % O, 41 % A). The mean donor age was 31.7 ± 11.7 years and the
mean recipient age 52.6 ± 12.8 years. The mean ischemic time was 3.2 ± 1.1
hours. The mean left ventricular ejection fraction for the donors was 61.6
± 7.1 %. Only 10 % of donors with an ejection fraction below 50 % were
utilized for transplantation.
The median donor sequence number was 3 and the 75th percentile for donor
sequences was 10. 90 % of all donors in the database were accepted with
a sequence number of 27 or less. This indicates that it was rare to trans-
plant using a heart which had been turned down for more than 27 recipi-
ents. We analyzed graft survival by sequence number to assess whether
this avoidance was warranted. The 5 year survival for 13438 evaluable
patients was 74.5 %. When subdivided by donor sequence of 1-10 versus
higher than 10, there was no difference (p= 0.21). Similarly, graft sur-
vival was similar with a cutpoint of donor sequence 30 or less (p= 0.10
log rank).
Conclusion: Relatively few donors are taken with a sequence number greater
than 27, yet the survival appears similar. Obviously these data are skewed by
selection bias since the analysis only includes donors utilized for transplant.
Nevertheless, these data suggest an opportunity to utilize more donors that
are currently not being considered.
2( 13)
Intermediate Outcomes with Ex-Vivo Allograft Perfusion for Heart
Transplantation
F. Esmailian ,1 J.L. Chan,2 H. Reich,2 D. Ramzy,2 M. Thottam,3 Z. Xu,3
T. Aintablian,3 F. Liou,3 J. Patel,3 M. Kittelson,3 L.S. Czer,3 A. Trento,2
J. Kobashigawa.3  1Cedars-Sinai Heart Institute, Los Angeles, CA;
2Surgery, Cedars-Sinai Heart Institute, Los Angeles, CA; 3Medicine,
Cedars-Sinai Heart Institute, Los Angeles, CA.
Purpose: The Organ Care System, an ex-vivo heart perfusion platform, rep-
resents an alternative to the current standard of cold organ storage that sus-
tains the donor heart in a near-physiologic state. Whether using the Organ
Care System has any effects on two-year outcomes after heart transplant
is unknown. We reviewed our institutional experience to assess two-year
outcomes on patients randomized to the Organ Care System versus standard
cold storage.
Methods: Between 2011 and 2013, 38 heart transplant patients from a single
tertiary-care medical center enrolled within the PROCEED II trial were rand-
omized to either standardard cold storage or Organ Care System. Outcomes
assessed included two-year survival, freedom from cardiac allograft vascu-
lopathy (CAV), any-treated rejection (ATR), biopsy-proven cellular rejection
(CMR), biopsy-proven antibody-mediated rejection (AMR) and non-fatal
major cardiac events (NF-MACE),
Results: A total of 38 patients were randomly assigned to the Organ Care
System group (n= 19) or the standard of care cold storage group (n= 19).
Recipient demographic characteristics in each group were similar. There
was no significant difference in the 2-year patient survival rate between the
Abstracts S87

two groups (Organ Care System 72.2% vs. cold storage 81.6%, p= 0.38).
Similarly, there was no difference in freedom from CAV, ATR, CMR, AMR
and NF-MACE. The Organ Care System group had significant longer total
ischemic time (361 +/- 96 vc 207 +/- 50 min) and significantly shorter cold
ischemic time compared to cold storage group (134 +/- 45 vs 207 +/- 50
mins).
Conclusion: The Organ Care System represents a promising platform for
donor heart transportation with similar intermediate results to conventional
cold strategies while providing potential benefits of physiologic preservation,
resuscitation, and improved organ utilization.

Patient survival and freedom from adverse events at two years after heart
transplantation

Organ Care System Cold Storage p-value

(N= 19) (N= 19)

Survival 72.2% 81.6% 0.38

Freedom from CAV 100% 78.5% 0.09
Freedom from ATR 53.0% 61.8% 0.48
Freedom from CMR 72.5% 69.6% 0.93
Freedom from AMR 92.0% 100% 0.30
Freedom from NF-MACE 90.9% 94.7% 0.90

2( 14)
Plasma RIP3 Is Decreased in PGD after Lung Transplantation
C. D’Errico ,1 M. Hotz,1 E. Cantu,1 M. Porteous,1 M. Oyster,1 R. Shah,2
S. Arcasoy,3 L. Snyder,4 K.M. Wille,5 M. Hartwig,4 L.B. Ware,6 P. Shah,7
M. Crespo,8 C. Hage,9 A. Weinacker,10 V. Lama,11 Y. Suzuki,1 J. Orens,7
S. Kawut,1 S. Palmer,4 D.J. Lederer,3 J.D. Christie,1 N. Mangalmurti,1
J.M. Diamond.1  1University of Pennsylvania, Philadelphia, PA;
2University of California San Francisco, San Francisco, CA; 3Columbia

University, New York, NY; 4Duke University, Durham, NC; 5University of

Alabama Birmingham, Birmingham, AL; 6Vanderbilt University, Nashville,
TN; 7Johns Hopkins University, Baltimore, MD; 8University of Pittsburgh,
Pittsburgh, PA; 9Indiana University, Indianapolis, IN; 10Stanford
University, Stanford, CA; 11University of Michigan, Ann Arbor, MI.

Purpose: Primary Graft Dysfunction (PGD), a form of acute lung injury

occurring after lung transplant, remains a significant cause of early morbid-
ity and mortality for lung transplant recipients. Receptor-interacting ser-
ine/threonine-protein kinase 3 (RIP3), is a critical mediatory of regulated
necrotic cell death, (necroptosis), and is elevated in non-survivors of sepsis.
We therefore sought to assess the association of RIP3 with PGD after lung
transplantation.
Methods: We conducted a case-control study nested within the multicenter
Lung Transplant Outcomes Group cohort, including patients transplanted
between 2008 and 2012. We focused on extreme phenotypes, with cases
defined as grade 3 PGD at 48 or 72hrs post reperfusion and controls defined
as grade 0 PGD at all time points according to ISHLT criteria. Cases and
controls were frequency matched on pre-transplant diagnosis. RIP3 was
measured in plasma samples collected 24 hours after reperfusion using a
commercially available ELISA. Median protein concentrations were com-
pared using Wilcoxon rank sum tests.
Results: The study included 35 cases and 31 controls. In the overall popula-
tion, RIP3 plasma concentrations were significantly lower in cases (19.5;
interquartile range: 7.6, 57.3) compared to controls (56.4; IQR: 14.4, 114.8)
(p= 0.03). Among patients with IPF, plasma levels were also significantly
lower in cases (19.7, IQR: 8.15, 57.3) compared to controls (91.2, IQR: 29.1,
118.1) (p= 0.003). Among patients with COPD, there was no difference in
RIP3 plasma levels between cases (19.5, IQR: 7.6, 46.4) and controls (19.5,
IQR: 5.0, 69.4) (p= 0.98). (Figure 1)
Conclusion: Lower post-transplant plasma RIP3 is associated with
increased risk of PGD, with the most significant association seen in
patients with IPF. We speculate that programmed cell death pathways,
including necroptosis, may be essential for tissue homeostasis and protect
the allograft from progressive injury in the setting of reperfusion. Further
study is needed to evaluate the role of necroptosis in the development
of PGD.
2( 15)
Role of Donor Microbiota in the Development of Primary Graft
Dysfunction Following Human Lung Transplantation
Z. Xu ,1 R. Schuessler,1 D. Nayak,1 W. Yang,2 E. Trulock,3 A. Patterson,1
D. Kreisel,1 R. Hachem,3 T. Mohanakumar.4  1Surgery, Washington
University School of Medicine, St. Louis, MO; 2Genetics, Washington
University School of Medicine, St. Louis, MO; 3Medicine, Washington
University School of Medicine, St. Louis, MO; 4Surgery, Pathology &
Immunology, Washington University School of Medicine, St. Louis, MO.
Purpose: The microbiome of the donor lung can be imported to the recipient
following lung transplantation (LTx) and its role in immediate and long-term
function remains unknown. The aim was to define the lower respiratory
tract microbiome of the donor and recipients’ lungs following LTx and to
determine its impact in the development of primary graft dysfunction (PGD).
Methods: The V3 region of the bacterial 16S rRNA in the bronchoalveolar
lavage (BAL) from 24 donor lungs and serial samples following transplanta-
tion were amplified for Illumina MiSeq sequencing. Reads were clustered
into operational taxonomic unit s by QIIME using UCLUST at a threshold
of 97% similarity.
Results: Significant increase in the bacterial 16S rRNA gene copies were
noted in recipients compared to donor lungs. The bacterial community from
donor lungs was taxonomically diverse and dynamic over time following
transplantation. Phyla Actinobacteria had a greater predominance in the
recipient lungs over time. However, classes Bacilli, Alphaproteobacteria,