Shortage of lung donors has led transplantation programs to work on new approaches to getting potential donors. In contrast, lung transplant surgeons face the advances in treatments for critically ill patients, including the increased use of extracorporeal membrane oxygenation (ECMO) support. The use of donors on ECMO raises some concerns: endothelial injury and pulmonary edema because of extracorporeal circulation-induced systemic inflammatory response syndrome; pulmonary congestion, caused by increased left ventricle afterload (venoarterial ECMO); alveolar hemorrhage induced by pulmonary edema; and anticoagulation therapies.1 Also, the criteria for determination of death and the assessment of graft quality are challenging in potential donors on ECMO.2 We report the experience of lung recipients from donors after neurological determination of death (DBD) while on ECMO support from 3 centers of the European Society of Thoracic Surgeons Lung Transplantation Working Group.
From 2013 to April 2019, 4 patients were transplanted with grafts from DBD donors on ECMO (Table 1). All donors were supported with venoarterial-ECMO for cardiovascular failure; 3 recipients needed a bridge to transplant. Early postoperative course was characterized by grade-3 primary graft dysfunction in 3 cases. Postoperative respiratory function was satisfactory; no airway complications occurred. The very first patient had a dramatic clinical course with a single lung retransplantation after 69 d of venoarterial-ECMO bridge.
TABLE 1.
Donor and recipient characteristics
| Variables | Value |
|---|---|
| Patients, N | 4 |
| Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Milan, Italy | 2 |
| Zurich University Hospital, Switzerland | 1 |
| University Hospitals Leuven, Belgium | 1 |
| Donor | |
| ECMO indication | |
| Cardiac arrest | 3 (75) |
| Cardiogenic shock | 1 (25) |
| Venoarterial ECMO | 4 (100) |
| ECMO duration (h) | 32–137 |
| Sex: male | 4 (100) |
| Age (y) | 30–59 |
| BMI (kg/m2) | 25–33.9 |
| Cause of brain death | |
| Anoxia | 3 (75) |
| Vascular | 1 (25) |
| Mechanical ventilation (d) | 1–8 |
| Smoking habit: never smoker | 3 (75) |
| Chest x-ray | |
| Clear | 2 (50) |
| Minor opacity | 2 (50) |
| Opacity ≤1 lobe | 0 (0) |
| Opacity >1 lobe | 0 (0) |
| Secretions at bronchoscopy | |
| None | 2 (50) |
| Minor | 0 (0) |
| Moderate | 2 (50) |
| Major | 0 (0) |
| Medical history: previous cardiac surgery | 2 (50) |
| Organs retrieved | |
| Lung only | 1 (25) |
| Lung + abdominal organs | 3 (75) |
| Lung + heart | 0 (0) |
| Lung + heart + abdominal organs | 0 (0) |
| Transplantation | |
| Machine perfusion evaluation | |
| Yes, EVLP | 3 (75) |
| Not used | 1 (25) |
| Cold ischemia time (min) | |
| First lung | 258–606 |
| Second lung | 607–795 |
| Type: bilateral | 3 (75) |
| Intraoperative ECMO (VA/VV) | 3 (75) (1/2) |
| Recipient | |
| Sex: male | 2 (50) |
| Age (y) | 16–42 |
| Indication | |
| Cystic fibrosis | 2 (50) |
| Interstitial lung disease | 1 (25) |
| Pulmonary vascular disease | 1 (25) |
| Bridge to transplantation | |
| Yes, ECMO (VA/VV) | 3 (75) (1/2) |
| No | 1 (25) |
| Bridge duration (d) | 3–69 |
| PGD(72h) grade 3 | 3 (75) |
| Postoperative MV duration (d) | 1–25 |
| Postoperative ECMO (VA/VV) | 3 (75) (1/2) |
| Postoperative ECMO duration (d) | 1–22 |
| Postoperative ICU stay (d) | 4–58 |
| Postoperative hospital length of stay (d) | 29–58 |
| 30-d mortality | 0 (0) |
| Best FEV1 (%)a | 70–107 |
| Airway complications | 0 (0) |
| CLAD | 2 (50) |
| Retransplantation | 0 (0) |
Values are expressed as number (%), range.
a1 missing data.
BMI, body mass index; CLAD, chronic lung allograft dysfunction; ECMO, extracorporeal membrane oxygenation; EVLP, ex vivo lung perfusion; FEV1, forced expiratory volume in 1 s; ICU, intensive care unit; IRCCS, Istituti di Ricovero e Cura a Carattere Scientifico; MV, mechanical ventilation; PGD (72 h), primary graft dysfunction in the first 72 h after transplantation; VA, venoarterial; VV, venovenous.
To our knowledge, only 3 cases of lung procurement from DBD donors on ECMO have been reported because of major challenges connected to this kind of donation.3-5 For intensivists, the management of patients on ECMO and the determination of death are complicated. In this setting, the apnea test is not standardized. It should be performed by lowering to 0 (usually 1 L/min) the sweep gas flow to the oxygenator; therefore, ventilation and oxygenation are completely dependent on the ventilator and hypercapnia is induced. In some cases, additional CO2 can be added to the gas exchanger to further reach the thresholds for hypercapnic stimulation of the control centers for respiration. Ancillary tests can be of aid for death determination.
Lung transplant surgeons also face a great challenge because of graft evaluation. Lung suitability is assessed according to usual parameters. As always, macroscopic inspection after opening the pleurae is of primary relevance; a careful and complete recruitment of all parenchyma under direct vision is mandatory. In these cases, pulmonary vein blood gas analysis could provide objective data on lungs functionality. Finally, because an in situ assessment of this type of donor may be partial and particularly demanding, ex situ evaluation becomes crucial: ex vivo lung perfusion can be used for lung evaluation and reconditioning.
This study is limited by its small population size and the severe conditions of the recipients, which should also be considered when interpreting our results. Considering this and the challenging assessment of lungs, our multicenter case series suggests that the outcomes of transplantation using DBD donors on ECMO support are encouraging. We advocate for systematic consideration of these as potential donors and not an a priori contraindication; nevertheless, these findings need to be confirmed in larger series.
Footnotes
A.P., I.I., D.E.V.R., and A.N. participated in the research design. J.E., L.J.C., A.R., V.M., and A.P. participated in the performance of the research. A.P., V.M., I.I., D.E.V.R., and G.C. participated in data analysis; all authors participated in the writing, reviewing, and editing of the article.
The authors declare no funding or conflicts of interest.
All patients signed written informed consent for the anonymous use of clinical data; the Institutional Review Board approved the study.
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