Ex vivo lung perfusion to improve donor lung function and increase the number of organs available for transplantation

Abstract

This paper describes the initial clinical experience of ex vivo lung perfusion (EVLP) at the Fondazione Ca’ Granda in Milan between January 2011 and May 2013. EVLP was considered if donor PaO2/FiO2 was below 300 mmHg or if lung function was doubtful. Donors with massive lung contusion, aspiration, purulent secretions, pneumonia, or sepsis were excluded. EVLP was run with a low-flow, open atrium and low hematocrit technique. Thirty-five lung transplants from brain death donors were performed, seven of which after EVLP. EVLP donors were older (54 ± 9 years vs. 40 ± 15 years, EVLP versus Standard, P < 0.05), had lower PaO2/FiO2 (264 ± 78 mmHg vs. 453 ± 119 mmHg, P < 0.05), and more chest X-ray abnormalities (P < 0.05). EVLP recipients were more often admitted to intensive care unit as urgent cases (57% vs. 18%, P = 0.05); lung allocation score at transplantation was higher (79 [40–84] vs. 39 [36–46], P < 0.05). After transplantation, primary graft dysfunction (PGD72 grade 3, 32% vs. 28%, EVLP versus Standard, P = 1), mortality at 30 days (0% vs. 0%, P = 1), and overall survival (71% vs. 86%, EVLP versus Standard P = 0.27) were not different between groups. EVLP enabled a 20% increase in available donor organs and resulted in successful transplants with lungs that would have otherwise been rejected (ClinicalTrials.gov number: NCT01967953).

Ex Vivo Lung Perfusion in the Rat: Detailed Procedure and Videos

“…Flow rate was also increased stepwise to reduce hemodynamic stress. Of note, in order to avoid hydrostatic edema, we elected to use a moderately low flow rate coupled with an open atrium strategy [13], though this approach is typically associated with high flow rates in the clinical setting [1]. Ventilation was started only when lung temperature reached the physiological range.…”

“…In clinical EVLP, the perfusate is replaced periodically to preserve lung function [13, 32]. However, we elected not to perform solution substitutions in order to evaluate concentration of inflammatory mediators, cells, electrolytes, and metabolites over time.…”

Successful Transplantation of Lungs From an Uncontrolled Donor After Circulatory Death Preserved In Situ by Alveolar Recruitment Maneuvers and Assessed by Ex Vivo Lung Perfusion

“…EVLP was run as previously described 20. Briefly, during the first 40 min of the procedure blood flow was gradually increased up to a target perfusate flow of 40% of the estimated cardiac output, and temperature of the perfusate gradually increased from 25°C to a left atrium target temperature of 37°C.…”

The role of ex vivo lung perfusion in lung transplantation

“…The EVLP group in Italy, led by Gattinoni, has also recently published their experience from 2011 to 2013. 50 Of 36 sets of lungs from brain death donors during this period, seven sets (with initial PO 2 :FiO 2 ratios <300 mmHg) were placed on EVLP and were successfully transplanted. Even though lung allocation scores were significantly greater in these lungs, post-transplant PGD, 30-day mortality and survival were not significantly different to standard transplant patients.…”