Postdoctoral National Institutes of Health F32 Grants: Broken Pipeline in the Development of Surgeon-Scientists.

OBJECTIVE: We examined trainees in surgery and internal medicine who received National Institutes of Health (NIH) F32 postdoctoral awards to determine their success rates in obtaining future NIH funding. BACKGROUND: Trainees participate in dedicated research years during residency (surgery) and fellowship (internal medicine). They can obtain an NIH F32 grant to fund their research time and have structured mentorship. METHODS: We collected NIH F32 grants (1992-2021) for Surgery Departments and Internal Medicine Departments from NIH RePORTER, an online database of NIH grants. Nonsurgeons and noninternal medicine physicians were excluded. We collected demographic information on each recipient, including gender, current specialty, leadership positions, graduate degrees, and any future NIH grants they received. A Mann-Whitney U test was used for continuous variables, and a χ 2 test was utilized to analyze categorical variables. An alpha value of 0.05 was used to determine significance. RESULTS: We identified 269 surgeons and 735 internal medicine trainees who received F32 grants. A total of 48 surgeons (17.8%) and 339 internal medicine trainees (50.2%) received future NIH funding ( P < 0.0001). Similarly, 24 surgeons (8.9%) and 145 internal medicine trainees (19.7%) received an R01 in the future ( P < 0.0001). Surgeons who received F32 grants were more likely to be department chair or division chiefs ( P =0.0055 and P < 0.0001). CONCLUSIONS: Surgery trainees who obtain NIH F32 grants during dedicated research years are less likely to receive any form of NIH funding in the future compared with their internal medicine colleagues who received F32 grants.

Comprehensive National Institutes of Health funding analysis of academic cardiac surgeons.

OBJECTIVE: To determine trends in National Institutes of Health (NIH) funding for cardiac surgeons, hypothesizing they are at a disadvantage in obtaining funding owing to intensive clinical demands. METHODS: Cardiac surgeons (adult/congenital) currently at the top 141 NIH-funded institutions were identified using institutional websites. The NIH funding history for each cardiac surgeon was queried using the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER). Total grant funding, publications, and type was collected. Academic rank, secondary degrees, and fellowship information was collected from faculty pages. Grant productivity was calculated using a validated grant impact metric. RESULTS: A total of 818 academic cardiac surgeons were identified, of whom 144 obtained 293 NIH grants totaling $458 million and resulting in 6694 publications. We identified strong associations between an institution's overall NIH funding rank and the number of cardiac surgeons, NIH grants to cardiac surgeons, and amount of NIH funding to cardiac surgeons (P < .0001 for all). The majority of NIH funding to cardiac surgeons is concentrated in the top quartile of institutions. Cardiac surgeons had a high conversion rates from K awards (mentored development awards) to R01s (6 of 14; 42.9%). Finally, we demonstrate that the rate of all NIH grants awarded to cardiac surgeons has increased, driven primarily by P and U (collaborative project) grants. CONCLUSIONS: NIH-funded cardiac surgical research has had a significant impact over the last 3 decades. Aspiring cardiac surgeon-scientists may be more successful at top quartile institutions owing to better infrastructure and mentorship.

Reduced-flow ex vivo lung perfusion to rehabilitate lungs donated after circulatory death.

BACKGROUND: Current ex vivo lung perfusion (EVLP) protocols aim to achieve perfusion flows of 40% of cardiac output or more. We hypothesized that a lower target flow rate during EVLP would improve graft function and decrease inflammation of donation after circulatory death (DCD) lungs. METHODS: A porcine DCD and EVLP model was utilized. Two groups (n = 4 per group) of DCD lungs were randomized to target EVLP flows of 40% (high-flow) or 20% (low-flow) predicted cardiac output based on 100 ml/min/kg. At the completion of 4 hours of normothermic EVLP using Steen solution, left lung transplantation was performed, and lungs were monitored during 4 hours of reperfusion. RESULTS: After transplant, left lung-specific pulmonary vein partial pressure of oxygen was significantly higher in the low-flow group at 3 and 4 hours of reperfusion (3-hour: 496.0 ± 87.7 mm Hg vs. 252.7 ± 166.0 mm Hg, p = 0.017; 4-hour: 429.7 ± 93.6 mm Hg vs. 231.5 ± 178 mm Hg, p = 0.048). Compliance was significantly improved at 1 hour of reperfusion (20.8 ± 9.4 ml/cm H2O vs. 10.2 ± 3.5 ml/cm H2O, p = 0.022) and throughout all subsequent time points in the low-flow group. After reperfusion, lung wet-to-dry weight ratio (7.1 ± 0.7 vs. 8.8 ± 1.1, p = 0.040) and interleukin-1ß expression (927 ± 300 pg/ng protein vs. 2,070 ± 874 pg/ng protein, p = 0.048) were significantly reduced in the low-flow group. CONCLUSIONS: EVLP of DCD lungs with low-flow targets of 20% predicted cardiac output improves lung function, reduces edema, and attenuates inflammation after transplant. Therefore, EVLP for lung rehabilitation should use reduced flow rates of 20% predicted cardiac output.

Are You Making Yourself Clear? You Can't Communicate, or Think, Effectively If You Can't Write Clearly.

In the not too distant past, illegible handwriting was considered to be the biggest problem with medical record keeping. Now the primary problem with medical records is that they are disorganized, and usually undigested, data dumps. A solution to at least part of this problem lies in utilizing the principles of the problem-oriented record. When one contemplates the optimal format for progress notes, it is worth considering the purposes of progress notes. While progress notes do, of course, play a role in billing, the primary purposes of a progress note should be to provide efficient and effective communication with all who are caring for that patient and to facilitate efficient and effective contemplation of the condition of and the plans for that patient. Although it is beyond the scope of this treatise on creating progress notes, it is also worth pointing out that all patient care notes will also occasionally have legal implications and lawyers reading clinical notes will pay far more attention to assessments and plans than they will to data and results recorded in progress notes that are always easily available elsewhere in the patient record. In other words, lawyers reviewing medical records want to know what the clinicians caring for a patient were thinking, in addition to what those clinicians actually did for that patient. While all of these issues must be kept in mind, we will focus primarily on the role of clinical notes in providing optimal patient care, particularly in the realm of cardiothoracic surgery, though the principles to be enunciated can apply to most disciplines and to most clinical environments.

Adenosine 2A Receptor Activation Attenuates Ischemia Reperfusion Injury During Extracorporeal Cardiopulmonary Resuscitation.

OBJECTIVE: We tested the hypothesis that systemic administration of an A2AR agonist will reduce multiorgan IRI in a porcine model of ECPR. SUMMARY BACKGROUND DATA: Advances in ECPR have decreased mortality after cardiac arrest; however, subsequent IRI contributes to late multisystem organ failure. Attenuation of IRI has been reported with the use of an A2AR agonist. METHODS: Adult swine underwent 20 minutes of circulatory arrest, induced by ventricular fibrillation, followed by 6 hours of reperfusion with ECPR. Animals were randomized to vehicle control, low-dose A2AR agonist, or high-dose A2AR agonist. A perfusion specialist using a goal-directed resuscitation protocol managed all the animals during the reperfusion period. Hourly blood, urine, and tissue samples were collected. Biochemical and microarray analyses were performed to identify differential inflammatory markers and gene expression between groups. RESULTS: Both the treatment groups demonstrated significantly higher percent reduction from peak lactate after reperfusion compared with vehicle controls. Control animals required significantly more fluid, epinephrine, and higher final pump flow while having lower urine output than both the treatment groups. The treatment groups had lower urine NGAL, an early marker of kidney injury (P = 0.01), lower plasma aspartate aminotransferase, and reduced rate of troponin rise (P = 0.01). Pro-inflammatory cytokines were lower while anti-inflammatory cytokines were significantly higher in the treatment groups. CONCLUSIONS: Using a novel and clinically relevant porcine model of circulatory arrest and ECPR, we demonstrated that a selective A2AR agonist significantly attenuated systemic IRI and warrants clinical investigation.

Preparing for the Lurch into a Surgery Clerkship.

Over our combined nearly 50 years as surgical educators, we have been asked many times by medical students how they should prepare for and function in a Surgery Clerkship. It is still easy for me (C.G.T.) to recall, as a medical student myself, having the same questions. While I had initially thought that the transition from college to medical school would be challenging, I quickly realized that the first few years of medical school were not as much of a transition as I had imagined. However, as the clerkship year approached for my medical school classmates and me, it was quite clear to us that we were about to enter an educational environment for which our prior years in college and medical school had likely not optimally prepared us. And, when the primary advice we were given about how we should function as medical students rotating through the clerkships was that we should "just live the life of the house officer," we realized that we had little to no idea what we were actually supposed to do once we began the clerkship year.

Can Lung Transplant Surgeons Still Be Scientists? High Productivity Despite Competitive Funding.

BACKGROUND: Today's declining federal budget for scientific research is making it consistently more difficult to become federally funded. We hypothesized that even in this difficult era, surgeon-scientists have remained among the most productive and impactful researchers in lung transplantation. METHODS: Grants awarded by the NIH for the study of lung transplantation between 1985 and 2015 were identified by searching NIH RePORTER for 5 lung transplantation research areas. A grant impact metric was calculated for each grant by dividing the sum of impact factors for all associated manuscripts by the total funding for that grant. We used nonparametric univariate analysis to compare grant impact metrics by department. RESULTS: We identified 109 lung transplantation grants, totaling approximately $300 million, resulting in 2304 papers published in 421 different journals. Surgery has the third highest median grant impact metric (4.2 per $100,000). The department of surgery had a higher median grant impact metric compared to private companies (P <.0001). There was no statistical difference in the grant impact metric compared to all other medical specialties, individual departments with multiple grants, or all basic science departments (all P >.05). CONCLUSIONS: Surgeon-scientists in the field of lung transplantation have received fewer grants and less total funding compared to other researchers but have maintained an equally high level of productivity and impact. The dual-threat academic surgeon-scientist is an important asset to the research community and should continue to be supported by the NIH.

Ex Vivo Assessment of Porcine Donation After Circulatory Death Lungs That Undergo Increasing Warm Ischemia Times.

BACKGROUND: Increased utilization of donation after circulatory death (DCD) lungs may help alleviate the supply/demand mismatch between available donor organs and lung transplant candidates. Using an established porcine DCD model, we sought to determine the effect of increasing warm ischemia time (WIT) after circulatory arrest on lung function during ex vivo lung perfusion (EVLP). METHODS: Porcine donors (n = 15) underwent hypoxic cardiac arrest, followed by 60, 90, or 120 minutes of WIT before procurement and 4 hours of normothermic EVLP. Oxygenation, pulmonary artery pressure, airway pressure, and compliance were measured hourly. Lung injury scores were assessed histologically after 4 hours of EVLP. RESULTS: After EVLP, all 3 groups met all the criteria for transplantation, except for 90-minute WIT lungs, which had a mean pulmonary artery pressure increase greater than 15%. There were no significant differences between groups as assessed by final oxygenation capacity, as well as changes in pulmonary artery pressure, airway pressure, or lung compliance. Histologic lung injury scores as well as lung wet-to-dry weight ratios did not significantly differ between groups. CONCLUSIONS: These results suggest that longer WIT alone (up to 120 minutes) does not predict worse lung function at the conclusion of EVLP. Expanding acceptable WIT after circulatory death may eventually allow for increased utilization of DCD lungs in procurement protocols.

On Becoming a Surgical Intern: Navigating the Lurch from Medical School to Internship.

There are three major transitions in the educational trajectory of those heading into a career in surgery. The first transition is from the first year or two of medical school to the clerkships of the third year.  The second is the transition from medical school into the first postgraduate year of residency training. The third, which is widely held to be the toughest transition of all, is from residency into independent practice.  This review, which could be called 'a rookie's survival guide,' will address the second of those 'lurches,' that of the transition from medical school into a surgical internship.

Reoperative Cardiac Surgery - Part II.

The preparation for a reoperative cardiac surgical case was covered in Part I of this two part review [Tribble 2018]. Part II will cover primarily intraoperative strategies and techniques.  As noted in Part I, there has been surprisingly little written about the strategies and techniques of reoperative cardiac surgery. Thus, the goal of this two-part review is to collect and collate some of the lessons, abjurations, and tenets related to reoperative cardiac surgery that may be valuable to cardiac surgeons, especially those in training or early in their careers.Some time-honored admonitions that can apply to all complex operations, often enunciated by "old salts," bear repeating:•  Everything matters. Nothing is neutral.•  Some say that a "life or death" decision is made, on average, every 10 seconds during cardiac surgery. â€¢  If something can go wrong, presume that it will.•  If it seems absolutely impossible for something to go wrong, it will anyway, at least some of the time.•  When something does go wrong, it generally does so all at once.•  If what you are doing is working, keep on doing it. If it ain't working, do something else.

Cardiothoracic and Vascular Surgeons Achieve High Rates of K Award Conversion Into R01 Funding.

BACKGROUND: Obtaining National Institutes of Health (NIH) R01 funding remains extremely difficult. The utility of career development grants (K awards) for achieving the goal of R01 funding remains debated, particularly for surgeon-scientists. We examined the success rate for cardiothoracic and vascular (CTV) surgeons compared with other specialties in converting K-level grants into R01 equivalents. METHODS: All K (K08 and K23) grants awarded to surgeons by the NIH between 1992 and 2017 were identified through NIH Research Portfolio Online Report Tools (RePORTER), an online database combining funding, publications, and patents. Only grants awarded to CTV surgeons were included. Grants active within the past year were excluded. Mann-Whitney U tests and χ2 tests were used to compare groups. RESULTS: During this period, 62 K grants were awarded to CTV surgeons. The analysis excluded 16 grants that were still active within the last year. Twenty-two (48%) of the remaining K awardees successfully transitioned to an R01 or equivalent grant. Awardees with successful conversion published nine publications per K grant compared with four publications for those who did not convert successfully (p = 0.01). The median time for successful conversion to an R grant was 5.0 years after the K award start date. Importantly, the 10-year conversion rate to R01 was equal for CTV surgeons compared with other clinician-investigators (52.6% vs 42.5%). CONCLUSIONS: CTV surgeons have an equal 10-year conversion rate to the first R01 award compared with other clinicians. These data suggest that NIH achieves a good return on investment when funding CTV surgeon-scientists with K-level funding.

Expanding the donor lung pool: how many donations after circulatory death organs are we missing?

BACKGROUND: The number of patients with end-stage pulmonary disease awaiting lung transplantation is at an all-time high, while the supply of available organs remains stagnant. Utilizing donation after circulatory death (DCD) donors may help to address the supply-demand mismatch. The objective of this study is to determine the potential donor pool expansion with increased procurement of DCD organs from patients who die at hospitals. MATERIAL AND METHODS: The charts of all patients who died at a single, rural, quaternary-care institution between August 2014 and June 2015 were reviewed for lung transplant candidacy. Inclusion criteria were age <65 y, absence of cancer and lung pathology, and cause of death other than respiratory or sepsis. RESULTS: A total of 857 patients died within a 1-year period and were stratified by age: pediatric <15 y (n = 32, 4%), young 15-64 y (n = 328, 38%), and old >65 y (n = 497, 58%). Those without cancer totaled 778 (90.8%) and 512 (59%) did not have lung pathology. This leaves 85 patients qualifying for DCD lung donation (pediatric n = 10, young n = 75, and old n = 0). Potential donors were significantly more likely to have clear chest X-rays (24.3% versus 10.0%, P < 0.0001) and higher mean PaO2/FiO2 (342.1 versus 197.9, P < 0.0001) compared with ineligible patients. CONCLUSIONS: A significant number of DCD lungs are available every year from patients who die within hospitals. We estimate the use of suitable DCD lungs could potentially result in a significant increase in the number of lungs available for transplantation.

Cardiothoracic surgery training grants provide protected research time vital to the development of academic surgeons.

BACKGROUND: The Ruth L. Kirschstein Institutional National Research Service Award (T32) provides institutions with financial support to prepare trainees for careers in academic medicine. In 1990, the Cardiac Surgery Branch of the National Heart, Lung and Blood Institute (NHLBI) was replaced by T32 training grants, which became crucial sources of funding for cardiothoracic (CT) surgical research. We hypothesized that T32 grants would be valuable for CT surgery training and yield significant publications and subsequent funding. METHODS: Data on all trainees (past and present) supported by CT T32 grants at two institutions were obtained (T32), along with information on trainees from two similarly sized programs without CT T32 funding (Non-T32). Data collected were publicly available and included publications, funding, degrees, fellowships, and academic rank. Non-surgery residents and residents who did not pursue CT surgery were excluded. RESULTS: Out of 76 T32 trainees and 294 Non-T32 trainees, data on 62 current trainees or current CT surgeons (T32: 42 vs Control: 20) were included. Trainees who were supported by a CT T32 grant were more likely to pursue CT surgery after residency (T32: 40% [30/76] vs Non-T32: 7% [20/294], P < .0001), publish manuscripts during residency years (P < .0001), obtain subsequent NIH funding (T32: 33% [7/21] vs Non-T32: 5% [1/20], P = .02), and pursue advanced fellowships (T32: 41% [9/22] vs Non-T32: 10% [2/20], P = .02). CONCLUSIONS: T32 training grants supporting CT surgery research are vital to develop academic surgeons. These results support continued funding by the NHLBI to effectively develop and train the next generation of academic CT surgeons.

String Music: Creating Coronary Artery and other Vascular Anastomoses.

The initial version of this treatise was written as I (Curt Tribble) was learning to do coronary anastomoses over 30 years ago, and I worried that I was not being taught very well how to go about doing them. It seemed to me that my teachers were channeling Dr. Alain Carpentier, who often answered questions about his mitral valve repair techniques by saying, "Oh, you just know." These frustrations were compounded by the fact that the best cardiovascular techniques books, including even those texts dedicated to coronary artery bypass techniques, did not describe these anastomotic techniques in detail, which remains the case to the present day [Kaiser 2007; Copeland 1986].

In vivo lung perfusion rehabilitates sepsis-induced lung injury.

BACKGROUND: Sepsis is the leading cause of lung injury in adults and can lead to acute respiratory distress syndrome (ARDS). Using a novel technique of isolated in vivo lung perfusion (IVLP), we hypothesized that normothermic IVLP will improve oxygenation and compliance in a porcine model of sepsis-induced lung injury. METHODS: Mature adult swine (n = 8) were administered lipopolysaccharide (LPS; 50 µg/kg over 2 hours) via the external jugular vein, followed by sternotomy and central extracorporeal membrane oxygenation (ECMO) cannulation (right atrium to ascending aorta). The left pulmonary artery (inflow) and left superior and inferior pulmonary veins (outflow) were dissected out and cannulated to deliver isolated perfusion to the left lung. After 4 hours of normothermic IVLP with Steen solution, the left lung then underwent 4 hours of reperfusion after IVLP decannulation. Airway pressures and lung-specific pulmonary vein blood gases from the right lung (LPS control) and left lung (LPS + IVLP) of the same animal were compared. RESULTS: All animals demonstrated a significant reduction in the ratio of partial pressure of oxygen in arterial blood (PaO2)/fraction of inspired oxygen (FiO2) (P/F ratio) and total lung compliance at 2 hours after the start of LPS infusion (mean, 469 ± 19.7 mm Hg vs 222.2 ± 21.4 mm Hg; P < .0001). After reperfusion, 6 animals (75%) exhibited improved lung function, allowing for ECMO decannulation. Lung-specific oxygenation was superior in the left lung after 4 hours of reperfusion (mean, 310.5 ± 54.7 mm Hg vs 201.1 ± 21.7 mm Hg; P = .01). Similarly, total lung compliance improved after IVLP of the left lung. The lung wet weight to dry weight ratio demonstrated reduced edema in rehabilitated left lungs (mean, 6.5 ± 0.3 vs 7.5 ± 0.4; P = .04). CONCLUSIONS: IVLP successfully rehabilitated LPS-injured lungs compared to ECMO support alone in this preclinical porcine model.

Give My Poor Heart Ease.

We came to The University of Virginia (UVA) within a year of each other nearly four decades ago: one (DN) to join the UVA basketball team during four of the best years of UVA basketball, and to earn 2 degrees, first in English and then in Sports Psychology; and the other (CT) to begin 7 years of training in general, vascular, thoracic, and cardiac surgery, which culminated with a faculty appointment in the UVA Department of Surgery, with part of the charge being to organize most of the Department's educational programs. Realizing that the education and training of medical students and surgical residents would require knowledge, skills, and understanding above and beyond the usual training of a resident in surgery, I (CT) started an informal, though enriching, attempt to find those on the grounds of the University who might share ideas and insights that could enhance the educational programs in the Department. This process embodied the vision of the founders of the University to create an "academical village."

The Skeleton in the Closet: Harvesting a Skeletonized IMA.

There is a considerable amount of data that using more than one arterial graft provides a survival advantage for patients undergoing coronary bypass operations. The Society of Thoracic Surgeons has a set of official guidelines for the use of arterial grafts which include the following recommendations:Internal mammary arteries (IMA's) should be used to bypass the left anterior descending (LAD) artery when bypass of the LAD is indicated.As an adjunct to left internal mammary artery (LIMA), a second arterial graft (right IMA or radial artery [RA]) should be considered in appropriate patients.Use of bilateral IMA's (BIMA's) should be considered in patients who do not have an excessive risk of sternal complications.To reduce the risk of sternal infection with bilateral IMA's, skeletonized grafts should be considered, smoking cessation is recommended, glycemic control should be considered, and enhanced sternal stabilization may be considered.Use of arterial grafts should be a part of the discussion of the heart team in determining the optimal approach for each patient.         [Ann Thorac Surg 2016; 101: 801-9].

Median Sternotomy for Lung Transplantation: Techniques and Advantages.

Lung transplantation is traditionally performed with a clamshell thoracotomy or bilateral anterior thoracotomy incisions. We have performed 121 lung transplants with a median sternotomy incision from 2013-2017. We present our technique for lung transplantation utilizing cardiopulmonary bypass with a median sternotomy, and discuss the potential advantages of this technique.

Lungs donated after circulatory death and prolonged warm ischemia are transplanted successfully after enhanced ex vivo lung perfusion using adenosine A2B receptor antagonism.

OBJECTIVE: The current supply of acceptable donor lungs is not sufficient for the number of patients awaiting transplantation. We hypothesized that ex vivo lung perfusion (EVLP) with targeted drug therapy would allow successful rehabilitation and transplantation of donation after circulatory death lungs exposed to 2 hours of warm ischemia. METHODS: Donor porcine lungs were procured after 2 hours of warm ischemia postcardiac arrest and subjected to 4 hours of cold preservation or EVLP. ATL802, an adenosine A2B receptor antagonist, was administered to select groups. Four groups (n = 4/group) were randomized: cold preservation (Cold), cold preservation with ATL802 during reperfusion (Cold + ATL802), EVLP (EVLP), and EVLP with ATL802 during ex vivo perfusion (EVLP + ATL802). Lungs subsequently were transplanted, reperfused, and assessed by measuring dynamic lung compliance and oxygenation capacity. RESULTS: EVLP + ATL802 significantly improved dynamic lung compliance compared with EVLP (25.0 ± 1.8 vs 17.0 ± 2.4 mL/cmH2O, P = .04), and compared with cold preservation (Cold: 12.2 ± 1.3, P = .004; Cold + ATL802: 10.6 ± 2.0 mL/cmH2O, P = .002). Oxygenation capacity was highest in EVLP (440.4 ± 37.0 vs Cold: 174.0 ± 61.3 mm Hg, P = .037). No differences in oxygenation or pulmonary edema were observed between EVLP and EVLP + ATL802. A significant decrease in interleukin-12 expression in tissue and bronchoalveolar lavage was identified between groups EVLP and EVLP + ATL802, along with less neutrophil infiltration. CONCLUSIONS: Severely injured donation after circulatory death lungs subjected to 2 hours of warm ischemia are transplanted successfully after enhanced EVLP with targeted drug therapy. Increased use of lungs after uncontrolled donor cardiac death and prolonged warm ischemia may be possible and may improve transplant wait list times and mortality.

Ex Vivo Lung Perfusion Rehabilitates Sepsis-Induced Lung Injury.

BACKGROUND: Sepsis is the number one cause of lung injury in adults. Ex vivo lung perfusion (EVLP) is gaining clinical acceptance for donor lung evaluation and rehabilitation and may expand the use of marginal organs for transplantation. We hypothesized that 4 hours of normothermic EVLP would improve compliance and oxygenation in a porcine model of sepsis-induced lung injury. METHODS: We used intravenous lipopolysaccharide (LPS) to induce a systemic inflammatory response in a porcine model of lung injury. Two groups of 4 animals each received a 2-hour infusion of LPS through the external jugular vein. Serial measurements of blood gases were performed every 30 minutes until the partial pressure of oxygen/fraction of inspired oxygen ratio dropped below 150 on two consecutive readings. Lungs were then randomized to treatment with 4 hours of normothermic EVLP with STEEN Solution (XVIVO Perfusion Inc, Englewood, CO) or 4 additional hours of in vivo perfusion (control). Airway pressures and blood gases were recorded for calculation of dynamic lung compliance and partial pressure of oxygen/fraction of inspired oxygen ratios. EVLP was performed with hourly recruitment maneuvers and oxygen challenge. RESULTS: All animals reached a partial pressure of oxygen/fraction of inspired oxygen ratio of less than 150 mm Hg within 3 hours after start of the LPS infusion. Oxygenation and compliance in the control animals continued to decline during the 4-hour in vivo perfusion period, and 3 of the 4 animals died of severe hypoxia within 4 hours. The EVLP group demonstrated significant improvements hour 1 to hour 4 in oxygenation (365.8 ± 53.0 vs 584.4 ± 21.0 mm Hg, p = 0.02) and dynamic compliance (9.0 ± 2.8 vs 15.0 ± 3.6, p = 0.02 mL/cm H2O). CONCLUSIONS: EVLP successfully rehabilitated LPS-induced lung injury in this preclinical porcine model and may thus provide a means to rehabilitate many types of acute lung injury.