Overcoming the Limits of Reconditioning: Seventeen Hours of Ex Vivo Lung Perfusion (EVLP) with Successful Transplantation from Uncontrolled Circulatory Death Donor

Alessandro Palleschi Lorenzo RossoGiulia Maria RuggeriGiorgio Alberto CrociValeria RossettiGiuseppe CiterioGiacomo GrasselliMario NosottiAlberto Zanella Transplantation . 2021 Jan 25.  doi: 10.1097/TP.0000000000003646. . Milan.  PMID: 33496562 DOI:

Background:
Uncontrolled donors after circulatory death (DCD) are an extraordinary resource to increase the number of lungs available for transplantation. However, the risk of the warm ischemia resulting from cardiac arrest to irreversibly damage the organs is considerable. Moreover, graft preservation issues and organizational problems often worsen the dangerous effects of warm ischemia. Ex-Vivo Lung Perfusion (EVLP) enables to evaluate and recondition lungs whose functionality is doubtful, as well as to overcome the difficulties related to time and logistics.

Methods:
We report the case of uncontrolled DCD lungs successfully treated with an exceptionally prolonged EVLP. Since the donor’s blood count and liver biopsy showed signs of a possible leukaemia, EVLP was protracted up to seventeen hours while waiting for immunohistochemical analyses to rule out this diagnosis; eventually, the results came back negative and lungs were judged suitable for transplantation.

Results:
The recipient was a 32-year old male with cystic fibrosis, colonized by Pandoraea pnomenusa. Bilateral transplantation required central extracorporeal membrane oxygenation. The patient was extubated after 36 hours and was discharged 21 days after the operation. Despite early re-colonization by Pandoraea pnomenusa and airway complications requiring pneumatic dilatation, he is alive and has a satisfactory respiratory function 15 months after transplantation.

Conclusions:
Uncontrolled DCD represents a challenge due to both logistical issues and the complexity of grafts evaluation before procurement: EVLP with cellular perfusate could be a valuable tool to overcome these limits. Nonetheless, caution should be exercised when interpreting the effects of this technique on airway healing.