Australia’s Experience with Ex-Vivo Lung Perfusion of Highly Marginal Donors

Abstract

Purpose From 1996-2010 at our institution, 6% of all lung donors were deemed highly marginal (≥2 risk factors) and associated with an odds ratio of 10.3 for death at 3 months post lung transplant (LT). Preliminary data suggests the clinical outcome of ex-vivo lung perfusion (EVLP) of marginal donors is at least equivalent to standard donation, although experience with highly marginal donors is limited. Aim To report clinical results of EVLP utilising highly marginal donors, compared to standard donation. Methods and Materials Prospective analysis of EVLP cases from October 2011 at The Prince Charles Hospital, Brisbane with lungs deemed unsuitable for LT despite donor optimisation. Key indications for EVLP included poor gas exchange, abnormal chest radiograph, donor age >45 years with ischaemic time >6 hours, PEEP dependency, >20 pack years smoking and patients living in remote areas. Technique utilised the Vivoline system with 2 litres of Steen solution and 2 units packed red blood cells. Results From October 2011, 29 LT were performed from 74 solid organ donors (procurement rate 39.2%), including 4 EVLP lung transplants and 25 standard donation. Indications for EVLP included poor oxygenation (n=3), high PEEP (n=2), ischaemic time (n=2), CXR abnormality (n=4), remote patient (n=1) and donor smoking (n=4). For EVLP lungs, mean blood gas in donor was 189 + 96mmHg (range 122-331), best EVLP gas 458 + 37 (425-510) and mean reconditioning and evaluation time 140 + 32 minutes (108-179). Actuarial 1 year survival is 100% for EVLP, none have airway complications or graft dysfunction at mean follow up 5.5 months. No patients in the EVLP group developed PGD grade 3 compared to 3 in the standard group. There was no difference between the groups in time to extubation, length of ICU or hospital stay and incidence of acute rejection. 1 lung referred for EVLP was deemed unsuitable despite 4 hours of reconditioning due to persistent oedema and pulmonary infarction. Conclusions Our preliminary experience with donors with at least 2 marginal risk factors is highly encouraging utilising EVLP.