Direct Procurement of Thoracic Organs Along with Abdominal Normothermic Regional Perfusion in Donation After Circulatory Death

Abstract

<h3>Purpose</h3> Direct procurement of thoracic organs as compared to using abdominal normothermic regional perfusion (aNRP) is the preferred method for thoracic organ procurement in donors after circulatory death (DCD). The use of aNRP improves outcomes from liver transplantation. We have developed a technique for thoracic organ isolation during aNRP that allows successful co-procurement of thoracic and abdominal organs. <h3>Methods</h3> In order to achieve successful thoracic isolation both the brain perfusion and volume loss must be prevented. After certification of circulatory death and a standoff period the thoraco-abdominal incision is performed. Blood is collected from the donor right atrium or a side-arm of the aNRP circuit to prime the organ care system (OCS) before isolation of vascular structures in a systematic way. 1. The left pleura is opened, and the lung retracted to allow identification and clamping of the descending thoracic aorta above the diaphragm. 2. The ascending aorta is clamped, and the aortic arch vented cranial to the clamp. Abdominal NRP can then commence. 3. The inferior vena-cava is clamped within the pericardium. 4. The superior vena-cava and azygos vein are tied off. 5. The heart is vented on the left and right side before induction of cardioplegia. The diagram illustrates complete vascular isolation of the thoracic cavity enabling explantation of the heart and lung after delivery of selective antegrade pneumoplegia while abdominal organs continue to be perfused for 2-hours before the start of abdominal procurement. <h3>Results</h3> Between 2019-21 we successfully performed seven such procurements. Three heart and lungs, three lungs and one heart procurement alone. All organs were successfully implanted with successful immediate outcome in all thoracic and abdominal recipients. <h3>Conclusion</h3> Direct procurement of thoracic organs is a feasible option during aNRP. This will potentially expand the thoracic organ donor pool and improve outcome of liver transplantation.