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Lung transplantation following donation after circulatory death. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Egan TM, Haithcock BE, Lobo J, Mody G, Love RB, Requard JJ, Espey J, Ali MH. Donation after circulatory death donors in lung transplantation. J Thorac Dis 2022; 13:6536-6549. [PMID: 34992833 PMCID: PMC8662509 DOI: 10.21037/jtd-2021-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 12/13/2022]
Abstract
Transplantation of any organ into a recipient requires a donor. Lung transplant has a long history of an inadequate number of suitable donors to meet demand, leading to deaths on the waiting list annually since national data was collected, and strict listing criteria. Before the Uniform Determination of Death Act (UDDA), passed in 1980, legally defined brain death in the U.S., all donors for lung transplant came from sudden death victims [uncontrolled Donation after Circulatory Death donors (uDCDs)] in the recipient’s hospital emergency department. After passage of the UDDA, uDCDs were abandoned to Donation after Brain Death donors (DBDs)—perhaps prematurely. Compared to livers and kidneys, many DBDs have lungs that are unsuitable for transplant, due to aspiration pneumonia, neurogenic pulmonary edema, trauma, and the effects of brain death on lung function. Another group of donors has become available—patients with a devastating irrecoverable brain injury that do not meet criteria for brain death. If a decision is made by next-of-kin (NOK) to withdraw life support and allow death to occur by asphyxiation, with NOK consent, these individuals can have organs recovered if death occurs relatively quickly after cessation of mechanical ventilation and maintenance of their airway. These are known as controlled Donation after Circulatory Death donors (cDCDs). For a variety of reasons, in the U.S., lungs are recovered from cDCDs at a much lower rate than kidneys and livers. Ex-vivo lung perfusion (EVLP) in the last decade has had a modest impact on increasing the number of lungs for transplant from DBDs, but may have had a larger impact on lungs from cDCDs, and may be indispensable for safe transplantation of lungs from uDCDs. In the next decade, DCDs may have a substantial impact on the number of lung transplants performed in the U.S. and around the world.
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Affiliation(s)
- Thomas M Egan
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
| | | | - Jason Lobo
- Department of Medicine, UNC at Chapel Hill, Chapel Hill, NC, USA
| | - Gita Mody
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
| | - Robert B Love
- Department of Surgery, Feinberg School of Medicine, Chicago, IL, USA
| | | | - John Espey
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
| | - Mir Hasnain Ali
- Department of Surgery, UNC at Chapel Hill, Chapel Hill, NC, USA
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Ex Vivo Assessment of Porcine Donation After Circulatory Death Lungs That Undergo Increasing Warm Ischemia Times. Transplant Direct 2018; 4:e405. [PMID: 30584586 PMCID: PMC6283086 DOI: 10.1097/txd.0000000000000845] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 10/07/2018] [Indexed: 01/11/2023] Open
Abstract
Background Increased utilization of donation after circulatory death (DCD) lungs may help alleviate the supply/demand mismatch between available donor organs and lung transplant candidates. Using an established porcine DCD model, we sought to determine the effect of increasing warm ischemia time (WIT) after circulatory arrest on lung function during ex vivo lung perfusion (EVLP). Methods Porcine donors (n = 15) underwent hypoxic cardiac arrest, followed by 60, 90, or 120 minutes of WIT before procurement and 4 hours of normothermic EVLP. Oxygenation, pulmonary artery pressure, airway pressure, and compliance were measured hourly. Lung injury scores were assessed histologically after 4 hours of EVLP. Results After EVLP, all 3 groups met all the criteria for transplantation, except for 90-minute WIT lungs, which had a mean pulmonary artery pressure increase greater than 15%. There were no significant differences between groups as assessed by final oxygenation capacity, as well as changes in pulmonary artery pressure, airway pressure, or lung compliance. Histologic lung injury scores as well as lung wet-to-dry weight ratios did not significantly differ between groups. Conclusions These results suggest that longer WIT alone (up to 120 minutes) does not predict worse lung function at the conclusion of EVLP. Expanding acceptable WIT after circulatory death may eventually allow for increased utilization of DCD lungs in procurement protocols.
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Abstract
Lung transplantation nowadays is a well-accepted and routine treatment for well selected patients with terminal respiratory disease. However, it took several decades of experimental studies and clinical attempts to reach this success. In this paper, we describe the early experimental activity from the mid-forties until the early sixties. The first clinical attempt in humans was reported by Hardy and Webb in 1963 followed by others with short survival only except for one case by Derom et al. who lived for 10 months. Long-term successes were not reported until after the discovery of cyclosporine as a new immunosuppressive agent. Successful heart-lung transplantation (HLTx) for pulmonary vascular disease was performed by the Stanford group starting in 1981 while the Toronto group described good outcome after single-lung transplantation (SLTx) for pulmonary fibrosis in 1983 and after double-lung transplantation for emphysema in 1986. Further evolution in surgical techniques and in transplant type for the various forms of end-stage lung diseases are reviewed. The evolution in lung transplantation still continues nowadays with the use of pulmonary allografts coming from living-related donors, from donors after circulatory death, or after prior assessment and reconditioning during ex vivo lung perfusion (EVLP) in an attempt to overcome the critical shortage of suitable organs. Early outcome has significantly improved over the last three decades. Better treatment and prevention of chronic lung allograft dysfunction will hopefully result in further improvement of long-term survival after lung transplantation.
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Affiliation(s)
- Federico Venuta
- Department of Thoracic Surgery, Policlinico Umberto I and University of Rome La Sapienza, Rome, Italy
| | - Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven and Department of Clinical and Experimental Medicine, KU Leuven University, Leuven, Belgium
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Erasmus ME, van Raemdonck D, Akhtar MZ, Neyrinck A, de Antonio DG, Varela A, Dark J. DCD lung donation: donor criteria, procedural criteria, pulmonary graft function validation, and preservation. Transpl Int 2016; 29:790-7. [DOI: 10.1111/tri.12738] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 08/02/2015] [Accepted: 12/21/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Michiel E. Erasmus
- Department of Cardiothoracic Surgery; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Dirk van Raemdonck
- Department of Thoracic Surgery; University Hospitals Leuven; Leuven Belgium
| | - Mohammed Zeeshan Akhtar
- Nuffield Department of Surgical Sciences; Oxford Transplant Centre; University of Oxford; Oxford UK
| | - Arne Neyrinck
- Department of Thoracic Surgery; University Hospitals Leuven; Leuven Belgium
| | | | - Andreas Varela
- Thoracic Department; Hospital Universitario Puerta de Hierro Majadahonda; Madrid Spain
| | - John Dark
- Institute of Cellular Medicine; Newcastle University; Newcastle upon Tyne UK
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Abstract
Lung transplantation (LTx) is the definitive treatment of patients with end-stage lung disease. Availability of donor lungs remains the primary limitation and leads to substantial wait-list mortality. Efforts to expand the donor pool have included a resurgence of interest in the use of donation after cardiac death (DCD) lungs. Unique in its physiology, lung viability seems more tolerant to the variable durations of ischemia that occur in DCD donors. Initial experience with DCD LTx is promising and, in combination with ex vivo lung perfusion systems, seems a valuable opportunity to expand the lung donor pool.
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Pérez-Villares J, Lara-Rosales R, Pino-Sánchez F, Fuentes-García P, Gil-Piñero E, Osuna Ortega A, Cozar Olmo J. Código alfa. Inicio de un nuevo programa de donación en asistolia. Med Intensiva 2013; 37:224-31. [DOI: 10.1016/j.medin.2012.07.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 07/05/2012] [Accepted: 07/06/2012] [Indexed: 11/26/2022]
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Detry O, Le Dinh H, Noterdaeme T, De Roover A, Honoré P, Squifflet JP, Meurisse M. Categories of donation after cardiocirculatory death. Transplant Proc 2012; 44:1189-95. [PMID: 22663982 DOI: 10.1016/j.transproceed.2012.05.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The interest in donation after cardiocirculatory death (DCD) was renewed in the early 1990s, as a means to partially overcome the shortage of donations after brain death. In some European countries and in the United States, DCD has become an increasingly frequent procedure over the last decade. To improve the results of DCD transplantation, it is important to compare practices, experiences, and results of various teams involved in this field. It is therefore crucial to accurately define the different types of DCD. However, in the literature, various DCD terminologies and classifications have been used, rendering it difficult to compare reported experiences. The authors have presented herein an overview of the various DCD descriptions in the literature, and have proposed an adapted DCD classification to better define the DCD processes, seeking to provide a better tool to compare the results of published reports and to improve current practices. This modified classification may be modified in the future according to ongoing experiences in this field.
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Affiliation(s)
- O Detry
- Department of Abdominal Surgery and Transplantation, CHU Liège, University of Liège, Liège, Belgium.
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Early effects of the ex vivo evaluation system on graft function after swine lung transplantation. Eur J Cardiothorac Surg 2011; 40:956-61. [PMID: 21354808 DOI: 10.1016/j.ejcts.2010.12.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 12/07/2010] [Accepted: 12/24/2010] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Ex vivo lung evaluation (ex vivo) has been developed as a useful method by which to assess lungs from donation-after-cardiac death (DCD) donors prior to transplant. However, the safety of the ex vivo circulation itself with respect to grafts has not been fully investigated. The aim of this study is to evaluate the effects of the ex vivo circuit using a swine lung transplant model. METHODS Lungs with or without 2-h warm ischemia were used. To assess post-transplant graft function, the left lung was transplanted after 2-h ex vivo or cold preservation; blood gas analysis of the left pulmonary vein (partial pressure of oxygen, PO(2)) was performed during the 6-h post-transplant follow-up period. Data were compared between the ex vivo (+) and ex vivo (-) groups. RESULTS Partial pressure of oxygen/ inspired oxygen fraction (PO(2)/FiO(2)) in the ex vivo (-) group was significantly greater than that in the ex vivo (+) group until 3h after transplant. The PO(2)/FiO(2) levels in both groups then increased and became similar at 6 h after transplant, regardless of whether ischemic or non-ischemic lungs (p<0.001 and p=0.004, respectively) were used. CONCLUSIONS Negative effects of the ex vivo system were limited and seen only in the immediate post-transplant period. Therefore, in DCD swine lung transplantation, the ex vivo system appears to be safe.
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Donación tras la muerte cardíaca. Parada cardíaca en el mantenimiento del donante en muerte encefálica. Med Intensiva 2009; 33:327-35. [DOI: 10.1016/j.medin.2008.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Accepted: 12/20/2008] [Indexed: 11/18/2022]
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Update on donor assessment, resuscitation, and acceptance criteria, including novel techniques--non-heart-beating donor lung retrieval and ex vivo donor lung perfusion. Thorac Surg Clin 2009; 19:261-74. [PMID: 19662970 DOI: 10.1016/j.thorsurg.2009.02.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The shortage of adequate organ donors remains a great challenge in clinical lung transplantation. With increasing experience in the medical management and surgical technique of lung transplantation, gradual expansion of the criteria for lung donor selection has occurred with beneficial effects on the donor pool. Interest in donation after cardiac death also is increasing as the gap increases between donors and the needs of listed patients. Successful use of these new sources of lungs depends on the accurate assessment and prediction of transplanted lung function. Promising techniques for lung assessment and diagnostics include investigating key genes associated with graft failure or good graft performance using molecular approaches, and ex vivo evaluation. Further studies are needed to answer remaining questions about the best technique and solution to reperfuse human lungs for several hours without edema formation. As the predictive ability to discern good from injured donor lungs improves, strategies to repair donor lungs become increasingly important. Prolonged normothermic EVLP seems to be a platform on which many reparative strategies can be realized. With these new methods for assessing and resuscitating lungs accurately, it is hoped that inroads will be made toward providing every listed patient a chance for successful lung transplantation.
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Ohki S, Oshima K, Tsutsumi H, Koike N, Matsumoto K, Takeyoshi I. The suppression of proinflammatory cytokines improves heart function from non-heart-beating donors following transplantation in a canine model. Int Heart J 2009; 50:235-45. [PMID: 19367033 DOI: 10.1536/ihj.50.235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We evaluated the effectiveness of a suppressant of the production of proinflammatory cytokines such as interleukin (IL)-1 and tumor necrosis factor (TNF)-alpha on a canine heart transplantation model with non-heart-beating donors (NHBDs).Adult mongrel dogs were divided into 3 groups of 5: a control group; FR-1 in which donors were given FR167653, a potent suppressant of IL-1beta and TNF-alpha production; and FR-2 in which both donors and recipients were given FR167653. After measuring the baseline hemodynamic parameters, including cardiac output (CO), left ventricular pressure (LVP), and maximum and minimum rates of increase in LVP (+/- LVdp/dt), FR167653 was administered continuously for 30 minutes before ischemia in the FR-1 and FR-2 groups. Cardiac arrest was obtained by rapid exsanguination from the abdominal aorta and inferior vena cava. The organ was left in the cadaver for 30 minutes. The coronary vascular beds were washed out with 4 degrees C Celsior solution, and then the donor heart was preserved in 4 degrees C Celsior solution for 4 hours. The donor heart was transplanted orthotopically with cardiopulmonary bypass (CPB). FR167653 was administered intravenously from 15 minutes before aortic-cross clamping until the end of the experiment in the FR-2 group. The recipient was weaned from CPB 1 hour after reperfusion. We compared the hemodynamic parameters at 3 hours after reperfusion with the preoperative values in donor animals with the right atrial pressure at 10 mmHg and a 5 microg/kg/min dopamine infusion. Histopathological analysis was also performed.There were no significant differences in the recovery rates of the hemodynamic parameters between the control and FR-1 groups and between the FR-1 and FR-2 groups. However, the recovery rates of CO and -LVdp/dt in the FR-2 group were significantly (P < 0.05) higher than those in the control group. Histopathological analysis showed that myofilaments were better preserved in the FR-2 group compared with the control group.The administration of a suppressant of proinflammatory cytokines before both ischemia and reperfusion effectively preserves donor heart function after transplantation with NHBDs.
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Affiliation(s)
- Shigeru Ohki
- Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Gunma, Japan
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Retrograde Flush Following Warm Ischemia in the Non-Heart-Beating Donor Results in Superior Graft Performance at Reperfusion. J Surg Res 2009; 154:118-25. [DOI: 10.1016/j.jss.2008.06.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2008] [Revised: 05/22/2008] [Accepted: 06/04/2008] [Indexed: 11/20/2022]
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del Río F, Escudero D, de la Calle B, Gordo Vidal F, Valentín Paredes M, Ramón Núñez J. Evaluación y mantenimiento del donante pulmonar. Med Intensiva 2009; 33:40-9. [DOI: 10.1016/s0210-5691(09)70304-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lascano EC, Bertolotti A, Gómez CB, Ossés J, Negroni JA, Cuniberti L, Yannarelli GG, Molinari LE, Laguens R, Favaloro R. Failure of IL-8 to assess early reperfusion injury following lung transplantation of cardiac death donor pigs. Transpl Int 2009; 22:574-82. [PMID: 19175556 DOI: 10.1111/j.1432-2277.2008.00833.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Although interleukins (IL) 8 and 10 predict lung viability in lung transplantation from heart beating donors (HBD) and IL-1beta is a marker of ex vivo performance from after cardiac death donors (ACDD), IL expression in the recipient remains unknown. This study assessed IL-1beta, IL-8 and IL-10 as indicators of functional performance in single-lung transplantation from ACDD pigs. Animals were divided into: (i) HBD: immediate lung excision; (ii) ACDD: fibrillation, 30 min warm ischemia and 3 h topical cooling. Left lungs of both groups were then flushed with Perfadex and stored at 3-4 degrees C for 3 h. IL in bronchoalveolar lavage fluid (BAL) and hemodynamic and graft function were measured in the donor and during the 2 h reperfusion period in the recipient. Myeloperoxidase, nuclear factor kappa beta, wet/dry weight ratio and a histologic injury score were assessed from biopsies in basal conditions in the donor and at the end of reperfusion. Despite similar pulmonary function and histologic markers of injury in both groups and higher IL-1beta in the donor of ACDD, IL-8 during reperfusion was significantly lower in ACDD (119 +/- 33% of basal) than in HBD (306 +/- 238%, P < 0.05) recipients. The paradoxical behavior of IL-8 makes it an unreliable predictor of ACDD early outcome in this transplantation model.
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Affiliation(s)
- Elena C Lascano
- Department of Physiology, Pharmacology and Biochemistry, Favaloro University, Favaloro Foundation, Buenos Aires, Argentina.
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Stern M, Souilamas R, Tixier D, Mal H. [Lung transplantation: supply and demand in France]. Rev Mal Respir 2009; 25:953-65. [PMID: 18971802 DOI: 10.1016/s0761-8425(08)74412-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION For a decade lung transplantation has suffered from a lack of donor organs which aroused a national debate and led to planned action in collaboration with The French National Agency for Transplantation. BACKGROUND Analysis of the stages of the process from potential donor to lung transplantation identified lung procurement as the main priority. An increase in the number of potential lung donors and revision of the acceptance criteria led to a doubling of the annual rate of lung transplantation in less than two years. VIEWPOINTS In the near future we may solve the problem of donor family refusals and establish scientifically based criteria for lung acceptance to increase the rate of lung transplantation. Transplantation from non heart-beating donors and the reconditioning of ex vivo non acceptable lungs might supply additional organs to fulfill demand in the long term. CONCLUSIONS The rate of lung transplantation activity in France doubled as the result of a dramatic increase of donor lung proposals. The current improvement in the results of lung transplantation might create new demands and generate future difficulties in the supply of donor lungs. New approaches, such as transplantation from non heart-beating donors and reconditioning ex vivo non acceptable lungs, should be examined in the near future.
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Affiliation(s)
- M Stern
- Service de Pneumologie, Hôpital Foch, Suresnes, France.
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Oto T. Lung transplantation from donation after cardiac death (non-heart-beating) donors. Gen Thorac Cardiovasc Surg 2008; 56:533-8. [PMID: 19002751 DOI: 10.1007/s11748-008-0315-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2008] [Indexed: 12/23/2022]
Abstract
Although lung transplantation is a well-accepted treatment for advanced lung diseases, donor shortage remains a significant limiting factor resulting in an increasing number of deaths of people on waiting lists. Recently, some transplant centers have begun to use lungs retrieved from donors after circulatory arrest. This review outlines the relevant published experimental data and clinical experiences with lung transplantation from donation after cardiac-death donors (DCDs) or non-heart-beating donors (NHBDs). Techniques for lung preservation and ex vivo lung assessment of DCD (NHBD) lungs are reviewed, and aspects of primary graft dysfunction after DCD (NHBD) lung transplantation are discussed.
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Affiliation(s)
- Takahiro Oto
- Department of Cancer and Thoracic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama 700-8558, Japan.
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Abstract
The inflated lung, with its unique tolerance of the absence of a circulation, is particularly suited to retrieval from the non-heart beating donor. Absence of some of the squeal of brain death may be a further potential advantage. This concept has been embraced by several centers around the world, with promising early results.
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Snell GI, Levvey B, Oto T, McEgan R, Mennan M, Eriksson L, Williams T, Rosenfeldt F. EFFECT OF MULTIORGAN DONATION AFTER CARDIAC DEATH RETRIEVAL ON LUNG PERFORMANCE. ANZ J Surg 2008; 78:262-5. [DOI: 10.1111/j.1445-2197.2008.04432.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Isch DJ. In defense of the reverence of all life: Heideggerean dissolution of the ethical challenges of organ donation after circulatory determination of death. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2007; 10:441-59. [PMID: 17473990 DOI: 10.1007/s11019-007-9053-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Accepted: 02/22/2007] [Indexed: 05/15/2023]
Abstract
During the past 50 years since the first successful organ transplant, waiting lists of potential organ recipients have expanded exponentially as supply and demand have been on a collision course. The recovery of organs from patients with circulatory determination of death is one of several effective alternative approaches recommended to reduce the supply-and-demand gap. However, renewed debate ensues regarding the ethical management of the overarching risks, pressures, challenges and conflicts of interest inherent in organ retrieval after circulatory determination of death. In this article, the author claims that through the engagement of a Heideggerean existential phenomenological and hermeneutic framework what are perceived as ethical problems dissolve, including collapse of commitment to the dead donor rule. The author argues for a revisioned socially constructed conceptual and philosophical responsibility of humankind to recognize the limits of bodily finitude, to responsibly use the capacity of the transplantable organs, and to grant enhanced or renewed existence to one with diminished or life-limited capacity; thereby making the locus of ethical concern the donor-recipient as unitary ''life.'' What ethically matters in the life-cycle (life-world) of donor-recipient is the viability of the organs transplanted; thereby granting reverence to all life.
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Affiliation(s)
- D J Isch
- Hospital, Harris Methodist Fort Worth, Office of Ethics, 1301 Pennsylvania Avenue, Fort Worth, TX, 76104, USA.
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Lung transplantation using donors after cardiac death. Curr Opin Organ Transplant 2007. [DOI: 10.1097/mot.0b013e3282eff56d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Snell GI, Oto T, Levvey B, McEgan R, Mennan M, Higuchi T, Eriksson L, Williams TJ, Rosenfeldt F. Evaluation of techniques for lung transplantation following donation after cardiac death. Ann Thorac Surg 2007; 81:2014-9. [PMID: 16731122 DOI: 10.1016/j.athoracsur.2006.01.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2005] [Revised: 12/19/2005] [Accepted: 01/03/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lung transplantation using "donation after cardiac death" donors is a potential means to alleviate the shortage of suitable donor lungs for transplantation, but the practicality and utility of the various possible techniques need to be clarified. METHODS Using a dog model, we explored seven variations of standoff (ischemic) time (50 to 240 minutes), topical cooling (60 to 120 minutes), and flush cooling and cold storage (30 to 140 minutes) to mimic different human donor lung retrieval scenarios that can follow donation after cardiac death. The functional status of donation after cardiac death donor lungs was assessed initially with a 250 mL pulmonary arterial blood flush while ventilating with 100% oxygen and then on an ex-vivo perfusion rig for 120 minutes after retrieval. RESULTS All lungs achieved an excellent pO2/FiO2 ratio ranging from 472 to 586 with stable pulmonary artery pressures and pulmonary vascular resistance and no net weight gain (952 +/- 221 g versus 1,006 +/- 235 g) during the 120-minute evaluation period. Initial blood flush correlated well with measured perfusion rig pO2 at 30 minutes (R2 = 0.63). CONCLUSIONS This canine study suggests that lungs donated after cardiac death are reproducibly useable for transplantation with ischemic times of as long as 60 minutes. Although more study is needed, a blood flush evaluation is simple and may have a role as a secondary allograft assessment tool. The existing techniques of donor lung evaluation and preservation after donation following cardiac death thus appear both feasible and practical.
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Affiliation(s)
- Gregory I Snell
- Lung Transplant Service, Alfred Hospital, Monash University, Melbourne, Australia.
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Abt PL, Fisher CA, Singhal AK. Donation after Cardiac Death in the US: History and Use. J Am Coll Surg 2006; 203:208-25. [PMID: 16864034 DOI: 10.1016/j.jamcollsurg.2006.03.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2005] [Revised: 03/15/2006] [Accepted: 03/20/2006] [Indexed: 01/28/2023]
Affiliation(s)
- Peter L Abt
- Division of Solid Organ Transplantation, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
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Okazaki M, Date H, Inokawa H, Okutani D, Aokage K, Nagahiro I, Aoe M, Sano Y, Shimizu N. Optimal time for post-mortem heparinization in canine lung transplantation with non-heart-beating donors. J Heart Lung Transplant 2006; 25:454-60. [PMID: 16563977 DOI: 10.1016/j.healun.2005.08.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2005] [Revised: 08/08/2005] [Accepted: 08/16/2005] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND We previously reported that post-mortem heparinization by closed-chest cardiac massage is beneficial in lung transplantation from non-heart-beating donors by preventing formation of microthrombi. In this study, we evaluated the optimal time for post-mortem heparinization in canine lung transplantation from non-heart-beating donors. METHODS Left lung transplantation was performed in 25 weight-matched pairs of mongrel dogs. Donors were killed with an intravenous injection of potassium chloride and left at room temperature for 2 hours. The cadaver donors were assigned randomly to one of five study groups. In Group H0, heparin sodium (1,000 U/kg) was given intravenously before cardiac arrest. In Groups H10, H30, H45 and H60, heparin sodium (1,000 U/kg) was given intravenously 10, 30, 45 and 60 minutes after cardiac arrest, respectively, followed by closed-chest cardiac massage for 2 minutes. After 2 hours of cardiac arrest, donor lungs were flushed with low-potassium dextran glucose solution and preserved for 60 minutes. After left lung allotransplantation, the right pulmonary artery was ligated, and recipient animals were followed up for 3 hours. Uni- and multivariate repeat analyses were utilized for statistical assessment. RESULTS After transplantation, gas exchange was significantly worse in Groups H45 and H60 than in Groups H0, H10 and H30. Thrombin/anti-thrombin III complex concentration during warm ischemia was significantly higher in Groups H30, H45 and H60 than in Groups H0 and H10. CONCLUSIONS The optimal time for post-mortem heparinization in lung transplantation from non-heart-beating donors is approximately 30 minutes after cardiac arrest.
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Affiliation(s)
- Mikio Okazaki
- Department of Cancer and Thoracic Surgery (Surgery II), Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
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Nuñez JR, Del Rio F, Lopez E, Moreno MA, Soria A, Parra D. Non-heart-beating donors: an excellent choice to increase the donor pool. Transplant Proc 2006; 37:3651-4. [PMID: 16386494 DOI: 10.1016/j.transproceed.2005.09.105] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A specific program was adopted to obtain organs, for transplant purposes from people who die at home or in the street from sudden or unexpected death (type I non-heart-beating donors [NHBD] according to the Maastricht classification). The objective of our program was to increase the donor pool by obtaining organs from well-selected potential donors who die at home, work, or in the street and are maintained on advanced life support (ALS) until hospital arrival. The great number of people who die in a previously healthy situation constitute an excellent source of organs for transplant purposes. Our program includes pre- and in-hospital attendance. Prehospital attendance is based on application of cardiopulmonary resuscitation in situ and ALS until arrival at hospital. In hospital, specific preservation maneuvers must be performed and family assessment and judge permission obtained. In the last 15 years, we developed a kidney transplant program with better results than transplants performed with organs obtained from encephalic death donors (EDD). A specific NHBD subprogram for lung transplant was developed with excellent results as well. We are now improving the liver transplant program. NHBD are an important source of human tissues, including pancreas islets. It is clear that NHBD are a great source of organs and tissues for transplant, and that this kind of program must be established in all countries in which legal regulations allow it.
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Affiliation(s)
- J R Nuñez
- Hospital Clinico San Carlos, Madrid, Spain.
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Varela A, Marcos RC. [Lung transplantation for emphysema]. Med Clin (Barc) 2005; 125:616-7. [PMID: 16287571 DOI: 10.1157/13080837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Román A, Calvo V, Ussetti P, Borro JM, Lama R, Zurbano F, Pacheco A, Morell F, Solé A, De la Torre M, Varela A, Salvatierra A, Maiz L, Hernández M, Cañón J. Urgent Lung Transplantation in Spain. Transplant Proc 2005; 37:3987-90. [PMID: 16386605 DOI: 10.1016/j.transproceed.2005.09.117] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Lung donors are scarce and lung transplantation resources are limited. Because urgent lung transplantation (ULT) is assumed to yield poor results, its use is controversial. We assessed the outcome of patients who received ULT seeking to determine effectiveness and risk factors. PATIENTS AND METHOD We collected data from every ULT performed in Spain during 5 years (1998-2002). The survival of patients was studied using Kaplan-Meier, Cox regression, and chi-square statistical analyses. We compared outcomes and perioperative mortality (over 30 days) for ULT procedures, analyzing the influence of certain variables (age, type of transplant, diagnosis, indication, and time on waiting list). RESULTS Among 109 patients proposed for the procedure, 73 ULT were performed during the period. The most frequent indications were pulmonary fibrosis (19 cases) and cystic fibrosis (19 cases), showing the worst and the better survival rates, respectively. The bad prognosis, determined mainly by per operative mortality rate (35.62%), was significantly affected by age (worse for patients older than 40 years) and type of LT (single worse than double; P < .05). A longer time waiting for ULT also showed a worse prognosis (P < .005). CONCLUSIONS Long-term survival after ULT shows that the procedure is effective and efficient for a select group of patients, despite the high per operative risk. ULT should be reserved for younger patients. It also requires performance in a short period (just a few days), initially rejecting a single lung transplant, provided that the patient is adequately monitored.
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Affiliation(s)
- A Román
- Hospital General Vall d'Hebron, Barcelona, Spain.
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Varela de Ugarte A. [Primary graft failure following lung transplantation: is there hope for improvement?]. Arch Bronconeumol 2005; 41:473-4. [PMID: 16194507 DOI: 10.1016/s1579-2129(06)60264-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Singhal AK, Abrams JD, Mohara J, Hasz RD, Nathan HM, Fisher CA, Furukawa S, Goldman BI. Potential Suitability for Transplantation of Hearts From Human Non–Heart-Beating Donors: Data Review From the Gift of Life Donor Program. J Heart Lung Transplant 2005; 24:1657-64. [PMID: 16210144 DOI: 10.1016/j.healun.2004.11.043] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2004] [Revised: 11/12/2004] [Accepted: 11/21/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Organ availability limits use of heart transplantation for treatment for end-stage heart disease. Hearts are currently obtained from donors declared brain dead (heart-beating donors [HBDs]). Although use of hearts from non-heart-beating donors (NHBDs) could reduce the shortage, they are considered unusable because of possible peri-mortem ischemic injury. METHODS To project how use of NHBD hearts could increase heart donation, we retrospectively reviewed donor databases from the Gift of Life Donor Program (GLDP), our local organ procurement organization, from 2001 through 2003. We screened the NHBD population using conservative donor criteria, assuming an acceptable hypoxic/ischemic time (time from withdrawal of care to cross-clamp) of 30 minutes. RESULTS During the study period, there were 894 HBDs, 334 heart transplants and 119 NHBDs. NHBDs were similar to HBDs with respect to gender and ethnicity, but NHBDs were proportionately younger. Of 119 NHBDs, 55 did not meet the age criteria (< or =45 years) and 20 were eliminated because of incomplete data. Eighty-two NHBDs were cross-clamped within 30 minutes of care withdrawal. Twenty NHBDs met all cardiac donor criteria, and 14 of these 20 had hypoxic/ischemic times < or =30 minutes. Pro rata estimation for the 20 NHBDs with incomplete data suggested 7 potential additional donors. CONCLUSIONS Based on our assumptions, 12% to 18% of NHBDs in the study period (14 to 21 of 119 total) were potential heart donors, representing a 4% to 6% increase over of the number of heart transplants performed during the same time interval.
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Affiliation(s)
- Arun K Singhal
- Division of Cardiac and Thoracic Surgery, Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA
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Ridley S, Bonner S, Bray K, Falvey S, Mackay J, Manara A. UK guidance for non-heart-beating donation. Br J Anaesth 2005; 95:592-5. [PMID: 16183683 DOI: 10.1093/bja/aei235] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
This guidance offers consensus opinion on the optimum management of non-heart-beating organ donation in adult critical care units. The guidance is not meant to dictate practice but rather to offer suggestions as to what might be considered reasonable practice. The following sections mainly relate to the medical aspects of non-heart-beating organ donation. Fuller guidance on other aspects of organ and tissue donation is available on the Society's website (www.ics.ac.uk). There are a number of parallel areas of work, such as the law on consent, the definition of death and revision of the original Code of Practice describing brainstem testing, which means that many aspects of organ donation are changing rapidly. This guidance is designed to help critical care practitioners while these issues are resolved.
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Affiliation(s)
- S Ridley
- Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7AU, UK.
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Varela de Ugarte A. ¿Se puede mejorar el fallo primario del injerto en el trasplante pulmonar? Arch Bronconeumol 2005. [DOI: 10.1157/13078646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Rega FR, Wuyts WA, Vanaudenaerde BM, Jannis NC, Neyrinck AP, Verleden GM, Lerut TE, Van Raemdonck DEM. Nebulized N-Acetyl Cysteine Protects the Pulmonary Graft Inside the Non–Heart-Beating Donor. J Heart Lung Transplant 2005; 24:1369-77. [PMID: 16143259 DOI: 10.1016/j.healun.2004.10.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2004] [Revised: 10/11/2004] [Accepted: 10/11/2004] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The use of lungs from non-heart-beating donors (NHBD) might significantly alleviate the organ shortage. The tolerable warm ischemic period after cardiac arrest, however, is limited to approximately 1 hour. If the lung could be safely protected inside the cadaver, this time period may be prolonged. This would help to obtain family consent and to organize organ retrieval. METHODS Pigs (30.8 +/- 0.6 kg) were killed, left untouched for 3 hours, and divided into 3 groups. Nebulized N-acetyl cysteine (NAC) (300 mg), a precursor of the antioxidant agent glutathione, was administered during 10 minutes before death in Group I (NAC-NHBD, n = 6) and 15 minutes after death in Group II (NHBD-NAC, n = 6). In the control group, no aerosol was administered (NHBD, n = 6). After a warm ischemic interval of 3 hours, both lungs in all groups were topically cooled for 1 hour. Thereafter, the left lung was prepared for evaluation in an isolated reperfusion circuit. Hemodynamic, aerodynamic, and oxygenation parameters were measured. Wet-to-dry weight ratio (W/D) was calculated after reperfusion. The right lung was used to measure reduced glutathione (GSH) and oxidized glutathione (GSSG) levels (micromol/g) in lung homogenates and total protein levels in bronchial lavage fluid. RESULTS Pulmonary vascular resistance, mean airway pressure, and W/D were significantly decreased in NAC-NHBD (1930 +/- 144 Dynes x sec x cm(-5), 14.2 +/- 0.5 cm H2O, and 7.4 +/- 0.4; p < 0.01, 0.01, and 0.05, respectively) and NHBD-NAC (1837 +/- 180 Dynes x sec x cm(-5), 13.3 +/- 1.2 cm H2O, and 7.3 +/- 0.3; p < 0.01, 0.05, and 0.05, respectively) when compared with the control group (5051 +/- 530 Dynes x sec x cm(-5), 17 +/- 0.4 cm H2O, 8.5 +/- 0.1, respectively). GSH/GSSG ratio was significantly higher and protein levels were significantly lower in NAC-NHBD (1.7 +/- 0.1 and 1315 +/- 60 microg/ml; p < 0.05 and 0.05, respectively) and NHBD-NAC (1.7 +/- 0.2 and 1475 +/- 159 microg/ml; p < 0.05 and 0.05, respectively) when compared with the control group (1.2 +/- 0.1 and 2150 +/- 200 microg/ml). CONCLUSIONS Nebulized NAC administered before or shortly after death attenuates early ischemia reperfusion injury via upregulation of glutathione. NAC might be a promising tool to protect the pulmonary graft from both controlled and uncontrolled NHBD.
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Affiliation(s)
- Filip R Rega
- Center for Experimental Surgery and Anesthesiology, Katholieke Universiteit Leuven, Leuven, Belgium
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Borro JM. [Lung transplants in Spain: an update]. Arch Bronconeumol 2005; 41:457-67. [PMID: 16117951 DOI: 10.1016/s1579-2129(06)60261-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- J M Borro
- Complejo Hospitalario Juan Canalejo, A Coruña, España.
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Affiliation(s)
- Kalpaj Parekh
- Washington University School of Medicine, Department of Cardiothoracic Surgery, St. Louis, MO 63110, USA
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Van Raemdonck DEM, Rega FR, Neyrinck AP, Jannis N, Verleden GM, Lerut TE. Non-heart-beating donors. Semin Thorac Cardiovasc Surg 2004; 16:309-21. [PMID: 15635535 DOI: 10.1053/j.semtcvs.2004.09.014] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The widespread application of lung transplantation is limited by the shortage of suitable donor organs resulting in longer waiting times for listed patients with a substantial risk of dying before transplantation. To overcome this critical organ shortage, some transplant programs have now begun to explore the use of lungs from circulation-arrested donors, so called non-heart-beating donors (NHBDs). This review outlines the different categories of NHBDs, the relevant published experimental data that support the use of lungs coming from these donors and the clinical experience worldwide so far. Techniques for NHBD lung preservation and pretransplant functional assessment are reviewed. Ethical issues involved in transplanting lungs from asystolic donors are discussed.
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Affiliation(s)
- Dirk E M Van Raemdonck
- Thoracic Surgical Research Unit, Center for Experimental Surgery and Anaesthesiology, Catholic University, Leuven, Belgium.
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