Lung transplantation using controlled donation after circulatory death donors: Trials and tribulations

Abstract

Many lung transplant programs now use organs from donors after circulatory death (DCD). However, brain dead donors far outnumber DCD donors, particularly in the United States. At 12 years after the first report of a DCD transplant by Love et al, the numbers of DCD transplants in the United States remained dismal at a utilization rate of 1.9%. To obtain more information related to the infrequent use of DCD lungs, the International Society for Heart and Lung Transplantation (ISHLT) DCD working group performed a survey in 2014. The group sent separate questionnaires to active and non-active DCD centers. Of the 62 centers that responded to the survey, 50% of them had active DCD programs. Of the non-active DCD centers, 82% expressed interest in initiating a DCD program. Centers with and centers without DCD programs had similar perceptions of outcomes of DCD lung transplantation. About 80% of all respondents believed that lung transplant outcomes for recipients of DCD and brain dead donors have similar results. Regarding the primary reason for not using DCD donors, 85% of respondents stated that the main barriers consisted of complex logistics and absence of protocols related to DCD. Some centers also expressed concerns about starting a DCD program without having ex vivo lung perfusion technology (EVLP) in place. The medical literature contains detailed protocols that lead to successful DCD recovery with and without EVLP. DCD recovery requires a trained team of surgeons for the lung retrieval; however, some transplant teams overstate the complexity of the procedure. Once mechanical ventilation is restored after asystole and death declaration, flushing and preservation of the lungs occurs in a similar fashion as for DBD donation. The exact role of EVLP in category 3 DCD has not been established. Excellent results have been obtained without the routine use of EVLP. In contrast, EVLP may help to exclude lungs with injuries that have not been recognized after withdrawal of life support therapies (i.e., aspiration) and may help to expand more safely the utilization criteria for DCDs, including the acceptance of longer agonal times. Logistical issues, such as absence of protocols and insufficient numbers of trained personnel, create the primary obstacles to initiating and maintaining a successful DCD program. Because 30% to 40% of potential DCD donors do not go into cardiac arrest in a suitable time frame (60–90 minutes) for donor lung recovery, economic constraints also affect the willingness of transplant programs to use DCD. Transplant centers would be hesitant to send a team to a donor site if significant travel and operating room costs would be incurred if the lungs will not be evaluated because of absence of donor cardiac arrest in a suitable time. Better predictive tools for probability of cardiac arrest, collaboration with retrieval teams at donor sites, and creative ideas of lung preservation after cardiac arrest so that transplant teams may not need to be on standby before death is declared may overcome these limitations. Key priorities for successful use of DCD in lung transplantation in the near future should consist of knowledge transfer, education, and overcoming logistical barriers.