Lung Procurement Research Articles

Donation After Cardiac Death, a Possibility to Expand the Donor Pool: Review and the Hungarian Experience

IntroductionLung transplantation is the only successful treatment option for patients experiencing end-stage lung disease. Results have improved significantly in the last decade; however, the number one limiting factor is still the shortage of donor lungs. Due to the discrepancy between available donor lungs and patients awaiting lung transplantation, many centers have reintroduced donation after cardiac death (DCD). According to their results, DCD and donation after brain death (DBD) are comparable in terms of survival and graft function.Currently in Hungary, donation is only allowed from DBD donors; however, due to the Eurotransplant agreement, non-heart-beating donation (NHBD) organs can be transplanted into Hungarian patients, and in some cases Hungarian transplant teams can also take part in NHBDs within the Eurotransplant region.The Hungarian experience. A Hungarian patient received a lung from a 15-year-old uncontrolled DCD in Vienna. The donor was reanimated for 54 minutes and after lung procurement the lungs were put on ex vivo lung perfusion and later successfully implanted into the Hungarian recipient. The recovery was very successful and the patient is still alive.The Hungarian Lung Transplantation Team was involved in a controlled Maastricht III donation in 2017. A 49-year-old female donor was reported from Ghent, Belgium. A multiorgan donation was carried out with 15 minutes of warm ischemic time in the case of the lungs. ConclusionDCD is an effective, safe, and available method to increase the donor pool. In the case of controlled donations, the necessary protocols have already been prepared. Although DBD is working very successfully in Hungary, infrastructural developments, education of professionals, and social preparations are all needed to implement a DCD protocol in Hungary.

First 3 Years of the Hungarian Lung Transplantation Program

In this article we summarize the results of the first 3 years after launching the Hungarian Lung Transplantation Program. Patients and MethodsThe first lung transplant in Hungary was carried out on December 12, 2015, with the collaboration of the National Institute of Oncology and the Semmelweis University. Up to December 31, 2018, a total of 62 lung transplants were performed. Data were analyzed retrospectively. Patients were listed for lung transplant after the indication was established by the National Lung Transplantation Committee. Donor lungs were procured from brain-dead donors only. ResultsWithin this period our team was involved in 87 lung procurements, 61 of which resulted in bilateral lung transplant and 1 in single-sided transplant. The operative approach was unilateral thoracotomy (n = 1), bilateral thoracotomy (n = 1), or clamshell incision (n = 60) with venoarterial extracorporeal membrane oxygenation support. The underlying disease of the recipients was obstructive lung disease (n = 30), lung fibrosis (n = 11), cystic fibrosis (n = 18), primary pulmonary hypertension (n = 2), histiocytosis-X syndrome (n = 1), bronchiectasis (n = 2), lymphangioleiomyomatosis (n = 1), and retransplant because of bronchiolitis obliterans syndrome (n = 1). The youngest patient was 13 years of age, while the oldest was 65 years. Three patients died in the early postoperative phase. One-year survival was 80%. DiscussionThe number of cases rises steadily in the Hungarian Lung Transplantation Program, which is exceptional compared with the start of other centrums. The incidence of complications and mortality is comparable with those of other experienced centers around the world. Our future goal is to broaden our waiting list, thus increasing the number of lung transplants carried out.

Effect of Lung Protective Ventilation in Organ Donors on Lung Procurement and Recipient Survival: Results from a Nationwide Cohort Study

Purpose Previous studies have shown that lung protective strategy in selected potential organ donors after brain death (DBD) increased lung eligibility and procurement. This prospective nationwide cohort study aimed to evaluate the impact of lung protective ventilation (PV) in nonselected DBD upon lung procurement and recipient survival. Methods All reported DBD aged 18-70 years without lung recovery contraindication and with at least one organ recovered between January 2016 and December 2017 were included. Donor characteristics and management were collected at several times until decision on lung offer to transplant teams (t2). PV was defined as tidal volume ≤8 ml/kg of predicted body weight and PEEP≥ 8 cm H2O. The association between PV and lung procurement was determined with multivariable logistic regression stratified by propensity score quintile to account for PV and non PV group differences in baseline characteristics. Survival rates were estimated using Kaplan-Meier method and compared using log-rank test. Results Of the 1,626 included lung donors, 1,109 (68%) had at least one lung offered among whom 678 (61%) had at least one lung recovered. Among donors with lung offered, factors associated with reduced lung procurement were female gender (OR:0.63; 95%CI: 0.43-0.92, p=0.02), age (OR:0.97; 95%CI: 0.96-0.98, p 3 days (OR:0.51 95%CI: 0.38-0.69, p Conclusion The use of lung protective ventilation in nonselected DBD increased probability of lung procurement by 43%. Intermediate analysis suggests that 1-year survival did not differ between recipients of lungs from donors with or without PV.

Donor Lung Weight at Lung Procurement; Predictive Value for Transplant Suitability during Ex Vivo Lung Perfusion

Purpose Currently, pulmonary edema in donor lungs is evaluated via surgical inspection and palpation at procurement with no quantitative, standard diagnostic tool in use. The purpose of this study was to investigate the significance of lung weight at the donor hospital (LW0) as an indicator of pulmonary edema and predictor of transplant suitability in ex vivo lung perfusion (EVLP). Methods LW0 was recorded in standard donors (n = 53) and rejected donors (n = 69). Twenty-one rejected lungs were perfused in cellular EVLP and transplant suitability evaluated at 2 hours. Results There was a significant difference in LW0 between standard and rejected donors (814.7 ± 185.9 vs. 956.1 ± 275.1 g, p Conclusion Our findings demonstrate that donor lung weight could be a predictor of P/F ratio and transplant suitability during EVLP. The prospect for recovery of EVLP treated rejected donor lungs improved significantly if they weighed less than 1280 g.

One-Year Outcome after Lung Transplantation from Controllo DCD with Long WIT. Initial Experience

Purpose Although the lung tolerance to prolonged ischemia is theoretically widely accepted in donation after cardiac death (DCD) setting, most of the centres have strict criteria for warm ischemia time (WIT). We present the 1-year follow up of first 3 lung transplants (LuTx) from controlled DCD donors after extended WIT. Methods We established a dedicated technical protocol, consisting of a non-rapid normothermic open-lung procurement during abdominal normothermic regional perfusion (NRP) without pleural cooling before the pneumoplegia. After treatments withdrawal, asystole onset, death is declared (20-min of flat ECG). NRP is established percutaneously with the aortic balloon, respiratory setting provided cycles of recruitment manoeuvres and protective ventilation. During the lung procurement, we performed two NRP tests in order to decide the definitive retrieval. After lung block stored on ice, chest haemostasis ensured. NRP is continued until necessary for abdominal organs. The lungs are evaluated by ex vivo lung perfusion (EVLP). Results Table 1 shows recipients characteristics, details of procurement, EVLP run, transplantation and clinical outcome. Notably, in Case 1, treatments withdrawal did not include extubation. Due to detection of thrombi during retrograde perfusion, urokinase was added to the solution in Case 1 and we proceeded to atypical resection of parenchymal infarction of right lower lobe. For sizing mismatch, right upper lobectomy was carried out in Case 2. The recipients were females, median age 42 years; 2 patients had cystic fibrosis, 1 usual interstitial pneumonia. In all cases, we performed a bilateral transplantation. All 3 patients are alive, with good respiratory function. Patient 1 experienced an episode of acute rejection 6 weeks after transplantation. Conclusion Our initial experience resulted in successful LuTx without detrimental effects on abdominal organs procurement. Promising results confirm the possibility of overcoming the obstacle of a long WIT.

“Non-Touch” Vena Cava Technique as an Improvement in Combined Lung and Liver Procurement in Controlled Donation After Circulatory Death

The number of organs retrieved from donation after circulatory death (DCD) donors has continued to rise in recent years. The functional superiority of DCD organs is achieved when the lungs are perfused with cold perfusion and livers with normothermic regional perfusion (NRP). Thus, a precise surgical technique is required to combine thoracic and abdominal organ procurement.The technique used at our center consists of a rapid laparotomy and middle sternotomy, then the abdominal aorta (Ao) and abdominal inferior vena cava (VC) are cannulated and the descending thoracic Ao is cross-clamped. NRP is started at that point. As a variation of previously described techniques, the thoracic vena cava is not initially clamped in order to improve the return of blood volume to the NRP circuit. The pulmonary artery is cannulated to flush the lungs and the left atrial appendage is opened for drainage. After 120 minutes, NRP perfusion is stopped and the organs are flushed with cold preservation solution.In 2016, 3 livers and 6 lungs were harvested at our center using the technique described. After a minimum follow-up of 1 year, no evidence of biliary complications was observed.The combined procurement of lungs after room temperature perfusion and liver after NRP without initial clamping of the thoracic VC is feasible, with excellent function post-transplantation.

Direct Peritoneal Resuscitation Alters Leukocyte Infiltration in the Lung After Acute Brain Death.

Brain death is associated with significant lung injury and inflammation. This has been associated with worse long-term outcomes for transplanted lungs. Direct peritoneal resuscitation (DPR) reduces systemic inflammation in brain death and improves lung procurement rate. The effect of DPR on macrophage and neutrophil infiltration in the lungs is not known. Male Sprague-Dawley rats had a 4F Fogarty catheter inserted into the skull and the balloon inflated until brain death was achieved. Rats were resuscitated with normal saline to maintain a mean arterial pressure of 80 mmHg (targeted intravenous fluid, TIVF) and DPR animals received an intraperitoneal injection of commercial peritoneal dialysis solution. Rats were sacrificed at 0, 2, 4, and 6 h after brain death. Protein levels were assessed using quantitative ELISA. Leukocytes were quantified using flow cytometry and immunohistochemistry. At all time points, DPR downregulated multiple inflammatory cytokines including IFN-γ, TNF-α, IL-1α, and IL-6. Adhesion molecules ICAM, E-selectin, and P-selectin were increased above sham at 4 and 6 h after brain death and reduced with DPR, whereas VCAM was reduced at 2 and 6 h. Infiltration of macrophages and neutrophils were trended downward at 6 h with DPR, though this difference was not statistically significant. Animals that received TIVF alone had significant increases in inflammatory cytokines within the lung tissue, leading to adhesion molecule expression and ultimately leukocyte infiltration. Each stage of inflammation was affected by DPR. Using DPR in brain dead organ donors shows promise as a way to reduce lung injury and inflammation.

Progress in Xenogeneic Lung Transplantation Using Multi-Transgenic Donor Pigs and Targeted Supportive Drug Treatments

Purpose Significant progress in genetic engineering has enabled the generation of knock-out pigs that additionally express multiple human “transgenes” chosen to address various known xenogeneic rejection pathways. We evaluated which transgene combinations are associated with prevention of lung xenograft injury in a rigorous life-supporting pig-to-baboon lung xenograft model. Methods GTKO.hCD46 porcine donor organs with up to 4 additional genetic modifications, including hCD55, hTBM, hEPCR, hTFPI, hCD47, hCD39, hHO-1, HLA-E, A20 and humanized vWF were used in 48 left single lung transplants into baboons. A rationally designed “platform drug regimen” consisted of steroids, sC1Inh, thromboxane synthase inhibitor, histamine receptor blockers, and anti-GPIb Fab. Desmopressin (DDAVP) was given to the donor animals prior to lung procurement, to deplete pig endothelial VWF. Immunosuppression consisted of aCD20, ATG, MMF, aCD40, coupled with anti-IL6R moAb and/or Alpha-1 Antitrypsin. Xenograft function was assessed intermittently by transplant blood flow measurements and radiographs. Results Xenogeneic lungs with 6 genetic modifications (6-GE) transplanted into baboons survived for up to 8d (hCD55.hEPCR.hTBM.hCD39) and 9d (hEPCR.hTBM.hCD47.HO-1), vs <12hrs for most 3- or 4-GE lungs. Several other donor transgene-combinations resulted in 47d survival. Lungs of GTKO.hCD46.hCD55.hEPCR.hCD47.hTFPI and a few 3- or 4-GE phenotypes (eg including HLA-E and hvWF) consistently exhibited life-supporting (LS) lung function for 24-30h, with relatively normal macro- and microscopic lung appearance until 2-3 d. Lung xenograft failure was usually associated with rebounding anti-pig antibody titer and loss of lung vascular barrier function leading to alveolar flooding and consolidation, consistent with “delayed xenograft rejection”. Accumulated evidence suggests that, in addition to anti-non-Gal antibody, recipient NK cells (HLA-E) and donor macrophage activation (thromboxane) each play important roles to drive the residual inflammation. Conclusion Combining multi-transgenic donor organs with mechanism-directed drug treatments significantly prolongs life-supportive lung xenograft function and recipient survival. Aggregation of existing targeted genetic modifications, along with antibody depletion and mechanism-based drug additions appear likely to successfully control known pathogenic pathways, and further advance lung xenotransplantation towards clinical application. United Therapeutics SRA. NIH U19A1090959.

Analysis of the Lung Donors in the Chinese Mainland

Background The report of Chinese lung donor in the new era (Criminals’ organ donations after their death has been forbidden officially since January 1, 2015). This a study to summarize the assessment, maintenance and procurement of donors’ lungs in 2017. Methods: From February 27, 2017 to December 4, 2017, a total of 107 donors were evaluated by the lung transplantation center of China-Japan Friendship Hospital. They were allocated to our hospital by the National Network for Organ Sharing. According to the geographic regional principle, the percentage of donors from Beijing, Tianjin relatively high. This paper intends to report the present situation of lung donation in China by analyzing various factors, including donors’ region, gender, ages, smoking history, reasons of brain death, ventilation time, pulmonary infection level, liquid management strategy, the ratio of final procurement, the reasons of abandonment, then a cross-sectional study was carried out by statistical analysis. Results: The data were analyzed by using SPSS 19.0 of the 107 donors, 92 were men, accounting for 85.98%, and 15 were women, 14.02%. The distribution of donor region is crossing the whole country. Beijing has the most donations and Tianjin is the second, the details are as follows: Beijing (70 cases, 65.42%), Tianjin (13 cases, 12.15%), Shandong province (7 cases, 6.54%), Guangdong province (6 cases, 5.61%), Zhejiang province (2 cases,1.87%). As for the blood type, type A Rh (+) is 20.56%, type B Rh (+) is 35.51%, type O Rh (+) 37.38%, type AB Rh (+) 6.54%. Ages range from 14 to 66 years old; the mean age is (35.97 ± 11.413) years old. Among them, age 40-49 is the most distribution (38 cases, 35.51%). The ventilation time is (7.64 ± 18.36) days. The group of age 20-29 have the longest ventilation time (16.59 ± 40.76) days. Brain vessel hemorrhage is the most important cause of brain death, accounting for 57.01%(61 cases, followed by brain injury (32 cases, 29.90%), cerebral infarction (5 cases, 4.67%), brain tumor (4 cases, 3.74%). Of the 107 donors, 76 were eventually procured. The proportion of organ procurement is 71.03%. The main causes of abandonment are lung infection (58.06%) and pulmonary edema (32.26%), or both (9.68%). The smoking rate of all donors is 28.97%, the smoking rate of the abandoned donors is 32.25%. The smoking index was not significantly related with P/F (R=0.31, p>0.05). Positive balance intravenous liquid group and the negative balance group have not statistically significant difference. Independent sample t test (F=0.054, P=0.270). Conclusion Our lung transplantation center is on the right track in the Chinese New Era and can be introduced to the international associations. Maintenance of donor’s lung strategy in ICU needs to be strengthened to improve the percentage of lung procurement.

Cardiac and pulmonary donor procurement.

Within the United States, donor heart and lung procurement varies between institutions and among surgeons within the same institution sometimes. The purpose of this article is to review the history of donor heart and lung procurement, the surgical techniques, and pitfalls. The current article covers the important intraoperative evaluation of the donor heart and lungs at the procurement hospital and the surgical pitfalls that can be prevented to ensure good procurement of donor heart and lungs. The current article provides a review of the history of donor procurement. The article will also provide recommendations for surgical techniques and to prevent possible complications of donor procurement at the time of surgery.

Donor pretreatment with nebulized complement C3a receptor antagonist mitigates brain-death induced immunological injury post-lung transplant.

Donor brain death (BD) is an inherent part of lung transplantation (LTx) and a key contributor to ischemia-reperfusion injury (IRI). Complement activation occurs as a consequence of BD in other solid organ Tx and exacerbates IRI, but the role of complement in LTx has not been investigated. Here, we investigate the utility of delivering nebulized C3a receptor antagonist (C3aRA) pretransplant to BD donor lungs in order to reduce post-LTx IRI. BD was induced in Balb/c donors, and lungs nebulized with C3aRA or vehicle 30minutes prior to lung procurement. Lungs were then cold stored for 18hours before transplantation into C57Bl/6 recipients. Donor lungs from living donors (LD) were removed and similarly stored. At 6hours and 5days post-LTx, recipients of BD donor lungs had exacerbated IRI and acute rejection (AR), respectively, compared to recipients receiving LD lungs, as determined by increased histopathological injury, immune cells, and cytokine levels. A single pretransplant nebulized dose of C3aRA to the donor significantly reduced IRI as compared to vehicle-treated BD donors, and returned IRI and AR grades to that seen following LD LTx. These data demonstrate a role for complement inhibition in the amelioration of IRI post-LTx in the context of donor BD.

Effect of Lung Protective Ventilation on Lung Procurement in a Real-life Setting

Effect of Lung Protective Ventilation on Lung Procurement in a Real-life Setting

Lung Focused Resuscitation at a Specialized Donor Care Facility Improves Lung Procurement Rates

Lung procurement for transplantation occurs in approximately 20% of brain dead donors and is a major impediment to wider application of lung transplantation. We investigated the effect of lung protective management at a specialized donor care facility on lung procurement rates from brain dead donors. Our local organ procurement organization instituted a protocol of lung protective management at a freestanding specialized donor care facility in 2008. Brain dead donors from 2001 to 2007 (early period) were compared with those from 2009 to 2016 (current period) for lung procurement rates and other solid-organ procurement rates using a prospectively maintained database. An overall increase occurred in the number of brain dead donors during the study period (early group, 791; late group, 1,333; p < 0.0001). The lung procurement rate (lung donors/all brain dead donors) improved markedly after the introduction of lung protective management (early group, 157 of 791 [19.8%]; current group, 452 of 1,333 [33.9%]; p < 0.0001). The overall organ procurement rate (total number of organs procured/donor) also increased during the study period (early group, 3.5 organs/donor; current group, 3.8 organs/donor; p= 0.006). Lung protective management in brain dead donors at a specialized donor care facility is associated with higher lung utilization rates compared with conventional management. This strategy does not adversely affect the utilization of other organs in a multiorgan donor.

Pharmacologic Protection of Mitochondrial DNA Integrity May Afford a New Strategy for Suppressing Lung Ischemia-Reperfusion Injury.

Lung ischemia-reperfusion (IR) injury contributes to post-transplant complications, including primary graft dysfunction. Decades of reports show that reactive oxygen species generated during lung IR contribute to pulmonary vascular endothelial barrier disruption and edema formation, but the specific target molecule(s) that "sense" injury-inducing oxidant stress to activate signaling pathways culminating in pathophysiologic changes have not been established. This review discusses evidence that mitochondrial DNA (mtDNA) may serve as a molecular sentinel wherein oxidative mtDNA damage functions as an upstream trigger for lung IR injury. First, the mitochondrial genome is considerably more sensitive than nuclear DNA to oxidant stress. Multiple studies suggest that oxidative mtDNA damage could be transduced to physiologic dysfunction by pathways that are either a direct consequence of mtDNA damage per se or involve formation of proinflammatory mtDNA damage-associated molecular patterns. Second, transgenic animals or cells overexpressing components of the base excision DNA repair pathway in mitochondria are resistant to oxidant stress-mediated pathophysiologic effects. Finally, published and preliminary studies show that pharmacologic enhancement of mtDNA repair or mtDNA damage-associated molecular pattern degradation suppresses reactive oxygen species-induced or IR injury in multiple organs, including preclinical models of lung procurement for transplant. Collectively, these findings point to the interesting prospect that pharmacologic enhancement of DNA repair during procurement or ex vivo lung perfusion may increase the availability of lungs for transplant and reduce the IR injury contributing to primary graft dysfunction.

Lung Transplantation From Donors After Previous Cardiac Surgery: Ideal Graft in Marginal Donor?

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.

Standard donor lung procurement with normothermic ex vivo lung perfusion: A prospective randomized clinical trial

Ex vivo lung perfusion (EVLP) was primarily developed for evaluation of impaired donor lungs. The good clinical results raise the question for its possible impact on lungs meeting standard criteria. Before application of EVLP on such lungs enters routine clinical practice, it must be demonstrated whether EVLP would affect or improve outcome when used in standard donor lungs. We performed a prospective randomized trial to investigate the role of EVLP in standard lung transplantation (Tx). This prospective randomized clinical trial compared patients who underwent Tx with ex vivo evaluated donor lungs with an equivalent patient population without previous EVLP. From October 2013 to May 2015, 193 lung Tx were performed at the Medical University of Vienna. During this period, 80 recipient/donor pairs that met the inclusion criteria were included in this trial, 41 pairs in the control group, and 39 in the EVLP group. In the EVLP group, 4 lungs (10.2%) ultimately did not qualify for Tx and were rejected for lung Tx owing to technical reasons (n = 2) and quality criteria (n = 2). Donor and recipient characteristics were comparable in both groups. Total cold ischemic time in the EVLP group was significantly longer for both implanted lungs (first side, 372 minutes vs 291 minutes, p < 0.001; second side, 437 minutes vs 370 minutes, p = 0.001); median duration of surgery showed no differences (277 minutes vs 275 minutes). Median oxygen partial pressure/fraction of inspired oxygen ratio at 24 hours after Tx was 516 (range, 280-557) in the EVLP group and 491 (range, 352-575) in the control group (p = 0.63). Incidence of primary graft dysfunction >1 was lower in the EVLP group at all time points compared with the control group (24 hours, 5.7% vs 19.5%, p = 0.10), and need for post-operative prolonged extracorporeal membrane oxygenation was lower in the EVLP group (5.7% vs 12.2%, p = 0.44). Short-term clinical outcomes did not differ between recipients in the 2 groups. Patients remained intubated (1.6 days vs 1.6 days, p = 0.67), in the intensive care unit (6 days vs 6 days, p = 0.76), and in the hospital (23 days vs 19 days, p = 0.42) for a comparable period of time. The 30-day survival was 97.1% vs 100% (p = 0.46). This study provides evidence that EVLP can safely be used in standard donor lungs. Functional results and perioperative outcome are comparable to those achieved with standard donor lung preservation techniques. As an evaluation tool, EVLP allows clinicians to identify and to possibly exclude lungs with functional impairment. Finally, EVLP can safely extend total preservation time.

Process Improvement in Thoracic Donor Organ Procurement: Implementation of a Donor Assessment Checklist

Donor organs are often procured by junior staff in stressful, unfamiliar environments where a single adverse event can be catastrophic. A formalized checklist focused on preprocedural processes related to thoracic donor organ procurement could improve detection and prevention of near miss events. A checklist was developed centered on patient identifiers, organ compatibility and quality, and team readiness. It went through five cycles of feedback and revision using a panel of expert procurement surgeons. Educational in-service sessions were held on the use of the checklist as well as best organ assessment practices. Near miss events before the survey were tallied by retrospective review of 20 procurements, and near misses after checklist implementation were prospectively recorded. We implemented the checklist for 40 donor lung and heart procurements: 20 from Cleveland Clinic and 20 from the University of Minnesota. A final survey assessment was used to determine ease of use. Nine near miss events were reported in 20 procurements before use of the checklist. Thirty-one near miss events of 40 organ procurements were identified and potentially prevented by the checklist. Eighty-seven percent of fellows found the checklist to be unobtrusive to work flow, and 100% believed its use should be mandatory. Mortality was the same before and after implementation of the checklist despite increased patient volumes. Implementation of a simple checklist for use during thoracic organ procurement uncovered a substantial number of near miss events. A preprocedural checklist for all thoracic organ transplants in the United States and abroad is feasible and would likely reduce adverse events.

Does Lung Donation by Heart Donors Have an Impact on Survival in Heart Transplant Recipients?

Lung procurement is increasing during multiorgan recovery and substantially alters the explant process. This study evaluated whether lung donation by a heart donor affects survival in heart transplant recipients. Retrospective analysis of United Network for Organ Sharing (UNOS) adult heart transplantation data from 1998 to 2012 was performed. Lung donors (LDs) were defined as those having at least one lung procured and transplanted. Non-LDs had neither lung transplanted. Heart transplant recipients who had previous transplants, who had heterotopic transplants, who were waitlisted for other organs or who were temporarily delisted were excluded from the analysis. Kaplan-Meier survival analysis and Cox proportional hazards regression were performed. Of 23 590 heart transplant recipients meeting criteria during the study period, 8638 (36.6%) transplants were from LDs. Donors in the LD group had less history of cigarette use (15.5% vs. 29.5%, p < 0.001). On univariate analysis, LDs were associated with improved patient survival (p < 0.001). On multivariate analysis, LDs were not significantly associated with patient survival (adjusted hazard ratio 0.98, 95% confidence interval 0.94-1.03). Analysis of the UNOS registry suggested that donor pulmonary status and lung procurement had no detrimental effect on survival in heart transplant recipients, supporting the present practice of using donor lungs whenever possible.

Pulmonary artery patch for an inadequate donor atrial cuff in the absence of donor pericardium in lung transplantation.

In cadaveric lung transplantation (LTx), a donor lung with an inadequate donor left atrial cuff is considered a "surgically marginal donor lung". The donor pericardium is commonly applied to reconstruct the inadequate donor left atrial cuff; however, in some cases, the donor pericardium is inadvertently removed during the lung procurement. We devised an alternative technique for reconstruction to overcome the absence of pericardium in a donor lung with an inadequate atrial cuff, using a patch of the donor pulmonary artery (PA) in single lung transplantation. In a recent case of lung transplantation in which the donor pericardium had been removed, we harvested a segment of the right PA distal to the main PA of the donor and used a PA patch to repair the inadequate donor left atrial cuff. No vascular complications were encountered in the recipient, who remains in good health after the transplantation.

Donors with a prior history of cardiac surgery are a viable source of lung allografts.

End-stage lung disease continues to rise despite the lack of suitable lung donors, limiting the numbers of lung transplants performed each year. Expanded donor criteria, use of donation after cardiac death donors and the advent of ex vivo lung perfusion have resulted only in a slight increase in donor lung utilization. Organ donors with prior cardiac surgery (DPCS) present risks and technical challenges; however, they may be a potential source of suitable lung allografts with an experienced procurement surgeon. We present our experience having evaluated potential lung donors with a prior history of cardiac surgery, resulting in successful transplant outcomes. This is a single-institution retrospective review of brain-dead organ donors that were evaluated for lung donation in the period 2012-15. Donor and recipient characteristics were collected. Post-lung transplant survival was recorded. From 2012 to 2015, 259 donors were evaluated, 12 with a prior history of cardiac surgery of which 4 had coronary artery bypass, 3 had aortic root replacement, 2 had aortic valve replacement, 1 pulmonary embolectomy, 1 two-time reoperative valve replacement and 1 paediatric congenital ventricular septal defect repair. DPCS, 6/12 (50% dry run) provided suitable allografts generating six single-lung transplants (three right and three left, 1 donor provided twin single-lung transplants) and one double-lung transplant. Interval between cardiac surgery and procurement for those rejected was median 5840 (IQR 2350-8640) days and interval for the donors that provided allografts was median 438 (IQR 336-1095) days (Mann-Whitney, P = 0.07). Recipient 1-year survival from DPCS is 100%. Recipient 1-year survival was 92% in allografts explanted from donors with no prior cardiac surgery (2012-13). To date, this is the largest single-centre experience using lung allografts from brain-dead DPCS. Our experience shows despite predicted technical difficulties, with good communication between thoracic and abdominal teams, successful transplant outcomes are possible, when surgeons with experience in reoperative cases are sent for lung procurements.