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Sablone S, Musajo Somma C, Ruta F, Bellino M, Ciciriello T, Saracino M, Attimonelli Petraglione R, Michelangeli G, Gianelli Castiglione A, Cardillo M, Introna F, Gesualdo L. Organ procurement in forensic deaths: A retrospective analysis of the Italian context with a focus on the Puglia Region virtuous experience. J Forensic Leg Med 2024; 102:102657. [PMID: 38387233 DOI: 10.1016/j.jflm.2024.102657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 12/14/2023] [Accepted: 02/16/2024] [Indexed: 02/24/2024]
Abstract
Organ transplantation is one the most important contributions of modern medicine to society since it provides a unique therapy for terminal organ failure. However, the development of this therapeutic approach is hindered by the limited organ supply. In Italy, organ procurement requires a multidisciplinary medical-surgical approach in which legal medical doctors (LMDs) are generally tasked with ascertaining the reality of death. Sometimes, a medico-legal report is required when the deceased's family deny their consent to the organs and tissues removal from a potential deceased donor. LMDs can also be appointed by law to carry out post-mortem examinations of potential deceased donors. In these cases, the public prosecutors' interest in preserving the corpse integrity for forensic purposes seems to conflict with the ethical-humanitarian interest in promoting, at most, the opportunity to donate; however, a LMD can act as a mediator and allow both goals. This paper aims to illustrate the Apulia Region experience in reconciling the justice interests with those of a culture promoting deceased organ and tissue donation. It has been pursued by analyzing the virtuous regional organ procurement trend in forensic deaths before and after a crucial 2015 initiative, comparing the results with the national ones, and contextualizing them in the relevant literature to show systemic strengths and weaknesses and inform future Italian policy development.
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Affiliation(s)
- Sara Sablone
- Section of Legal Medicine, Interdisciplinary Department of Medicine, Bari Policlinico Hospital, University of Bari, 70124, Bari, Italy.
| | - Chiara Musajo Somma
- Puglia Regional Transplant Center (CRT Puglia), Bari Policlinico Hospital, University of Bari, 70124, Bari, Italy.
| | - Federico Ruta
- Health Agency BAT, General Direction, 76121, Andria (BT), Italy.
| | - Mara Bellino
- Section of Legal Medicine, Interdisciplinary Department of Medicine, Bari Policlinico Hospital, University of Bari, 70124, Bari, Italy.
| | - Tommaso Ciciriello
- Section of Anesthesia, Intensive Care and Pain Unit, Interdisciplinary Department of Medicine, Bari Policlinico Hospital, University of Bari, 70124, Bari, Italy.
| | - Michele Saracino
- Puglia Regional Transplant Center (CRT Puglia), Bari Policlinico Hospital, University of Bari, 70124, Bari, Italy.
| | | | | | | | - Massimo Cardillo
- Italian National Transplant Center (CNT), Istituto Superiore di Sanità, Rome, Italy.
| | - Francesco Introna
- Section of Legal Medicine, Interdisciplinary Department of Medicine, Bari Policlinico Hospital, University of Bari, 70124, Bari, Italy.
| | - Loreto Gesualdo
- Puglia Regional Transplant Center (CRT Puglia), Bari Policlinico Hospital, University of Bari, 70124, Bari, Italy.
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Lazzeri C, Bonizzoli M, Di Valvasone S, Peris A. Uncontrolled Donation after Circulatory Death Only Lung Program: An Urgent Opportunity. J Clin Med 2023; 12:6492. [PMID: 37892627 PMCID: PMC10607380 DOI: 10.3390/jcm12206492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 10/29/2023] Open
Abstract
Uncontrolled donation after circulatory death (uDCD) represents a potential source of lungs, and since Steen's 2001 landmark case in Sweden, lungs have been recovered from uDCD donors and transplanted to patients in other European countries (France, the Netherlands, Spain and Italy) with promising results. Disparities still exist among European countries and among regions in Italy due to logistical and organizational factors. The present manuscript focuses on the clinical experiences pertaining to uDCD lungs in North America and European countries and on different lung maintenance methods. Existing experiences (and protocols) are not uniform, especially with respect to the type of lung maintenance, the definition of warm ischemic time (WIT) and, finally, the use of ex vivo perfusion (available in the last several years in most centers). In situ lung cooling may be superior to protective ventilation, but this process may be difficult to perform in the uDCD setting and is also time-consuming. On the other hand, the "protective ventilation technique" is simpler and feasible in every hospital. It may lead to a broader use of uDCD lung donors. To date, the results of lung transplants performed after protective ventilation as a preservation technique are scarce but promising. All the protocols comprise, among the inclusion criteria, a witnessed cardiac arrest. The detectable differences included preservation time (240 vs. 180 min) and donor age (<55 years in Spanish protocols and <65 years in Toronto protocols). Overall, independently of the differences in protocols, lungs from uDCD donors show promising results, and the possibility of optimizing ex vivo lung perfusion may broaden the use of these organs.
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Affiliation(s)
- Chiara Lazzeri
- Intensive Care Unit and Regional ECMO Referral Center Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy (A.P.)
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Noda K, Furukawa M, Chan EG, Sanchez PG. Expanding Donor Options for Lung Transplant: Extended Criteria, Donation After Circulatory Death, ABO Incompatibility, and Evolution of Ex Vivo Lung Perfusion. Transplantation 2023; 107:1440-1451. [PMID: 36584375 DOI: 10.1097/tp.0000000000004480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Only using brain-dead donors with standard criteria, the existing donor shortage has never improved in lung transplantation. Currently, clinical efforts have sought the means to use cohorts of untapped donors, such as extended criteria donors, donation after circulatory death, and donors that are ABO blood group incompatible, and establish the evidence for their potential contribution to the lung transplant needs. Also, technical maturation for using those lungs may eliminate immediate concerns about the early posttransplant course, such as primary graft dysfunction or hyperacute rejection. In addition, recent clinical and preclinical advances in ex vivo lung perfusion techniques have allowed the safer use of lungs from high-risk donors and graft modification to match grafts to recipients and may improve posttransplant outcomes. This review summarizes recent trends and accomplishments and future applications for expanding the donor pool in lung transplantation.
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Affiliation(s)
- Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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Palleschi A, Zanella A, Citerio G, Musso V, Rosso L, Tosi D, Fumagalli J, Bonitta G, Benazzi E, Lopez G, Rossetti V, Morlacchi LC, Uslenghi C, Cardillo M, Blasi F, Grasselli G, Valenza F, Nosotti M. Lung Transplantation From Controlled and Uncontrolled Donation After Circulatory Death (DCD) Donors With Long Ischemic Times Managed by Simple Normothermic Ventilation and Ex-Vivo Lung Perfusion Assessment. Transpl Int 2023; 36:10690. [PMID: 36846600 PMCID: PMC9945516 DOI: 10.3389/ti.2023.10690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 01/26/2023] [Indexed: 02/11/2023]
Abstract
Donation after cardiac death (DCD) donors are still subject of studies. In this prospective cohort trial, we compared outcomes after lung transplantation (LT) of subjects receiving lungs from DCD donors with those of subjects receiving lungs from donation after brain death (DBD) donors (ClinicalTrial.gov: NCT02061462). Lungs from DCD donors were preserved in-vivo through normothermic ventilation, as per our protocol. We enrolled candidates for bilateral LT ≥14 years. Candidates for multi-organ or re-LT, donors aged ≥65 years, DCD category I or IV donors were excluded. We recorded clinical data on donors and recipients. Primary endpoint was 30-day mortality. Secondary endpoints were: duration of mechanical ventilation (MV), intensive care unit (ICU) length of stay, severe primary graft dysfunction (PGD3) and chronic lung allograft dysfunction (CLAD). 121 patients (110 DBD Group, 11 DCD Group) were enrolled. 30-day mortality and CLAD prevalence were nil in the DCD Group. DCD Group patients required longer MV (DCD Group: 2 days, DBD Group: 1 day, p = 0.011). ICU length of stay and PGD3 rate were higher in DCD Group but did not significantly differ. LT with DCD grafts procured with our protocols appears safe, despite prolonged ischemia times.
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Affiliation(s)
- Alessandro Palleschi
- University of Milan, Milan, Italy
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- University of Milan, Milan, Italy
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine, University of Milano - Bicocca, Milano, Italy
- Neurointensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Valeria Musso
- University of Milan, Milan, Italy
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Rosso
- University of Milan, Milan, Italy
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Tosi
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Jacopo Fumagalli
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Elena Benazzi
- Coordinamento Trapianti North Italy Transplantation Program (NITp), Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluca Lopez
- Pathology Unit, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Rossetti
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Letizia Corinna Morlacchi
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Clarissa Uslenghi
- University of Milan, Milan, Italy
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Francesco Blasi
- University of Milan, Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- University of Milan, Milan, Italy
- Department of Anaesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, Milan, Italy
| | - Franco Valenza
- University of Milan, Milan, Italy
- Department of Anaesthesia and Critical Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Mario Nosotti
- University of Milan, Milan, Italy
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
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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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Schwarz S, Gökler J, Moayedifar R, Atteneder C, Bocchialini G, Benazzo A, Schweiger T, Jaksch P, Zuckermann AO, Aliabadi-Zuckermann AZ, Hoetzenecker K. Prioritizing direct heart procurement in organ donors after circulatory death does not jeopardize lung transplant outcomes. JTCVS Tech 2022; 16:182-195. [PMID: 36510519 PMCID: PMC9737044 DOI: 10.1016/j.xjtc.2022.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/09/2022] [Accepted: 08/26/2022] [Indexed: 11/06/2022] Open
Abstract
Background Controlled donation after circulatory death (cDCD) has become a standard in liver, kidney, and lung transplantation (LTx). Based on recent innovations in ex vivo heart preservation, heart transplant centers have started to accept cDCD heart allografts. Because the heart has very limited tolerance to warm ischemia, changes to the cDCD organ procurement procedures are needed. These changes entail delayed ventilation and prolonged warm ischemia for the lungs. Whether this negatively impacts lung allograft function is unclear. Methods A retrospective analysis of cDCD lungs transplanted between 2012 and February 2022 at the Medical University of Vienna was performed. The heart + lung group consisted of cases in which the heart was procured by a cardiac team for subsequent normothermic ex vivo perfusion. A control group (lung group) was formed by cases where only the lungs were explanted. In heart + lung group cases, the heart procurement team placed cannulas after circulatory death and a hands-off time, collected donor blood for ex vivo perfusion, and performed rapid organ perfusion with Custodiol solution, after which the heart was explanted. Up to this point, the lung procurement team did not interfere. No concurrent lung ventilation or pulmonary artery perfusion was performed. After the cardiac procurement team left the table, ventilation was initiated, and lung perfusion was performed directly through both stumps of the pulmonary arteries using 2 large-bore Foley catheters. This study analyzed procedural explant times, postoperative outcomes, primary graft dysfunction (PGD), duration of mechanical ventilation, length of intensive care unit (ICU) stay, and early survival after LTx. Results A total of 56 cDCD lungs were transplanted during the study period. In 7 cases (12.5%), the heart was also procured (heart + lung group); in 49 cases (87.5%), only the lungs were explanted (lung group). Basic donor parameters were comparable in the 2 groups. The median times from circulatory arrest to lung perfusion (24 minutes vs 13.5 minutes; P = .002) and from skin incision to lung perfusion (14 minutes vs 5 minutes; P = .005) were significantly longer for the heart + lung procedures. However, this did not affect post-transplantation PGD grade at 0 hours (P = .851), 24 hours (P = .856), 48 hours (P = .929), and 72 hours (P = .874). At 72 hours after transplantation, none of the lungs in the heart + lung group but 1 lung (2.2%) in lung group was in PGD 3. The median duration of mechanical ventilation (50 hours vs 41 hours; P = .801), length of ICU stay (8 days vs 6 days; P = .951), and total length of hospital stay (27 days vs 25 days; P = .814) were also comparable in the 2 groups. In-hospital mortality occurred in only 1 patient of the lung group (2.2%). Conclusions Although prioritized cDCD heart explantation is associated with delayed ventilation and significantly longer warm ischemic time to the lungs, post-LTx outcomes within the first year are unchanged. Prioritizing heart perfusion and explantation in the setting of cDCD procurement can be considered acceptable.
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Key Words
- CA, circulatory arrest
- DBD, donation after brain death
- ECMO, extracorporeal membrane oxygenation
- EVLP, ex vivo lung perfusion
- ICU, intensive care unit
- ISHLT, International Society for Heart and Lung Transplantation
- LTx, lung transplantation
- NRP, normothermic regional perfusion
- PGD, primary graft dysfunction
- PHP, prioritized heart procurement
- SWIT, surgical warm ischemic time
- WIT, warm ischemic time
- WLST, withdrawal of life support therapy
- cDCD, controlled donation after circulatory death
- donation after circulatory death
- heart transplantation
- lung transplantation
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Affiliation(s)
- Stefan Schwarz
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Johannes Gökler
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Roxana Moayedifar
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Clemens Atteneder
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Giovanni Bocchialini
- Department of Thoracic Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Alberto Benazzo
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Schweiger
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Peter Jaksch
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | | | | | - Konrad Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria,Address for reprints: Konrad Hoetzenecker, MD, PhD, Division of Thoracic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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Gori F, Fumagalli J, Lonati C, Carlin A, Leonardi P, Biancolilli O, Rossetti A, Righi I, Tosi D, Palleschi A, Rosso L, Morlacchi LC, Blasi F, Vivona L, Florio G, Scaravilli V, Valenza F, Zanella A, Grasselli G. Lung Biomolecular Profile and Function of Grafts from Donors after Cardiocirculatory Death with Prolonged Donor Warm Ischemia Time. J Clin Med 2022; 11:jcm11113066. [PMID: 35683455 PMCID: PMC9181171 DOI: 10.3390/jcm11113066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/30/2022] [Accepted: 05/23/2022] [Indexed: 11/16/2022] Open
Abstract
The acceptable duration of donor warm ischemia time (DWIT) after cardiocirculatory death (DCD) is still debated. We analyzed the biomolecular profile and function during ex vivo lung perfusion (EVLP) of DCD lungs and their correlation with lung transplantation (LuTx) outcomes. Donor data, procurement times, recipient outcomes, and graft function up to 1 year after LuTx were collected. During EVLP, the parameters of graft function and metabolism, perfusate samples to quantify inflammation, glycocalyx breakdown products, coagulation, and endothelial activation markers were obtained. Data were compared to a cohort of extended-criteria donors after brain death (EC-DBD). Eight DBD and seven DCD grafts transplanted after EVLP were analyzed. DCD’s DWIT was 201 [188;247] minutes. Donors differed only regarding the duration of mechanical ventilation that was longer in the EC-DBD group. No difference was observed in lung graft function during EVLP. At reperfusion, “wash-out” of inflammatory cells and microthrombi was predominant in DCD grafts. Perfusate biomolecular profile demonstrated marked endothelial activation, characterized by the presence of inflammatory mediators and glycocalyx breakdown products both in DCD and EC-DBD grafts. Early graft function after LuTx was similar between DCD and EC-DBD. DCD lungs exposed to prolonged DWIT represent a potential resource for donation if properly preserved and evaluated.
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Affiliation(s)
- Francesca Gori
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (J.F.); (O.B.); (V.S.); (G.G.)
| | - Jacopo Fumagalli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (J.F.); (O.B.); (V.S.); (G.G.)
| | - Caterina Lonati
- Center of Preclinical Research, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Andrea Carlin
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
| | - Patrizia Leonardi
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
| | - Osvaldo Biancolilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (J.F.); (O.B.); (V.S.); (G.G.)
| | - Antonello Rossetti
- Hospital Medical Direction, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Ilaria Righi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.R.); (D.T.)
| | - Davide Tosi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.R.); (D.T.)
| | - Alessandro Palleschi
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.R.); (D.T.)
| | - Lorenzo Rosso
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (I.R.); (D.T.)
| | - Letizia Corinna Morlacchi
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Luigi Vivona
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
| | - Gaetano Florio
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (J.F.); (O.B.); (V.S.); (G.G.)
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
| | - Franco Valenza
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
- Department of Anesthesia and Critical Care, Fondazione IRCCS Istituto Nazionale dei Tumori, 20133 Milan, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (J.F.); (O.B.); (V.S.); (G.G.)
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
- Correspondence: ; Tel.: +39-02-55033674; Fax: +39-02-55033230
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (J.F.); (O.B.); (V.S.); (G.G.)
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (A.C.); (P.L.); (A.P.); (L.R.); (F.B.); (L.V.); (G.F.); (F.V.)
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Van Raemdonck D, Ceulemans LJ, Neyrinck A, Levvey B, Snell GI. Donation After Circulatory Death in lung transplantation. Thorac Surg Clin 2022; 32:153-165. [PMID: 35512934 DOI: 10.1016/j.thorsurg.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The continuing shortage of pulmonary grafts from donors after brain death has led to a resurgence of interest in lung transplantation from donors after circulatory death (DCD). Most lungs from donors after withdrawal from life-sustaining therapy can be recovered rapidly and transplanted directly without ex-vivo assessment in case functional warm ischemic time is limited to 30 to 60 min. The potential of the DCD lung pool is still underutilized and should be maximized in countries with existing legislation. Countries lacking a DCD pathway should be encouraged to develop national ethical, professional, and legal frameworks to address public and professional concerns.
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Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, UZ Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium; Department of Chronic Diseases and Metabolism, KU Leuven University, Leuven, Belgium.
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, UZ Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium; Department of Chronic Diseases and Metabolism, KU Leuven University, Leuven, Belgium
| | - Arne Neyrinck
- Department of Anesthesiology, University Hospitals Leuven, UZ Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium; Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium
| | - Bronwyn Levvey
- Lung Transplant Service, The Alfred Hospital and Monash University, 55 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Gregory I Snell
- Lung Transplant Service, The Alfred Hospital and Monash University, 55 Commercial Road, Melbourne, Victoria 3004, Australia
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Bery A, Ali A, Cypel M, Kreisel D. Centralized Organ Recovery and Reconditioning Centers. Thorac Surg Clin 2022; 32:167-174. [PMID: 35512935 DOI: 10.1016/j.thorsurg.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
An increased focus on improving efficiency and decreasing costs has resulted in alternative models of donor management and organ recovery. The specialized donor care facility model provides highly efficient and cost-effective donor care at a free-standing facility, resulting in improved organ yield, shorter ischemic times, decreased travel, and fewer nighttime operations. Ex vivo lung perfusion (EVLP) improves utilization of extended criteria donor lungs, and centralized EVLP facilities have the potential to increase transplant volumes for smaller transplant programs in specified geographic regions. These alternative models are increasingly being used in the United States to improve waitlist mortality and combat the ongoing donor organ shortage.
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Affiliation(s)
- Amit Bery
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8052, St Louis, MO 63110, USA.
| | - Aadil Ali
- Toronto Lung Transplant Program, Division of Thoracic Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, 9N969, Toronto, Ontario M5G 2C4, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Division of Thoracic Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, 9N969, Toronto, Ontario M5G 2C4, Canada
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, Campus Box 8234, 660 South Euclid Avenue, St Louis, MO 63110, USA; Department of Pathology & Immunology, Washington University School of Medicine, Campus Box 8234, 660 South Euclid Avenue, St Louis, MO 63110, USA
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10
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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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11
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Palleschi A, Rosso L, Ruggeri GM, Croci GA, Rossetti V, Citerio G, Grasselli G, Nosotti M, Zanella A. Overcoming the Limits of Reconditioning: Seventeen Hours of EVLP With Successful Transplantation From Uncontrolled Circulatory Death Donor. Transplantation 2021; 105:2620-2624. [PMID: 33496562 PMCID: PMC8612888 DOI: 10.1097/tp.0000000000003646] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/17/2020] [Accepted: 12/20/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Uncontrolled donation after circulatory death (DCD) donors 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 us 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. Because the donor's blood count and liver biopsy showed signs of possible leukemia, EVLP was protracted up to 17 h while waiting for immunohistochemical analyses to rule out this diagnosis; eventually, the results came back negative, and the lungs were judged suitable for transplantation. RESULTS The recipient was a 32-y-old male individual with cystic fibrosis, colonized by Pandoraea pnomenusa. Bilateral transplantation required central extracorporeal membrane oxygenation. The patient was extubated after 36 h and was discharged 21 d after the operation. Despite early recolonization by Pandoraea pnomenusa and airway complications requiring pneumatic dilatation, he is alive and has a satisfactory respiratory function 15 mo after transplantation. CONCLUSIONS Uncontrolled DCD represents a challenge due to both logistical issues and the complexity of graft 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.
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Affiliation(s)
- Alessandro Palleschi
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lorenzo Rosso
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giulia Maria Ruggeri
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Alberto Croci
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Pathology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Rossetti
- Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Citerio
- San Gerardo Hospital, ASST-Monza, Monza, Italy
- University of Milano-Bicocca, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alberto Zanella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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12
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Pushing the Envelope for Donor Lungs. Semin Respir Crit Care Med 2021; 42:357-367. [PMID: 34030199 DOI: 10.1055/s-0041-1729859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The shortage of organ donors remains the major limiting factor in lung transplant, with the number of patients on the waiting list largely exceeding the number of available organ donors. Another issue is the low utilization rate seen in some types of donors. Therefore, novel strategies are continuously being explored to increase the donor pool. Advanced age, smoking history, positive serologies, and size mismatch are common criteria that decrease the rate of use when it comes to organ utilization. Questioning these limitations is one of the purposes of this review. Challenging these limitations by adapting novel donor management strategies could help to increase the rate of suitable lungs for transplantation while still maintaining good outcomes. A second goal is to present the latest advances in organ donation after controlled and uncontrolled cardiac death, and also on how to improve these lungs on ex vivo platforms for assessment and future specific therapies. Finally, pushing the limit of the donor envelope also means reviewing some of the recent improvements made in lung preservation itself, as well as upcoming experimental research fields. In summary, donor lung optimization refers to a global care strategy to increase the total numbers of available allografts, and preserve or improve organ quality without paying the price of early-, mid-, or long-term negative outcomes after transplantation.
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13
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Ehrsam JP, Benden C, Immer FF, Inci I. Current status and further potential of lung donation after circulatory death. Clin Transplant 2021; 35:e14335. [PMID: 33948997 DOI: 10.1111/ctr.14335] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 12/13/2022]
Abstract
Chronic organ shortage remains the most limiting factor in lung transplantation. To overcome this shortage, a minority of centers have started with efforts to reintroduce donation after circulatory death (DCD). This review aims to evaluate the experimental background, the current international clinical experience, and the further potential and challenges of the different DCD categories. Successful strategies have been implemented to reduce the problems of warm ischemic time, thrombosis after circulatory arrest, and difficulties in organ assessment, which come with DCD donation. From the currently reported results, controlled-DCD lungs are an effective and safe method with good mid-term and even long-term survival outcomes comparable to donation after brain death (DBD). Primary graft dysfunction and onset of chronic allograft dysfunction seem also comparable. Thus, controlled-DCD lungs should be ceased to be treated as marginal and instead be promoted as an equivalent alternative to DBD. A wide implementation of controlled-DCD-lung donation would significantly decrease the mortality on the waiting list. Therefore, further efforts in establishment of legislation and logistics are crucial. With regard to uncontrolled DCD, more data are needed analyzing long-term outcomes. To help with the detailed assessment and improvement of uncontrolled or otherwise questionable grafts after retrieval, ex-vivo lung perfusion is promising.
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Affiliation(s)
- Jonas P Ehrsam
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland.,Department of Thoracic Surgery, Cantonal Hospital Aarau, Zurich, Switzerland
| | | | | | - Ilhan Inci
- Department of Thoracic Surgery, Cantonal Hospital Aarau, Zurich, Switzerland.,University of Zurich Faculty of Medicine, Zurich, Switzerland
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14
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Calabrese F, Schiavon M, Perissinotto E, Lunardi F, Marulli G, Di Gregorio G, Pezzuto F, Edith Vuljan S, Forin E, Wiegmann B, Jonigk D, Warnecke G, Rea F. Organ Care System Lung resulted in lower apoptosis and iNOS expression in donor lungs. Am J Transplant 2020; 20:3639-3648. [PMID: 32652873 DOI: 10.1111/ajt.16187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/24/2020] [Accepted: 06/28/2020] [Indexed: 01/25/2023]
Abstract
Ischemia-reperfusion (IR) injury after lung transplantation is still today an important complication in up to 25% of patients. The Organ Care System (OCS) Lung, an advanced normothermic ex vivo lung perfusion system, was found to be effective in reducing primary graft dysfunction compared to standard organ care (SOC) but studies on tissue/molecular pathways that could explain these more effective clinical results are lacking. This observational longitudinal study aimed to investigate IR injury in 68 tissue specimens collected before and after reperfusion from 17 OCS and 17 SOC preserved donor lungs. Several tissue analyses including apoptosis evaluation and inducible nitric oxide synthase (iNOS) expression (by immunohistochemistry and real-time reverse transcriptase-polymerase chain reaction) were performed. Lower iNOS expression and apoptotic index were distinctive of OCS preserved tissues at pre- and post-reperfusion times, independently from potential confounding factors. Moreover, OCS recipients had lower acute cellular rejection at the first 6-month follow-up. In conclusion, IR injury, in terms of apoptosis and iNOS expression, was less frequent in OCS- than in SOC-preserved lungs, which could eventually explain a better clinical outcome. Further studies are needed to validate our data and determine the role of iNOS expression as a predictive biomarker of the complex IR injury mechanism.
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Affiliation(s)
- Fiorella Calabrese
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Marco Schiavon
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Egle Perissinotto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Francesca Lunardi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Giuseppe Marulli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | | | - Federica Pezzuto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Stefania Edith Vuljan
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Edoardo Forin
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Bettina Wiegmann
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center of Lung Research, Hannover, Germany
| | - Danny Jonigk
- German Center of Lung Research, Hannover, Germany.,Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center of Lung Research, Hannover, Germany
| | - Federico Rea
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
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15
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Palleschi A, Rosso L, Morlacchi LC, Del Gobbo A, Ramondetta M, Gori A, Blasi F, Nosotti M. Early acute rejection after lung transplantation mimicking viral pneumonia in the middle of COVID-19 pandemic: A case report. Int J Surg Case Rep 2020; 77:80-85. [PMID: 33157338 PMCID: PMC7598439 DOI: 10.1016/j.ijscr.2020.10.105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/22/2020] [Accepted: 10/22/2020] [Indexed: 12/24/2022] Open
Abstract
An atypical clinical presentation of early antibody-mediated rejection in COVID era. The radiological features mimicked SARS-CoV2 pneumonia, but tests were negative. This is the first report of lung transplantation in the COVID era in Europe. Decide whether to keep lung transplantation programmes open in a COVID Hospital.
Introduction In addition to morbidity and mortality rate per se, COVID-19 outbreak leads to potential ‘side effects’, which are difficult to evaluate and predict. Lung transplantation is a consolidated treatment for end-stage chronic lung disease requiring significantly demanding management. Deciding whether to keep transplant programmes open during an epidemic of this size is not easy, as immunosuppressed subjects face the risk of infection and related mortality. Additionally, there is a chance for the patient’s standard care process to be compromised. Presentation of case We report the case of a patient undergoing bilateral lung transplantation during the explosion of COVID-19 epidemic in Lombardy; he died from definite early acute antibody-mediated rejection, clinically (persistent high fever, unresponsive to treatment) and radiologically mimicking viral pneumonia but persistently negative for SARS-CoV-2. Discussion The diagnosis was difficult given this atypical presentation, confounded by global scenario. Grafts were procured from a donation after circulatory death donor in an uncontrolled setting and a donor-recipient transmission was possible. Our institute became a COVID-Hospital right during the first post-transplantation days. Radiological imaging had the same features of SARS-CoV-2 pneumonia. Conclusions This is the first report of lung transplantation of the COVID-19 era in Europe. Our extremely fragile patient was COVID-19 free up to the end. Donor-recipient transmission is conceivable, but the risk should be assessed with respect to waiting list mortality. Ultimately, treating COVID-19 patients can be a resource-consuming activity but we decided to keep our centre open.
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Key Words
- AMR, antibody-mediated rejection
- Acute antibody-mediated rejection
- BAL, bronchoalveolar lavage
- COVID-19
- CT, computed tomography
- Case report
- DCD, donation after circulatory death
- DSA, donor-specific antibodies
- Donation after circulatory death donor
- FiO2, fraction of inspired oxygen
- ICU, intensive care unit
- Lung transplantation
- NIV, non-invasive ventilation
- PCR, polymerase chain reaction
- POD, post-operative day
- PaO2, partial arterial oxygen pressure
- SARS-CoV-2
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Affiliation(s)
- Alessandro Palleschi
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy; University of Milan, Italy.
| | - Lorenzo Rosso
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy; University of Milan, Italy
| | - Letizia Corinna Morlacchi
- Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy
| | - Alessandro Del Gobbo
- Pathology Unit, Center - Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy
| | - Miriam Ramondetta
- North Italy Transplant Program (NITp), Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy
| | - Andrea Gori
- University of Milan, Italy; Infectious Diseases Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy
| | - Francesco Blasi
- University of Milan, Italy; Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico of Milan, Italy; University of Milan, Italy
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16
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Musso V, Mendogni P, Scaravilli V, Morlacchi LC, Croci GA, Palleschi A. Extended-criteria uncontrolled DCD donor for a fragile recipient: A case report about a challenging yet successful lung transplantation. Int J Surg Case Rep 2020; 77S:S67-S71. [PMID: 33046417 PMCID: PMC7876926 DOI: 10.1016/j.ijscr.2020.09.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Lung donation after circulatory death (DCD) has proved to be an effective strategy for expanding the donor pool, but is still considered challenging. We report a successful case of lung procurement from an extended-criteria uncontrolled DCD. PRESENTATION OF CASE We evaluated the lungs of an uncontrolled DCD from a hospital without extracorporeal membrane oxygenation (ECMO) program. The donor was a non-smoker 20-year old male with a history of cardiomyopathy, cardiocirculatory arrests, and Lennox-Gastaut syndrome. Cardiac arrest occurred in a swimming pool, and bronchoscopy showed signs of inhalation. We employed our usual normothermic in-situ open-ventilated lung approach. After retrieval, lungs were stored on ice, then evaluated with ex-vivo lung perfusion (EVLP) and judged suitable for transplantation. The recipient was a 26-year old female with cystic fibrosis on long-term oxygen therapy, on the waitlist for up to 21 months due to her anthropomorphic characteristics. She required central VA-ECMO support during bilateral lung transplantation. Primary graft dysfunction (PGD) within the first 72 h reached grade 3; post-operative peripheral VV-ECMO support was discontinued two days after surgery. The patient was discharged 28 days after surgery; she is alive two years after transplantation with no signs of rejection nor anastomotic complications. DISCUSSION Despite the spreading use of lungs from controlled DCD, perplexities remain on uncontrolled DCD, namely: severe PDG, postoperative mortality, airway complications. CONCLUSION Our case report suggests that good results can be achieved with uncontrolled DCD despite the presence of relative contraindications: inhalation of water, prolonged ischemic times and recipient in poor conditions.
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Affiliation(s)
- Valeria Musso
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico of Milan, Milan, Italy; Università degli Studi di Milano, Milan, Italy
| | - Paolo Mendogni
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico of Milan, Milan, Italy.
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico of Milan, Milan, Italy
| | - Letizia Corinna Morlacchi
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Alberto Croci
- Division of Pathology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro Palleschi
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico of Milan, Milan, Italy
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17
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Zanierato M, Dondossola D, Palleschi A, Zanella A. Donation after circulatory death: possible strategies for in-situ organ preservation. Minerva Anestesiol 2020; 86:984-991. [DOI: 10.23736/s0375-9393.20.14262-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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18
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Coll E, Miñambres E, Sánchez-Fructuoso A, Fondevila C, Campo-Cañaveral de la Cruz JL, Domínguez-Gil B. Uncontrolled Donation After Circulatory Death: A Unique Opportunity. Transplantation 2020; 104:1542-1552. [PMID: 32732830 DOI: 10.1097/tp.0000000000003139] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Uncontrolled donation after circulatory death (uDCD) refers to donation from persons who die following an unexpected and unsuccessfully resuscitated cardiac arrest. Despite the large potential for uDCD, programs of this kind only exist in a reduced number of countries with a limited activity. Barriers to uDCD are of a logistical and ethical-legal nature, as well as arising from the lack of confidence in the results of transplants from uDCD donors. The procedure needs to be designed to reduce and limit the impact of the prolonged warm ischemia inherent to the uDCD process, and to deal with the ethical issues that this practice poses: termination of advanced cardiopulmonary resuscitation, extension of advanced cardiopulmonary resuscitation beyond futility for organ preservation, moment to approach families to discuss donation opportunities, criteria for the determination of death, or the use of normothermic regional perfusion for the in situ preservation of organs. Although the incidence of primary nonfunction and delayed graft function is higher with organs obtained from uDCD donors, overall patient and graft survival is acceptable in kidney, liver, and lung transplantation, with a proper selection and management of both donors and recipients. Normothermic regional perfusion has shown to be critical to achieve optimal outcomes in uDCD kidney and liver transplantation. However, the role of ex situ preservation with machine perfusion is still to be elucidated. uDCD is a unique opportunity to improve patient access to transplantation therapies and to offer more patients the chance to donate organs after death, if this is consistent with their wishes and values.
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Affiliation(s)
| | - Eduardo Miñambres
- Intensive Care Unit and Donor Coordination Unit, Hospital Universitario Marqués de Valdecilla-IDIVAL, Universidad de Cantabria, Santander, Spain
| | - Ana Sánchez-Fructuoso
- Nephrology Department, Hospital Universitario Clínico San Carlos, Facultad de Medicina, Universidad Complutense, Madrid, Spain
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19
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Healey A, Watanabe Y, Mills C, Stoncius M, Lavery S, Johnson K, Sanderson R, Humar A, Yeung J, Donahoe L, Pierre A, de Perrot M, Yasufuku K, Waddell TK, Keshavjee S, Cypel M. Initial lung transplantation experience with uncontrolled donation after cardiac death in North America. Am J Transplant 2020; 20:1574-1581. [PMID: 31995660 DOI: 10.1111/ajt.15795] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/12/2019] [Accepted: 01/08/2020] [Indexed: 01/25/2023]
Abstract
Uncontrolled donation after cardiac death (uDCD) has the potential to ameliorate the shortage of suitable lungs for transplant. To date, no lung transplant data from these donors are available from North America. We describe the successful use of these donors using a simple method of in situ lung inflation so that the organ can be protected from warm ischemic injury. Forty-four potential donors were approached, and family consent was obtained in 30 cases (68%). Of these, the lung transplant team evaluated 16 uDCDs on site, and 14 were considered for transplant pending ex vivo lung perfusion assessment. Five lungs were ultimately used for transplant (16.7% use rate from consented donors). The mean warm ischemic time was 2.8 hours. No primary graft dysfunction grade 3 was observed at 24, 48, or 72 hours after transplant. Median intensive care unit stay was 5 days (range: 2-78 days), and median hospital stay was 17 days (range: 8-100 days). The 30-day mortality was 0%. Four of 5 patients are alive at a median of 651 days (range: 121-1254 days) with preserved lung function. This study demonstrates the proof of concept and the potential for uDCD lung donation using a simple donor intervention.
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Affiliation(s)
- Andrew Healey
- Trillium Gift of Life Network, Toronto, Ontario, Canada.,Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Critical Care, Department of Medicine, William Osler Health System, Brampton, Ontario, Canada
| | - Yui Watanabe
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Caitlin Mills
- Trillium Gift of Life Network, Toronto, Ontario, Canada
| | | | - Susan Lavery
- Trillium Gift of Life Network, Toronto, Ontario, Canada
| | - Karen Johnson
- Trillium Gift of Life Network, Toronto, Ontario, Canada
| | | | - Atul Humar
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Yeung
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Laura Donahoe
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Pierre
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marc de Perrot
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kazuhiro Yasufuku
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program and Multiorgan Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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20
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Fumagalli J, Rosso L, Gori F, Morlacchi LC, Rossetti V, Tarsia P, Blasi F, Righi I, Mendogni P, Palleschi A, Tosi D, Bonitta G, Nosotti M, Benazzi E, Scaravilli V, Valenza F, Grasselli G, Zanella A. Early pulmonary function and mid-term outcome in lung transplantation after ex-vivo lung perfusion - a single-center, retrospective, observational, cohort study. Transpl Int 2020; 33:773-785. [PMID: 32219887 DOI: 10.1111/tri.13606] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/20/2020] [Accepted: 03/16/2020] [Indexed: 12/14/2022]
Abstract
Outcomes after transplantation of lungs (LuTX) treated with ex-vivo lung perfusion (EVLP) are debated. In a single-center 8 years of retrospective analysis, we compared: donors' and recipients' characteristics, gas exchange and lung mechanics at ICU admission, 3, 6, and 12 months, and patients' survival of LuTX from standard donors compared with EVLP-treated grafts. A total of 193 LuTX were performed. Thirty-one LuTX, out of 50 EVLP procedures, were carried out: 7 from nonheart beating and 24 from extended criteria brain-dead donors. Recipients' characteristics were similar. At ICU admission, compared with standard donors, EVLP patients had worse PaO2 /FiO2 [276 (206; 374) vs. 204 (133; 245) mmHg, P < 0.05], more frequent extracorporeal support (18% vs. 32%, P = 0.053) and longer mechanical ventilation duration [28 days of ventilator-free days: 27 (24; 28) vs. 26 (19; 27), P < 0.05]. ICU length of stay [4 (2; 9) vs. 6 (3; 12) days, P = 0.208], 28-day survival (99% vs. 97%, P = 0.735), and 1-year respiratory function were similar between groups. Log-rank analysis (median follow-up 2.5 years) demonstrated similar patients' survival (P = 0.439) and time free of chronic lung allograft disease (P = 0.484). The EVLP program increased by 16% the number of LuTX. Compared to standard donors, EVLP patients had worse respiratory function immediately after LuTX but similar early and mid-term outcomes.
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Affiliation(s)
- Jacopo Fumagalli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Rosso
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Francesca Gori
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Letizia Corinna Morlacchi
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Rossetti
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Tarsia
- Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Respiratory Unit & Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Righi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Mendogni
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro Palleschi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Tosi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluca Bonitta
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Elena Benazzi
- Coordinamento Trapianti North Italy Transplantation Program (NITp), Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Franco Valenza
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Anesthesia and Critical Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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22
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Othman MH, Dutta A, Kondziella D. Public opinion and legislations related to brain death, circulatory death and organ donation. J Neurol Sci 2020; 413:116800. [PMID: 32251871 DOI: 10.1016/j.jns.2020.116800] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/12/2020] [Accepted: 03/23/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND It is poorly understood how public perception of the difference between brain death and circulatory death may influence attitudes towards organ donation. We investigated the public opinion on brain death versus circulatory death and documented inconsistencies in the legislations of countries with different cultural and socioeconomic backgrounds. METHODS Using a crowdsourcing approach, we randomized 1072 participants from 30 countries to a case report of organ donation after brain death or to one following circulatory death. Further, we sampled guidelines from 24 countries and 5 continents. RESULTS Of all participants, 73% stated they would be willing to donate all organs, while 16% would want to donate some of their organs. To increase the rate of donations, 47% would agree with organ donation without family consent as the default. Exposure to "brain death" was not associated with a lesser likelihood of participants agreeing with organ donation (82.1%) compared to "circulatory death" (81.9%; relative risk 1.02, 95% CI 0.99 to 1.03; p = .11). However, participants exposed to "circulatory death" were more certain that the patient was truly dead (87.9% ± 19.7%) than participants exposed to "brain death" (84.1% ± 22.7%; Cohen's d 0.18; p = 0:004). Sampling of guidelines revealed large differences between countries regarding procedures required to confirm brain death and circulatory death, respectively. CONCLUSIONS Implementation of organ donation after circulatory death is unlikely to negatively influence the willingness to donate organs, but legislation is still brain death-based in most countries. The time seems ripe to increase the rate of circulatory death-based organ donation.
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Affiliation(s)
- Marwan H Othman
- Departments of Neurology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Anirban Dutta
- Department of Biomedical Engineering, University at Buffalo, State University of New York, NY, United States
| | - Daniel Kondziella
- Departments of Neurology, Rigshospitalet, Copenhagen University Hospital, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Palleschi A, Tosi D, Rosso L, Zanella A, De Carlis R, Zanierato M, Benazzi E, Tarsia P, Colledan M, Nosotti M. Successful preservation and transplant of warm ischaemic lungs from controlled donors after circulatory death by prolonged in situ ventilation during normothermic regional perfusion of abdominal organs. Interact Cardiovasc Thorac Surg 2020; 29:699-705. [PMID: 31243436 DOI: 10.1093/icvts/ivz160] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/17/2019] [Accepted: 05/23/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Donation after circulatory death (DCD) potentially provides transplantable lungs suitable for a transplant, but in Italy, the need for 20 min of a no-touch period after cardiac arrest for legal declaration of death poses real challenges to organ preservation. METHODS This is a single-institution, retrospective study using data collected prospectively between October and December 2017. After the approval of the multidisciplinary DCD study group of Regione Lombardia, Maastricht category III DCD donors became eligible for combined procurement of lungs and abdominal organs. Our group subsequently established a dedicated technical protocol. Our protocol consists of a non-rapid normothermic open-lung procurement process that takes place during abdominal normothermic regional perfusion, namely without pleural topical cooling before the start of pneumoplegia. After the lung is procured according to the technique described in the article, lung function is evaluated by ex vivo lung perfusion, which is run with the low-flow, open atrium, low haematocrit technique. RESULTS During the study, we managed 5 controlled DCDs. In 3 cases, the lungs were successfully transplanted. All 3 patients are alive after 1 year, with good respiratory function. CONCLUSIONS Our approach resulted in adequate lung preservation and successful transplants without detrimental effects on abdominal organ procurement, confirming the possibility of overcoming the obstacle of a long no-touch period in a DCD setting.
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Affiliation(s)
- Alessandro Palleschi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Tosi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Rosso
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Marinella Zanierato
- Department of Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Elena Benazzi
- Coordinamento trapianti North Italy Transplantation program (NITp), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Tarsia
- Department of Pathophysiology and Transplantation, Respiratory Unit and Regional Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michele Colledan
- Division of Liver and Small Bowel Transplantation, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Parent B, Caplan A, Angel L, Kon Z, Dubler N, Goldfrank L, Lindner J, Wall SP. The unique moral permissibility of uncontrolled lung donation after circulatory death. Am J Transplant 2020; 20:382-388. [PMID: 31550420 PMCID: PMC6984986 DOI: 10.1111/ajt.15603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/28/2019] [Accepted: 09/12/2019] [Indexed: 01/25/2023]
Abstract
Implementing uncontrolled donation after circulatory determination of death (uDCDD) in the United States could markedly improve supply of donor lungs for patients in need of transplants. Evidence from US pilot programs suggests families support uDCDD, but only if they are asked permission for using invasive organ preservation procedures prior to initiation. However, non-invasive strategies that confine oxygenation to lungs may be applicable to the overwhelming majority of potential uDCDD donors that have airway devices in place as part of standard resuscitation. We propose an ethical framework for lung uDCDD by: (a) initiating post mortem preservation without requiring prior permission to protect the opportunity for donation until an authorized party can be found; (b) using non-invasive strategies that confine oxygenation to lungs; and (c) maintaining strict separation between the healthcare team and the organ preservation team. Attempting uDCDD in this way has great potential to obtain more transplantable lungs while respecting donor autonomy and family wishes, securing public support, and enabling authorized persons to affirm or cease preservation decisions without requiring evidence of prior organ donation intent. It ensures prioritization of life-saving, the opportunity to allow willing donors to donate, and respect for bodily integrity while adhering to current ethical norms.
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Affiliation(s)
- Brendan Parent
- NYU Langone Health, Department of Population Health,
Division of Medical Ethics, New York, NY USA
| | - Arthur Caplan
- NYU Langone Health, Department of Population Health,
Division of Medical Ethics, New York, NY USA
| | - Luis Angel
- NYU Langone Transplant Institute, New York, NY USA
| | - Zachary Kon
- NYU Langone Transplant Institute, New York, NY USA
| | - Nancy Dubler
- NYU Langone Health, Department of Population Health,
Division of Medical Ethics, New York, NY USA
| | - Lewis Goldfrank
- NYU Langone Health, Ronald O. Perelman Department of
Emergency Medicine, New York, NY USA
| | - Jacob Lindner
- NYU Langone Health, Department of Population Health,
Division of Medical Ethics, New York, NY USA,University of Pennsylvania, History and Sociology of
Science Department, Philadelphia, PA USA
| | - Stephen P. Wall
- NYU Langone Health, Ronald O. Perelman Department of
Emergency Medicine, New York, NY USA,NYU Langone Health, Department of Population Health,
Division of Health and Behavior, New York, NY USA
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25
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Novel Organ Perfusion and Preservation Strategies in Transplantation – Where Are We Going in the United Kingdom? Transplantation 2020; 104:1813-1824. [DOI: 10.1097/tp.0000000000003106] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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26
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Donation after circulatory death in lung transplantation—five-year follow-up from ISHLT Registry. J Heart Lung Transplant 2019; 38:1235-1245. [DOI: 10.1016/j.healun.2019.09.007] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 09/08/2019] [Accepted: 09/09/2019] [Indexed: 12/12/2022] Open
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27
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Okamoto T, Niikawa H, Ayyat K, Sakanoue I, Said S, McCurry KR. Machine Perfusion of Lungs. CURRENT TRANSPLANTATION REPORTS 2019. [DOI: 10.1007/s40472-019-00258-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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28
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Impact of Cold Ischemic Time on Airway Complications After Lung Transplantation: A Single-center Cohort Study. Transplant Proc 2019; 51:2981-2985. [DOI: 10.1016/j.transproceed.2019.04.092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/13/2019] [Indexed: 11/21/2022]
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29
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Palleschi A, Rosso L, Musso V, Rimessi A, Bonitta G, Nosotti M. Lung transplantation from donation after controlled cardiocirculatory death. Systematic review and meta-analysis. Transplant Rev (Orlando) 2019; 34:100513. [PMID: 31718887 DOI: 10.1016/j.trre.2019.100513] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 09/26/2019] [Accepted: 10/04/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The interest in donation after cardiocirculatory death (DCD) donors for lung transplantation (LT) has been recently rekindled due to lung allograft shortage. Clinical outcomes following DCD have proved satisfactory. The aim of this systematic review is to provide a thorough analysis of published experience regarding outcomes of LT after controlled DCD compared with donation after brain death (DBD) donors. METHODS We performed a literature search in Cochrane Database of Systematic Reviews, PubMed and Web of Science using the items "lung transplantation" AND "donation after circulatory death" on November 1, 2018. The full text of relevant articles was evaluated by two authors independently. Quality assessment was performed using the NIH protocol for case-control and case series studies. A pooled Odds ratio (OR) and mean differences with inverse variance weighting using DerSimonian-Laird random effect models were computed to account for between-trial variance (τ2). RESULTS Of the 508 articles identified with our search, 9 regarding controlled donation after cardiac death (cDCD) were included in the systematic review, including 2973 patients (403 who received graft from DCD and 2570 who had DBD). Both 1-year survival and 2 and 3-grade primary graft dysfunction (PGD) were balanced between the two cohorts (OR = 1.00 and 1.03 respectively); OR for airway complications was 2.07 against cDCD. We also report an OR = 0.57 for chronic lung allograft dysfunction (CLAD) and an OR = 0.57 for 5-year survival against cDCD. CONCLUSIONS Our meta-analysis shows no significant difference between recipients after cDCD or DBD regarding 1-year survival, PGD and 1-year freedom from CLAD. Airway complications and long-term survival were both related with transplantation after cDCD, but these statistical associations need further research.
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Affiliation(s)
- Alessandro Palleschi
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
| | - Lorenzo Rosso
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy; Dipartimento di Scienze della Salute, Università degli studi di Milano, Milan, Italy
| | | | | | - Gianluca Bonitta
- Dipartimento di Fisiopatologia medico-chirurgica e dei Trapianti, Università degli studi di Milano, Milan, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy; Dipartimento di Fisiopatologia medico-chirurgica e dei Trapianti, Università degli studi di Milano, Milan, Italy
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30
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Factors That Complicated the Implementation of a Program of Donation After Unexpected Circulatory Death of Lungs and Kidneys. Lessons Learned From a Regional Trial in the Netherlands. Transplantation 2019; 103:e256-e262. [DOI: 10.1097/tp.0000000000002814] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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31
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Molina M, Domínguez-Gil B, Pérez-Villares JM, Andrés A. Uncontrolled donation after circulatory death: ethics of implementation. Curr Opin Organ Transplant 2019; 24:358-363. [PMID: 31090649 DOI: 10.1097/mot.0000000000000648] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Despite its potential to increase the donor pool, uncontrolled donation after circulatory death (uDCD) is available in a limited number of countries. Ethical concerns may preclude the expansion of this program. This article addresses the ethical concerns that arise in the implementation of uDCD. RECENT FINDINGS The first ethical concern is that associated with the determination of an irreversible cardiac arrest. Professionals must strictly adhere to local protocols and international standards on advanced cardiopulmonary resuscitation, independent of their participation in an uDCD program. Cardiac compression and mechanical ventilation are extended beyond futility during the transportation of potential uDCD donors to the hospital with the sole purpose of preserving organs. Importantly, potential donors remain monitored while being transferred to the hospital, which allows the identification of any return of spontaneous circulation. Moreover, this procedure allows the determination of death to be undertaken in the hospital by an independent health care provider who reassesses that no other therapeutic interventions are indicated and observes a period of the complete absence of circulation and respiration. Extracorporeal-assisted cardiopulmonary resuscitation programs can successfully coexist with uDCD programs. The use of normothermic regional perfusion with ECMO devices for the in-situ preservation of organs is considered appropriate in a setting in which the brain is subject to profound and prolonged ischemic damage. Finally, communication with relatives must be transparent and accurate, and the information should be provided respecting the time imposed by the family's needs and emotions. SUMMARY uDCD can help increase the availability of organs for transplantation while giving more patients the opportunity to donate organs after death. The procedures should be designed to confront the ethical challenges that this practice poses and respect the values of all those involved.
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Affiliation(s)
- María Molina
- Department of Nephrology, Hospital Universitario '12 de Octubre'
- Department of Nephrology, Hospital Universitario Arnau de Vilanova
- Institut de Recerca Biomèdica, Lleida
| | | | - José M Pérez-Villares
- Coordinación Sectorial de Trasplantes de Granada, Servicio de Medicina Intensiva Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Amado Andrés
- Department of Nephrology, Hospital Universitario '12 de Octubre'
- Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid
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34
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Valdivia D, Gómez de Antonio D, Hoyos L, Campo‐Cañaveral de la Cruz JL, Romero A, Varela de Ugarte A. Expanding the horizons: Uncontrolled donors after circulatory death for lung transplantation—First comparison with brain death donors. Clin Transplant 2019; 33:e13561. [DOI: 10.1111/ctr.13561] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/24/2019] [Accepted: 03/22/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Daniel Valdivia
- Department of Thoracic Surgery and Lung Transplantation Hospital Universitario Puerta de Hierro‐Majadahonda Madrid Spain
| | - David Gómez de Antonio
- Department of Thoracic Surgery and Lung Transplantation Hospital Universitario Puerta de Hierro‐Majadahonda Madrid Spain
| | - Lucas Hoyos
- Department of Thoracic Surgery and Lung Transplantation Hospital Universitario Puerta de Hierro‐Majadahonda Madrid Spain
| | | | - Alejandra Romero
- Department of Thoracic Surgery and Lung Transplantation Hospital Universitario Puerta de Hierro‐Majadahonda Madrid Spain
| | - Andrés Varela de Ugarte
- Department of Thoracic Surgery and Lung Transplantation Hospital Universitario Puerta de Hierro‐Majadahonda Madrid Spain
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35
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Possoz J, Neyrinck A, Van Raemdonck D. Ex vivo lung perfusion prior to transplantation: an overview of current clinical practice worldwide. J Thorac Dis 2019; 11:1635-1650. [PMID: 31179109 DOI: 10.21037/jtd.2019.04.33] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Lung transplantation is a lifesaving treatment in numerous forms of end-stage lung disease but organ shortage remains nowadays his biggest issue. Ex vivo lung perfusion (EVLP) has recently emerged as a solution to this problem and begins to be accepted is clinical practice. In this review, we will focus on his experience worldwide. We would like to describe the technique and the criteria used to select the donors and the transplantable lungs. We will also browse the acceptance rate described in literature as well as numerous other aspects of this new tool.
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Affiliation(s)
- Julien Possoz
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
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Suberviola B, Mons R, Ballesteros MA, Mora V, Delgado M, Naranjo S, Iturbe D, Miñambres E. Excellent long-term outcome with lungs obtained from uncontrolled donation after circulatory death. Am J Transplant 2019; 19:1195-1201. [PMID: 30582287 DOI: 10.1111/ajt.15237] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/04/2018] [Accepted: 12/08/2018] [Indexed: 01/25/2023]
Abstract
We aimed to propose a simple and effective preservation method in lungs procured for transplantation from uncontrolled donation after circulatory death (uDCD) associated with excellent long-term results. Outcome measures for lung recipients were survival and primary graft dysfunction (PGD) grade 3. Survival was estimated using the Kaplan-Meier method. A total of 9 lung uDCDs were evaluated and 8 lung transplants were performed. Mean no-flow time was 9.8 minutes (standard deviation [SD] 8.6). Mean time from cardiac arrest to topical cooling was 96.8 minutes (SD 16.8). Preservation time was 159 minutes (SD 31). Ex vivo lung perfusion was used to assess lung function prior to transplantation in 2 cases. Mean recipient age was 60.8 years (SD 3.1), and mean total ischemic time was 678 minutes (SD 132). PGD grade 3 was observed in 2 cases (25%). The 1-month, 1-year, and 5-year survival rates were 100%, 87.5%, and 87.5%, respectively. Mean follow-up was 52 months. The logistic complexity of procuring lungs from uDCDs for transplantation requires the development of new strategies designed to facilitate this type of donation. A program based on strict selection criteria, using a simple and effective preservation technique, may recover lung grafts with excellent long-term posttransplant outcomes.
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Affiliation(s)
- Borja Suberviola
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Roberto Mons
- Service of Thoracic Surgery, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Maria Angeles Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Victor Mora
- Service of Neumology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - María Delgado
- Service of Thoracic Surgery, Complexo Hospitalario Universitario A Coruña, La Coruña, Spain
| | - Sara Naranjo
- Service of Thoracic Surgery, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - David Iturbe
- Service of Neumology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain.,School of Medicine, University of Cantabria, Santander, Spain
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Past, present, and future of donation after circulatory death in Italy. Updates Surg 2019; 71:7-9. [DOI: 10.1007/s13304-019-00640-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 03/08/2019] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW Donation after circulatory death (DCD) is still performed in a limited number of countries. This article summarizes the development of DCD in Spain and presents recent Spanish contributions to gain knowledge on the potential benefits and the practical use of normothermic regional perfusion (nRP). RECENT FINDINGS DCD now contributes to 24% of deceased donors in Spain. The development of DCD has been based on an assessment of practices in the treatment of cardiac arrest and end-of-life care to accommodate the option of DCD; the creation of an adequate regulatory framework; and institutional support, professional training and public education. Appropriate posttransplant outcomes have been obtained with organs from both uncontrolled and controlled DCD donors. nRP is increasingly used, with preliminary data supporting improved results compared with other in-situ preservation/recovery approaches. Mobile teams with portable extracorporeal membrane oxygenation devices are making nRP possible in hospitals without these resources. To avoid the possibility of reestablishing brain circulation after the determination of death, a specific methodology has been validated. SUMMARY DCD has been successfully developed in Spain following a streamlined process. nRP may become a standard in DCD, although further evidence on the benefits of this technology is eagerly awaited.
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Nanni Costa A, Procaccio F. Organ donation after neurological or circulatory death? Two is better than one. Minerva Anestesiol 2018; 84:1337-1339. [DOI: 10.23736/s0375-9393.18.13111-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Schiavon M, Faggi G, Rebusso A, Lunardi F, Comacchio G, Di Gregorio G, Feltracco P, Gregori D, Calabrese F, Marulli G, Cozzi E, Federico R. Extended criteria donor lung reconditioning with the organ care system lung: a single institution experience. Transpl Int 2018; 32:131-140. [PMID: 30350894 DOI: 10.1111/tri.13365] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 08/21/2018] [Accepted: 10/15/2018] [Indexed: 01/28/2023]
Abstract
Lung transplantation is a life-saving procedure limited by donor's availability. Lung reconditioning by ex vivo lung perfusion represents a tool to expand the donor pool. In this study, we describe our experience with the OCS™ Lung to assess and recondition extended criteria lungs. From January 2014 to October 2016, of 86 on-site donors evaluated, eight lungs have been identified as potentially treatable with OCS™ Lung. We analyzed data from these donors and the recipient outcomes after transplantation. All donor lungs improved during OCS perfusion in particular regarding the PaO2 /FiO2 ratio (from 340 mmHg in donor to 537 mmHg in OCS) leading to lung transplantation in all cases. Concerning postoperative results, primary graft dysfunction score 3 at 72 h was observed in one patient, while median mechanical ventilation time, ICU, and hospital stay were 60 h, 14 and 36 days respectively. One in-hospital death was recorded (12.5%), while other two patients died during follow-up leading to 1-year survival of 62.5%. The remaining five patients are alive and in good conditions. This case series demonstrates the feasibility and value of lung reconditioning with the OCS™ Lung; a prospective trial is underway to validate its role to safely increase the number of donor lungs.
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Affiliation(s)
- Marco Schiavon
- Thoracic Surgery Division, Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Padova, Italy
| | - Giulio Faggi
- Anestesiology Division, Azienda Ospedaliera di Padova, Padova, Italy
| | - Alessandro Rebusso
- Thoracic Surgery Division, Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Padova, Italy
| | - Francesca Lunardi
- Pathology Division, Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Padova, Italy
| | - Giovanni Comacchio
- Thoracic Surgery Division, Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Padova, Italy
| | - Guido Di Gregorio
- Istituto di Anestesia e Rianimazione, Padova University Hospital, Padova, Italy
| | - Paolo Feltracco
- Istituto di Anestesia e Rianimazione, Padova University Hospital, Padova, Italy
| | - Dario Gregori
- Department of Statistics, University of Padova, Padova, Italy
| | - Fiorella Calabrese
- Pathology Division, Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Padova, Italy
| | - Giuseppe Marulli
- Thoracic Surgery Division, Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Padova, Italy
| | - Emanuele Cozzi
- Transplant Immunology Unit, Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Padova, Italy
| | - Rea Federico
- Thoracic Surgery Division, Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Padova, Italy
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41
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Abstract
Lung transplantation, heart transplantation, and heart-lung transplantation are life-saving treatment options for patients with lung and/or cardiac failure. Evolution in these therapies over the past several decades has led to better outcomes with application to more patients. The complexity and severity of illness of patients in the pretransplant phase has steadily increased, making posttransplant intensive care unit management more difficult. Despite these factors and the pervasive complications of immunosuppressive therapy, outcomes continue to improve.
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Palleschi A, Benazzi E, Rossi CF, Torelli R, Passamonti SM, Pellegrini C, Lucianetti A, Tarsia P, Meloni F, Parigi P, Nosotti M. Lung Allocation Score System: First Italian Experience. Transplant Proc 2018; 51:190-193. [PMID: 30736973 DOI: 10.1016/j.transproceed.2018.02.214] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/06/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lung transplantation is an established therapeutic option for patients with end-stage pulmonary disease. In May 2005, the lung allocation score (LAS) was introduced in the United States to maximize the benefit to the recipient population and reduce waiting list mortality. The LAS has been applied in a region of Italy since March 2016 on a provisional basis. The aims of the study were describing waiting list characteristics and short-term outcomes after lung transplantation before and after LAS introduction. METHODS All the patients who received transplants between January 1, 2011, and March 15, 2017, were included in our retrospective study. The study population was divided into 2 cohorts (historical cohort and post-LAS cohort) and a comparison among the main perioperative data was performed. RESULTS The historical cohort consisted of 415 patients on the waiting list with 91 deaths and 199 lung transplants; the post-LAS cohort consisted of 134 patients with 10 deaths on the waiting list and 51 transplants. Median waiting time and mortality on the list decreased from 223 to 106 days (P = .03) and from 11.2% to 7.5% (P > .05), respectively. The transplantation rate increased from 25% to 38% (P = .001) and the probability to receive a transplant in the first year in the post-LAS era increased significantly (P = .004). CONCLUSIONS The results of the introduction of the LAS system in our region are encouraging and have not shown any adverse short-term effects. The regional coordination decided to prolong the experimental application of LAS in order to accumulate more data and to evaluate medium-term outcomes.
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Affiliation(s)
- A Palleschi
- Thoracic Surgery and Lung Transplantation Unit, Ca' Granda Foundation Ospedale Maggiore Policlinico, Milan, Italy
| | - E Benazzi
- Nord Italia Transplant Program, Ca' Granda Foundation Ospedale Maggiore Policlinico, Milan, Italy
| | - C F Rossi
- Thoracic Surgery and Lung Transplantation Unit, Ca' Granda Foundation Ospedale Maggiore Policlinico, Milan, Italy.
| | - R Torelli
- Nord Italia Transplant Program, Ca' Granda Foundation Ospedale Maggiore Policlinico, Milan, Italy
| | - S M Passamonti
- Nord Italia Transplant Program, Ca' Granda Foundation Ospedale Maggiore Policlinico, Milan, Italy
| | - C Pellegrini
- Cardiac Surgery Department, University of Pavia, San Matteo Policlinico Hospital, Pavia, Italy
| | - A Lucianetti
- General Surgery and Abdominal Transplant Unit, "Papa Giovanni XXIII" Hospital, Bergamo, Italy
| | - P Tarsia
- Department of Pulmonology, Ca' Granda Foundation Ospedale Maggiore Policlinico, Milan, Italy
| | - F Meloni
- Department of Pulmonology, Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - P Parigi
- Department of Pulmonology, "Papa Giovanni XXIII" Hospital, Bergamo, Italy
| | - M Nosotti
- Thoracic Surgery and Lung Transplantation Unit, Ca' Granda Foundation Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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43
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Introducing the concept of semielective lung transplantation through the use of ex vivo lung perfusion. J Thorac Cardiovasc Surg 2018; 156:2350-2352. [PMID: 29961586 DOI: 10.1016/j.jtcvs.2018.05.056] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/13/2018] [Accepted: 05/16/2018] [Indexed: 12/16/2022]
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Abstract
This article summarizes recent knowledge and clinical advances in machine perfusion (MP) of thoracic organs. MP of thoracic organs has gained much attention during the last decade. Clinical studies are investigating the role of MP to preserve, resuscitate, and assess heart and lungs prior to transplantation. Currently, MP of the cardiac allograft is essential in all type DCD heart transplantation while MP of the pulmonary allograft is mandatory in uncontrolled DCD lung transplantation. MP of thoracic organs also offers an exciting platform to further investigate downregulation of the innate and adaptive immunity prior to reperfusion of the allograft in recipients. MP provides a promising technology that allows pre-transplant preservation, resuscitation, assessment, repair, and conditioning of cardiac and pulmonary allografts outside the body in a near physiologic state prior to planned transplantation. Results of ongoing clinical trials are awaited to estimate the true clinical value of this new technology in advancing the field of heart and lung transplantation by increasing the total number and the quality of available organs and by further improving recipient early and long-term outcome.
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Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, KU Leuven University, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium
| | - Steffen Rex
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
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45
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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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Venkataraman A, Blackwell JW, Funkhouser WK, Birchard KR, Beamer SE, Simmons WT, Randell SH, Egan TM. Beware Cold Agglutinins in Organ Donors! Ex Vivo Lung Perfusion From an Uncontrolled Donation After Circulatory-Determination-of-Death Donor With a Cold Agglutinin: A Case Report. Transplant Proc 2017; 49:1678-1681. [PMID: 28838463 PMCID: PMC6034983 DOI: 10.1016/j.transproceed.2017.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 04/27/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND We began to recover lungs from uncontrolled donation after circulatory determination of death to assess for transplant suitability by means of ex vivo lung perfusion (EVLP) and computerized tomographic (CT) scan. Our first case had a cold agglutinin with an interesting outcome. CASE REPORT A 60-year-old man collapsed at home and was pronounced dead by Emergency Medical Services personnel. Next-of-kin consented to lung retrieval, and the decedent was ventilated and transported. Lungs were flushed with cold Perfadex, removed, and stored cold. The lungs did not flush well. Medical history revealed a recent hemolytic anemia and a known cold agglutinin. Warm nonventilated ischemia time was 51 minutes. O2-ventilated ischemia time was 141 minutes. Total cold ischemia time was 6.5 hours. At cannulation for EVLP, established clots were retrieved from both pulmonary arteries. At initiation of EVLP with Steen solution, tiny red aggregates were observed initially. With warming, the aggregates disappeared and the perfusate became red. After 1 hour, EVLP was stopped because of florid pulmonary edema. The lungs were cooled to 20°C; tiny red aggregates formed again in the perfusate. Ex vivo CT scan showed areas of pulmonary edema and a pyramidal right middle lobe opacity. Dissection showed multiple pulmonary emboli-the likely cause of death. However, histology showed agglutinated red blood cells in the microvasculature in pre- and post-EVLP biopsies, which may have contributed to inadequate parenchymal preservation. CONCLUSIONS Organ donors with cold agglutinins may not be suitable owing to the impact of hypothermic preservation.
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Affiliation(s)
- A Venkataraman
- Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - J W Blackwell
- Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - W K Funkhouser
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - K R Birchard
- Department of Radiology, University of North Carolina, Chapel Hill, North Carolina
| | - S E Beamer
- Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - W T Simmons
- Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - S H Randell
- Department of Cell Biology and Physiology, University of North Carolina, Chapel Hill, North Carolina
| | - T M Egan
- Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, North Carolina.
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Slama A, Schillab L, Barta M, Benedek A, Mitterbauer A, Hoetzenecker K, Taghavi S, Lang G, Matilla J, Ankersmit H, Hager H, Roth G, Klepetko W, Aigner C. Standard donor lung procurement with normothermic ex vivo lung perfusion: A prospective randomized clinical trial. J Heart Lung Transplant 2017; 36:744-753. [DOI: 10.1016/j.healun.2017.02.011] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 02/11/2017] [Accepted: 02/15/2017] [Indexed: 01/26/2023] Open
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Palleschi A, Mendogni P, Tosi D, Montoli M, Carrinola R, Mariolo AV, Briganti F, Nosotti M. Lung Transplantation From Donors After Previous Cardiac Surgery: Ideal Graft in Marginal Donor? Transplant Proc 2017; 49:686-691. [PMID: 28457372 DOI: 10.1016/j.transproceed.2017.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Lung transplantation is a limited by donor pool shortage. Despite the efforts to extend the graft acceptability with recurrent donor criteria reformulations, previous cardiothoracic surgery is still considered a contraindication. A donor who underwent cardiac surgery could potentially provide an ideal lung but high intraoperative risks and intrinsic technical challenges are expected during the graft harvesting. The purpose of this study is to present our dedicated protocol and four clinical cases of successful lung procurements from donors who had a previous major cardiac surgery. One donor had ascending aortic root (AAR) substitution, another had mitral valve substitution, and two had coronary artery bypass surgery. The others' eligibility criteria for organ allocation, such as ABO compatibility, PaO2/FiO2 ratio, absence of aspiration, or sepsis were respected. In one of the cases with previous coronary bypass grafting, the donor had a veno-arterial extracorporeal membrane oxygenation support. Consequently, the grafts required an ex vivo lung perfusion evaluation. We report the technical details of procurement and postoperative courses of recipients. All procurements were uneventful, without lung damage or waste of abdominal organs related to catastrophic intraoperative events. All recipients had a successful clinical outcome. We believe that successful transplantation is achievable even in a complicated setting, such as cases involving donors with previous cardiac surgery frequently are. Facing lung donor shortage, we strongly support any effort to avoid the loss of possible acceptable lungs. In particular, previous major cardiac surgery does not strictly imply a poor quality of lungs as well as unsustainable graft procurement.
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Affiliation(s)
- A Palleschi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - P Mendogni
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - D Tosi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M Montoli
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - R Carrinola
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - A V Mariolo
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F Briganti
- Cardio-thoracic Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - M Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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49
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Blood Lactate Concentrations Before and After Withdrawal of Life-Sustaining Treatments in Controlled Donation After Circulatory Death: A Case Report From Italy. Transplant Proc 2017; 49:740-742. [DOI: 10.1016/j.transproceed.2017.02.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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50
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Charles EJ, Mehaffey JH, Sharma AK, Zhao Y, Stoler MH, Isbell JM, Lau CL, Tribble CG, Laubach VE, Kron IL. Lungs donated after circulatory death and prolonged warm ischemia are transplanted successfully after enhanced ex vivo lung perfusion using adenosine A2B receptor antagonism. J Thorac Cardiovasc Surg 2017; 154:1811-1820. [PMID: 28483262 DOI: 10.1016/j.jtcvs.2017.02.072] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 12/05/2016] [Accepted: 02/10/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The current supply of acceptable donor lungs is not sufficient for the number of patients awaiting transplantation. We hypothesized that ex vivo lung perfusion (EVLP) with targeted drug therapy would allow successful rehabilitation and transplantation of donation after circulatory death lungs exposed to 2 hours of warm ischemia. METHODS Donor porcine lungs were procured after 2 hours of warm ischemia postcardiac arrest and subjected to 4 hours of cold preservation or EVLP. ATL802, an adenosine A2B receptor antagonist, was administered to select groups. Four groups (n = 4/group) were randomized: cold preservation (Cold), cold preservation with ATL802 during reperfusion (Cold + ATL802), EVLP (EVLP), and EVLP with ATL802 during ex vivo perfusion (EVLP + ATL802). Lungs subsequently were transplanted, reperfused, and assessed by measuring dynamic lung compliance and oxygenation capacity. RESULTS EVLP + ATL802 significantly improved dynamic lung compliance compared with EVLP (25.0 ± 1.8 vs 17.0 ± 2.4 mL/cmH2O, P = .04), and compared with cold preservation (Cold: 12.2 ± 1.3, P = .004; Cold + ATL802: 10.6 ± 2.0 mL/cmH2O, P = .002). Oxygenation capacity was highest in EVLP (440.4 ± 37.0 vs Cold: 174.0 ± 61.3 mm Hg, P = .037). No differences in oxygenation or pulmonary edema were observed between EVLP and EVLP + ATL802. A significant decrease in interleukin-12 expression in tissue and bronchoalveolar lavage was identified between groups EVLP and EVLP + ATL802, along with less neutrophil infiltration. CONCLUSIONS Severely injured donation after circulatory death lungs subjected to 2 hours of warm ischemia are transplanted successfully after enhanced EVLP with targeted drug therapy. Increased use of lungs after uncontrolled donor cardiac death and prolonged warm ischemia may be possible and may improve transplant wait list times and mortality.
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Affiliation(s)
- Eric J Charles
- Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - J Hunter Mehaffey
- Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Ashish K Sharma
- Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Yunge Zhao
- Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Mark H Stoler
- Department of Pathology, University of Virginia Health System, Charlottesville, Va
| | - James M Isbell
- Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Christine L Lau
- Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Curtis G Tribble
- Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Victor E Laubach
- Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Irving L Kron
- Department of Surgery, University of Virginia Health System, Charlottesville, Va.
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