Lung Donation and Transplantation Following Thoraco-Abdominal Normothermic Regional Perfusion: A Case Series

Abstract

Purpose Donation after circulatory death (DCD) has successfully expanded the donor pool for lung transplantation (LTx). Recently, thoraco-abdominal normothermic regional perfusion (TA-NRP) for post-mortem organ resuscitation prior to preservation has emerged, although the effects of this technique on pulmonary grafts have not been elucidated. Any new technique should not compromise the success of DCD LTx since lungs are very resistant towards warm ischemia. We evaluated the TA-NRP technique as well as the short-term LTx outcome of TA-NRP pulmonary grafts. Methods From January 2020 to July 2021, five TA-NRP procedures were performed at our center, resulting in procurement of two pulmonary grafts for LTx. Three grafts were refused due to medical reasons. Results Donors were a 60-year-old male (asphyxia) and 52-year-old female (cerebral ischemia). After cardiac arrest, 5-minute no-touch, and declaration of death, the femoral artery and vein were cannulated, the supra-aortic vessels were clamped (case 1) and drained (case 2), and TA-NRP was initiated. Total warm ischemic time was 21 and 35 minutes (min), respectively. Ventilation was started immediately after onset of TA-NRP. Time between start of TA-NRP and pulmonary flush was 134 and 107 min, respectively, including 106 min TA-NRP in both donors. The recipients were a 60- and 64-year-old male with emphysema and pulmonary fibrosis. Following cold storage [case 1: 333 min (right) and 503 min (left), case 2: 275 min (right) and 511 min (left)], both were successfully transplanted. Primary graft dysfunction scores at 24h/48h/72h were 1/3/2 and 0/0/2, respectively. Intensive care unit/hospital stay were 46/86 (case 1) and 10/26 days (case 2). The first recipient died 16 months post-LTx from septic fungal spondylodiscitis, the second patient is alive and in good condition at 4 months post-LTx. Conclusion TA-NRP does not negatively affect the quality of pulmonary grafts and seems to be a feasible technique to procure lungs after circulatory death, enabling in-situ evaluation of the graft. However, larger series and long-term outcomes are awaited to explore if TA-NRP can be used to improve DCD LTx. Donation after circulatory death (DCD) has successfully expanded the donor pool for lung transplantation (LTx). Recently, thoraco-abdominal normothermic regional perfusion (TA-NRP) for post-mortem organ resuscitation prior to preservation has emerged, although the effects of this technique on pulmonary grafts have not been elucidated. Any new technique should not compromise the success of DCD LTx since lungs are very resistant towards warm ischemia. We evaluated the TA-NRP technique as well as the short-term LTx outcome of TA-NRP pulmonary grafts. From January 2020 to July 2021, five TA-NRP procedures were performed at our center, resulting in procurement of two pulmonary grafts for LTx. Three grafts were refused due to medical reasons. Donors were a 60-year-old male (asphyxia) and 52-year-old female (cerebral ischemia). After cardiac arrest, 5-minute no-touch, and declaration of death, the femoral artery and vein were cannulated, the supra-aortic vessels were clamped (case 1) and drained (case 2), and TA-NRP was initiated. Total warm ischemic time was 21 and 35 minutes (min), respectively. Ventilation was started immediately after onset of TA-NRP. Time between start of TA-NRP and pulmonary flush was 134 and 107 min, respectively, including 106 min TA-NRP in both donors. The recipients were a 60- and 64-year-old male with emphysema and pulmonary fibrosis. Following cold storage [case 1: 333 min (right) and 503 min (left), case 2: 275 min (right) and 511 min (left)], both were successfully transplanted. Primary graft dysfunction scores at 24h/48h/72h were 1/3/2 and 0/0/2, respectively. Intensive care unit/hospital stay were 46/86 (case 1) and 10/26 days (case 2). The first recipient died 16 months post-LTx from septic fungal spondylodiscitis, the second patient is alive and in good condition at 4 months post-LTx. TA-NRP does not negatively affect the quality of pulmonary grafts and seems to be a feasible technique to procure lungs after circulatory death, enabling in-situ evaluation of the graft. However, larger series and long-term outcomes are awaited to explore if TA-NRP can be used to improve DCD LTx.