Single center utilization and post-transplant outcomes of thoracoabdominal normothermic regional perfusion deceased cardiac donor organs.

INTRODUCTION: Thoracoabdominal normothermic regional perfusion (TA-NRP) following cardiac death is an emerging multivisceral organ procurement technique. Recent national studies on outcomes of presumptive TA-NRP-procured organs are limited by potential misclassification since TA-NRP is not differentiated from donation after cardiac death (DCD) in registry data. METHODS: We studied 22 donors whose designees consented to TA-NRP and organ procurement performed at our institution between January 20, 2020 and July 3, 2022. We identified these donors in SRTR to describe organ utilization and recipient outcomes and compared them to recipients of traditional DCD (tDCD) and donation after brain death (DBD) organs during the same timeframe. RESULTS: All 22 donors progressed to cardiac arrest and underwent TA-NRP followed by heart, lung, kidney, and/or liver procurement. Median donor age was 41 years, 55% had anoxic brain injury, 45% were hypertensive, 0% were diabetic, and median kidney donor profile index was 40%. TA-NRP utilization was high across all organ types (88%-100%), with a higher percentage of kidneys procured via TA-NRP compared to tDCD (88% vs. 72%, p = .02). Recipient and graft survival ranged from 89% to 100% and were comparable to tDCD and DBD recipients (p ≥ .2). Delayed graft function was lower for kidneys procured from TA-NRP compared to tDCD donors (27% vs. 44%, p = .045). CONCLUSION: Procurement from TA-NRP donors yielded high organ utilization, with outcomes comparable to tDCD and DBD recipients across organ types. Further large-scale study of TA-NRP donors, facilitated by its capture in the national registry, will be critical to fully understand its impact as an organ procurement technique.

Spinal Cord Infarction With Prolonged Femoral Venoarterial Extracorporeal Membrane Oxygenation.

OBJECTIVES: There have been sporadic reports of ischemic spinal cord injury (SCI) during venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. The authors observed a troubling pattern of this catastrophic complication and evaluated the potential mechanisms of SCI related to ECMO. DESIGN: This study was a case series. SETTING: This study was performed at a single institution in a University setting. PARTICIPANTS: Patients requiring prolonged VA-ECMO were included. INTERVENTIONS: No interventions were done. This was an observational study. MEASUREMENTS AND MAIN RESULTS: Four hypotheses of etiology were considered: (1) hypercoagulable state/thromboembolism, (2) regional hypoxia/hypocarbia, (3) hyperperfusion and spinal cord edema, and (4) mechanical coverage of spinal arteries. The SCI involved the lower thoracic (T7-T12 level) spinal cord to the cauda equina in all patients. Seven out of 132 (5.3%) patients with prolonged VA-ECMO support developed SCI. The median time from ECMO cannulation to SCI was 7 (range: 6-17) days.There was no evidence of embolic SCI or extended regional hypoxia or hypocarbia. A unilateral, internal iliac artery was covered by the arterial cannula in 6/7 86%) patients, but flow into the internal iliac was demonstrated on imaging in all available patients. The median total flow (ECMO + intrinsic cardiac output) was 8.5 L/min (LPM), and indexed flow was 4.1 LPM/m2. The median central venous oxygen saturation was 88%, and intracranial pressure was measured at 30 mmHg in one patient, suggestive of hyperperfusion and spinal cord edema. CONCLUSIONS: An SCI is a serious complication of extended peripheral VA-ECMO support. Its etiology remains uncertain, but the authors' preliminary data suggested that spinal cord edema from hyperperfusion or venous congestion could contribute.

Multimodal opioid-sparing pain management after lung transplantation and the impact of liposomal bupivacaine intercostal nerve block.

Opioid analgesics are commonly used post-lung transplant, but have many side effects and are associated with worse outcomes. We conducted a retrospective review of all lung transplant recipients who were treated with a multimodal opioid-sparing pain protocol. The use of liposomal bupivacaine intercostal nerve block was variable due to hospital restrictions. The primary objective was to describe opioid requirements and patient-reported pain scores early post-lung transplant and to assess the impact of intraoperative liposomal bupivacaine intercostal nerve block. We treated 64 lung transplant recipients with our protocol. Opioid utilization decreased to a mean of 43 milligram oral morphine equivalents by postoperative day 4. Median pain scores peaked at 4 on postoperative day 1 and decreased thereafter. Only three patients were discharged home with opioids, all of whom were taking opioid agonist therapy pre-transplant for opioid use disorder. Patients who received liposomal bupivacaine intercostal nerve block in the operating room had a significant reduction in opioid consumption over postoperative day 1 through 4 (228 mg vs. 517 mg, P= .032). A multimodal opioid-sparing pain management protocol is feasible and resulted in weaning of opioids prior to hospital discharge.

Bedside angiography of distal perfusion catheter for veno-arterial extracorporeal membrane oxygenation.

BACKGROUND: The aim of this study was to evaluate the ipsilateral lower extremity (ILE) outcomes of patients who underwent bedside angiography via the distal perfusion catheter while on femoral veno-arterial extracorporeal membrane oxygenation (VA ECMO). METHODS: This is a retrospective analysis of all patients placed on VA ECMO at a single center from January 2017 to December 2019 who underwent bedside angiography via the distal perfusion catheter. RESULTS: Twenty-four patients underwent bedside angiography via the distal perfusion catheter after being placed on VA ECMO. A vasodilator was directly administered in three patients for suspected spasm. One patient had distal thrombus and underwent thrombectomy and fasciotomy. One patient had a dislodged catheter and underwent thrombectomy, fasciotomy, and replacement of the catheter. One patient had severe ILE ischemia, however was not intervened upon due to critical acuity. Finally, one patient had inadvertent placement in the saphenous vein and had a new catheter placed in the SFA. No patients underwent amputation. Ultimately, 21 patients (87.5%) had no ILE compromise at the end their ECMO course. Survival to decannulation was 66.7% (n = 16). CONCLUSIONS: Bedside angiography of the distal perfusion catheter is feasible and can be a useful adjunct in informing the need for further intervention to the ILE. CLASSIFICATIONS: extracorporeal membrane oxygenation, ischemia.

Hemoadsorption for management of patients on veno-venous ECMO support for severe COVID-19 acute respiratory distress syndrome.

BACKGROUND AND AIM: Patients with severe coronavirus disease 2019 (COVID-19) develop a profound cytokine-mediated pro-inflammatory response. This study reports outcomes in 10 patients with COVID-19 supported on veno-venous extracorporeal membrane oxygenation (VV-ECMO) who were selected for the emergency use of a hemoadsorption column integrated in the ECMO circuit. MATERIALS AND METHODS: Pre and posttreatment, clinical data, and inflammatory markers were assessed to determine the safety and feasibility of using this system and to evaluate the clinical effect. RESULTS: During hemoadsorption, median levels of interleukin (IL)-2R, IL-6, and IL-10 decreased by 54%, 86%, and 64%, respectively. Reductions in other markers were observed for lactate dehydrogenase (-49%), ferritin (-46%), d-dimer (-7%), C-reactive protein (-55%), procalcitonin (-76%), and lactate (-44%). Vasoactive-inotrope scores decreased significantly over the treatment interval (-80%). The median hospital length of stay was 53 days (36-85) and at 90-days post cannulation, survival was 90% which was similar to a group of patients without the use of hemoadsorption. CONCLUSIONS: Addition of hemoadsorption to VV-ECMO in patients with severe COVID-19 is feasible and reduces measured cytokine levels. However, in this small series, the precise impact on the overall clinical course and survival benefit still remains unknown.

Perceptions of Training Pathways from Recent Cardiothoracic Surgery Graduates.

BACKGROUND: There are three cardiothoracic surgery (CTS) training pathways-general surgery residency followed by a CTS residency of 2-3 years (traditional), 4 years of general surgery and 3 years of CTS residency (4+3), and an integrated 6-year pathway (I-6). The goal of this study was to survey early career cardiothoracic surgeons regarding their training experiences. METHODS: An email-based survey was sent to cardiothoracic surgeons, who graduated between 2012-2017. Data on training pathway specific variables and overall satisfaction were collected. The primary endpoints were career preparation and satisfaction, scored on a scale from 1-100, 100 being the most positive. RESULTS: Four hundred seventy-seven emails were sent, with a response rate of 95/477 (20%). Seventy-six of the respondents (80%) were male; the mean age was 39. Seventy-seven (81.0%) completed a traditional training pathway, 7 (7.4%) completed a 4+3 pathway, and 11 (11.6%) completed an I-6 pathway. Participants felt prepared for practice with a mean response of 79.8 (range 31-100); mean career satisfaction was 87.6.  When asked which pathway respondents would choose in the current era, 52 (54.7%) would choose a traditional pathway, 17 (17.9%) a 4+3 pathway, and 19 (20.0%) an I-6 program; 7 (7.4%) did not respond. Twenty of 72 (27.8%) traditional pathway trained and 18/18(100%) integrated pathway trained surgeons would choose an integrated pathway. CONCLUSIONS: This is the first survey addressing perceptions of training from early-career cardiothoracic surgeons across all training pathways. Data from this study provides insights to better understand how to improve CTS training for the next generation of surgeons.

Comparison of device-specific adverse event profiles between Impella platforms.

BACKGROUND: The Impella (Abiomed) ventricular support system is a family of temporary mechanical circulatory support (MCS) devices used to treat patients with cardiogenic shock, acute cardiogenic decompensation, and for high-risk percutaneous or surgical revascularization. These devices include the percutaneously implanted 2.5/cardiac power (CP) and the surgically implanted 5.0/left direct (LD). Despite the beneficial effects and increased usage of these devices, data to assess adverse outcomes and guide clinician decision-making between the Impella CP and 5.0/LD are limited. METHODS: This is a retrospective analysis of 91 consecutive patients who required at least 24 h of Impella support, from January 1, 2015 to December 31, 2019. Groups were stratified based on either initial Impella CP or 5.0/LD placement. Clinical outcomes and in-hospital complications were compared. RESULTS: Impella CP was implanted in 66 patients (mean age: 61 ± 15 years, male 71.2%) and Impella 5.0/LD was implanted in 25 patients (mean age: 62 ± 9 years, male 84.0%). There was greater stability of device position (p = .033), less incidence of hemolysis (p < .001), and less frequent need for additional MCS (p = .001) in patients implanted with the Impella 5.0/LD compared with Impella CP in this study cohort. Patients with Impella 5.0/LD were more likely to survive from Impella and survive to discharge. CONCLUSIONS: This study suggests that for patients who require temporary MCS for more than 24 h, the Impella 5.0/LD may have a more favorable device-specific adverse profile compared with the Impella CP.

Strategic application of modular risk components to safely increase lung transplantation volume.

OBJECTIVES: Considerable growth of individual lung transplant programs remains challenging. We hypothesized that the systematic implementation of modular risk components to a lung transplantation program would allow for expeditious growth without increasing mortality. METHODS: All consecutive patients placed on the lung transplantation waitlist were reviewed. Patients were stratified by an 18-month period surrounding the systematic implementation of the modular risk components Era 1 (1/2014-6/2015) and Era 2 (7/2015-12/2016). Modular risk components were separately evaluated for donors, recipients, and perioperative features. RESULTS: One hundred and thirty-two waitlist patients (Era 1: 48 and Era 2: 84) and 100 transplants (Era 1: 32 and Era 2: 68) were identified. There was a trend toward decreased waitlist mortality (P = .07). In Era 2, the use of ex vivo lung perfusion (P = .05) and donor-recipient over-sizing (P = .005) significantly increased. Moreover, transplantation with a lung allocation score greater than 70 (P = .05), extracorporeal support (P = .06), and desensitization (P = .008) were more common. Transplant rate significantly improved from Era 1 to Era 2 (325 vs 535 transplants per 100 patient years, P = .02). While primary graft dysfunction (PGD) grade 3 at 72 hours (P = .05) was significantly higher in Era 2, 1-year freedom from rejection was similar (86% vs 90%, P = .69) and survival (81% vs 95%, P = .02) was significantly greater in Era 2. CONCLUSIONS: The systematic implementation of a modular risk components to a lung transplantation program can result in a significant increase in center volume. However, measures to mitigate an expected increase in the incidence of PGD must be undertaken to maintain excellent short and midterm outcomes.

Implantation of Left Ventricular Assist Device After Descending Aortic Stent Graft for Mural Thrombus.

In patients with intraluminal thrombus, commonly applied temporary circulatory support modalities are contraindicated secondary to concern regarding distal or proximal (specifically veno-arterial extracorporeal membrane oxygenation) embolization of the thrombus. Therefore, in patients with cardiogenic shock and synchronous intraluminal descending aortic thrombus, support options are quite limited. We report a case of a 66-year-old man in cardiogenic shock, due to an ischemic cardiomyopathy, who also had intramural thrombus with an intraluminal component in the descending thoracic aorta. An endovascular stent graft was inserted inside the aorta over the location of the mural thrombus. This allowed for the placement of an intra-aortic balloon pump (IABP) for pre-operative optimization. After 3 days, a left ventricular assist device (LVAD) was implanted via left anterolateral thoracotomy with hemi-sternotomy, and the IABP was removed. Post-operatively, he had a relatively uncomplicated course without signs of embolic phenomena and ultimately was discharged home. Surveillance computed tomography imaging at 6 months showed no endovascular leak or migration of the stent. This case demonstrates the feasibility of aortic stent graft placement to allow safe insertion of an IABP in the setting of aortic mural thrombus.  Furthermore, it demonstrates the safety and feasibility of LVAD implantation after recent aortic stent graft placement.

Early tracheostomy after initiation of venovenous extracorporeal membrane oxygenation is associated with decreased duration of extracorporeal membrane oxygenation support.

Timing of tracheostomy placement for patients with respiratory failure requiring venovenous extracorporeal membrane oxygenation support is variable and continues to depend on surgeon preference. We retrospectively reviewed all consecutive adult patients supported with peripheral venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome at a single institution with the hypothesis that early tracheostomy (within 7 days of extracorporeal membrane oxygenation initiation) decreases the duration of extracorporeal membrane oxygenation support. The primary endpoint was duration of extracorporeal membrane oxygenation support. Secondary endpoints included mortality, overall and intensive care unit length of stay, duration of mechanical ventilation, and time from extracorporeal membrane oxygenation initiation to liberation from ventilator, intensive care unit discharge, and hospital discharge. Overall and extracorporeal membrane oxygenation-associated hospital costs were compared. A total of 50 patients were identified for inclusion (early n = 21; late n = 29). Baseline characteristics including indices of disease severity were similar between groups. Duration of extracorporeal membrane oxygenation support was significantly shorter in the early tracheostomy group (12 vs. 21 days; p = 0.005). Median extracorporeal membrane oxygenation-related costs were significantly decreased in the early tracheostomy group ($3,624 vs. $5,603, p = 0.03). Early tracheostomy placement is associated with decreased time on extracorporeal membrane oxygenation support and reduced extracorporeal membrane oxygenation-related costs in this cohort. Validation in a prospective cohort or a clinical trial is indicated.

Outcomes of obese patients undergoing less invasive LVAD implantation.

BACKGROUND: Obesity and heart failure rates continue to rise, confronting heart failure centers with challenging left ventricular assist device (LVAD) implantations. Although less invasive approaches to implantation have been successfully implemented by many centers, this surgical approach has not yet been well evaluated in the obese population. Therefore, we sought to describe our experience with less invasive device implantation in this patient cohort. METHODS: All implants of centrifugal ventricular assist devices were retrospectively reviewed. Patients implanted with a less invasive approach via a left thoracotomy and upper hemisternotomy were included. Patients were stratified by body mass index (<30 vs ≥30 kg/m2 ). Perioperative and short-term outcomes were evaluated. RESULTS: Forty-two patients implanted with the less invasive approach (BMI <30: 27 vs. BMI ≥30 kg/m2 : 15) were identified. The obese cohort was significantly younger (58.5 vs 46.1 years, P = .022), while other preoperative demographics were similar. Postoperative mechanical ventilator time was longer in the obese cohort (22.9 vs 46.1 hour, P = .045). However, other perioperative and short-term outcomes were comparable. Wound dehiscence occurred in one obese patient. Six-month survival was also comparable between cohorts (96.3% vs 86.7%, P = .264). CONCLUSIONS: In this limited patient series, outcomes appear to be comparable in nonobese and obese patients undergoing less invasive LVAD implantation. Therefore, obesity should perhaps not be viewed as a lone contraindication to the application of this surgical approach.

Concomitant temporary mechanical support in high-risk coronary artery bypass surgery.

OBJECTIVES: Patients with low left ventricular ejection fraction (LVEF) undergoing high-risk coronary artery bypass grafting (CABG) are at increased risk for postcardiotomy cardiogenic shock. This report describes planned concomitant microaxial temporary mechanical support (MA-TMS) device placement as a viable bridge-to-recovery strategy for high-risk patients receiving surgical revascularization. METHODS: A retrospective review was performed for all patients from October 2017 to May 2019 with low LVEF (<30%), New York Heart Association Class III or IV symptoms, and myocardial viability who underwent CABG with prophylactic MA-TMS support at a single institution (n = 13). RESULTS: Mean patient age was 64.8 years, and 12 patients (92%) were male. Eight patients (62%) presented with acute coronary syndrome. Mean predicted risk of mortality was 4.6%, ranging from 0.6% to 15.6%. An average of 3.4 grafts were performed per patient. Greater than 60% of patients were extubated within 48 hours and out-of-bed within 72 hours, and the average duration of MA-TMS was 5.7 days. Mean postoperative length of stay was 16.7 days. There were no postoperative myocardial infarctions or deaths. CONCLUSIONS: Prophylactic MA-TMS may allow safe and effective surgical revascularization for patients with severe left ventricular dysfunction who may otherwise be offered a durable ventricular assist device.

Early airway dehiscence: Risk factors and outcomes with the rising incidence of extracorporeal membrane oxygenation as a bridge to lung transplantation.

BACKGROUND: Anastomotic complications occur in 7% to 18% of lung transplant recipients, among which airway dehiscence (AD) is particularly catastrophic. Using multi-institutional registry data, this study compared preoperative recipient/donor risk factors and outcomes in patients with and without AD and analyzed the effect of extracorporeal membrane oxygenation (ECMO) on the incidence of AD. METHODS: Data on adult lung transplants from 2007 to 2017 were provided by the Scientific Registry of Transplant Recipients. Patients receiving isolated lobar transplantation and patients with unknown AD status were excluded. Multivariable logistic regression identified independent risk factors for AD. Kaplan-Meier curves and log-rank tests describe mortality and graft survival. RESULTS: Of 18 122 lung transplants, 275 (1.5%) experienced AD. While the incidence of ECMO steadily increased from 0.7% to 5.9% over the study period, the incidence of AD remained relatively constant. Multivariable analysis revealed recipient male gender and prolonged ( > 48 hours) posttransplant mechanical ventilation as independent predictive factors for AD, while advanced donor age and single left lung transplant were protective factors. Recipient chronic steroid use, recipient diabetes, donor diabetes, and donor smoking history were not predictive of AD. Mortality and graft failure were significantly worse in the AD group. CONCLUSIONS: Despite increased ECMO utilization, the incidence of AD has remained stable. Multiple independent risk factors for AD were identified and poor postoperative outcomes confirmed. However, many known impediments to wound healing such as recipient chronic steroid use, recipient and donor diabetes, and donor smoking were not identified as risk factors for AD, reinforcing the critical role of technical performance.

A Novel Large Animal Model of Acute Respiratory Distress Syndrome Induced by Mitochondrial Products.

OBJECTIVE: We aimed to create a reproducible lung injury model utilizing injection of mitochondrial damage-associated molecular products. Our goal was to characterize the pathophysiologic response to damage-associated molecular pattern mediated organ injury. SUMMARY BACKGROUND DATA: There remain significant gaps in our understanding of acute respiratory distress syndrome, in part due to the lack of clinically applicable animal models of this disease. Animal models of noninfectious, tissue damage-induced lung injury are needed to understand the signals and responses associated with this injury. METHODS: Ten pigs (35-45 kg) received an intravenous dose of disrupted mitochondrial products and were followed for 6 hours under general anesthesia. These animals were compared to a control group (n = 5) and a model of lung injury induced by bacterial products (lipopolysaccharide n = 5). RESULTS: Heart rate and temperature were significantly elevated in the mitochondrial product (204 ±â€Š12 and 41 ±â€Š1) and lipopolysaccharide groups (178 ±â€Š18 and 42 ±â€Š0.5) compared with controls (100 ±â€Š13 and 38 ±â€Š0.5) (P <0.05). Lung oxygenation (PaO2/FiO2) was significantly lower 6 hours after injection in the mitochondrial products and lipopolysaccharide groups compared with controls (170 ±â€Š39, 196 ±â€Š27, and 564 ±â€Š75 mm Hg respectively, P = 0.001). Lung injury scoring of histological sections was significantly worse in mitochondrial and lipopolysaccharide groups compared with controls (mitochondrial-64 ±â€Š6, lipopolysaccharide-54 ±â€Š8, control-14 ±â€Š1.5, P= 0.002). CONCLUSIONS: Our data demonstrated that the presence of mitochondrial products in the circulation leads to systemic inflammatory response and lung injury. In its acute phase lung injury induced by tissue or bacterial products is clinically indistinguishable.

Externally visible thrombus partially predicts internal thrombus deposition in extracorporeal membrane oxygenators.

AIM: We sought to quantify the location and volume of thrombus in used hollow-fiber membrane oxygenators and correlate the volume of thrombus with patient demographics, flow characteristics and anticoagulation parameters. METHODS: Hollow-fiber membrane oxygenators (Quadrox D, Maquet, Rastatt, Germany) were collected after clinical use in ECMO circuits and divided into sections. Each section was digitally imaged and analyzed using ImageJ software. The location and total volume (cm3) of thrombus was calculated for different sections. In an effort to predict thrombus formation, we correlated thrombus volume with possible aggravating and mitigating variables. RESULTS: We collected 41 oxygenators from 27 patients. Twenty-seven (66%) were configured in the veno-venous mode and 14 (34%) in the veno-arterial mode. The median duration of use was 131 hours (interquartile range 61-214 hours). Eighteen (44%) were removed when the patient recovered, six (15%) were removed after withdrawal of care and seventeen (41%) were exchanged. The median volume of thrombus was 11.4 cm3 (interquartile range 2.2-44.5 cm3). CONCLUSIONS: A multivariable linear regression model suggested that the combination of median flow, configuration of ECMO and visible thrombus partially predicted internal thrombus volume (adjusted R2=0.39).

Thrombosis of the Right Internal Jugular Vein is Not a Contraindication to Ambulatory Veno-Venous Extracorporeal Membrane Oxygenation with a Bicaval Dual-Lumen, Single Cannula System.

BACKGROUND: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is an ever-emerging method of managing respiratory failure in patients who are refractory to conventional mechanical ventilatory support. An increasingly common method of cannulation involves placement of a bicaval dual-lumen, single cannula via the right internal jugular (IJ) vein. Thrombus in this vein has been considered a contraindication for cannula placement. CASE REPORT: A 45-year-old Hispanic male presented with bleomycin-induced respiratory failure resulting in acute respiratory distress syndrome (ARDS). Ambulatory VV-ECMO support was initiated, and during surgical cannula placement an occlusive thrombus was noted in the right IJ vein. A tract was dilated and the cannula was placed without any thromboembolic complications. CONCLUSION: This case demonstrates that cannulation for ambulatory VV-ECMO in the setting of an occlusive IJ thrombus can be safe and feasible.

Current state of ex-vivo lung perfusion.

PURPOSE OF REVIEW: The purpose of the current report is to review the ex-vivo peer-reviewed literature published in the last 5 years and to summarize the findings. RECENT FINDINGS: Encouraging data have been published by several centers utilizing ex-vivo lung perfusion (EVLP) as a means to identify viable grafts from the high-risk donor pool. The outcomes of transplanted lungs that were initially declined because of poor quality, but reevaluated with ex-vivo perfusion, are equivalent to standard criteria donor lungs. Further, research reports have emphasized the role of ex-vivo perfusion as a platform to improve graft quality and reduce the injurious effects of ischemia-reperfusion. SUMMARY: Over the last 10 years, EVLP has proved its value as a reassessment tool to increase donor utilization. As short- and long-term data demonstrate the safety of EVLP, its use as a therapeutic platform is emerging, along with the promise of a new era in lung transplantation.

Ex vivo lung perfusion in donation after circulatory death: A post hoc analysis of the Normothermic Ex Vivo Lung Perfusion as an Assessment of Extended/Marginal Donors Lungs trial.

OBJECTIVE: Donation after circulatory death (DCD) donors offer the ability to expand the lung donor pool and ex vivo lung perfusion (EVLP) further contributes to this ability by allowing for additional evaluation and resuscitation of these extended criteria donors. We sought to determine the outcomes of recipients receiving organs from DCD EVLP donors in a multicenter setting. METHODS: This was an unplanned post hoc analysis of a multicenter, prospective, nonrandomized trial that took place during 2011 to 2017 with 3 years of follow-up. Patients were placed into 3 groups based off procurement strategy: brain-dead donor (control), brain-dead donor evaluated by EVLP, and DCD donors evaluated by EVLP. The primary outcomes were severe primary graft dysfunction at 72 hours and survival. Secondary outcomes included select perioperative outcomes, and 1-year and 3-years allograft function and quality of life measures. RESULTS: The DCD EVLP group had significantly higher incidence of severe primary graft dysfunction at 72 hours (P = .03), longer days on mechanical ventilation (P < .001) and in-hospital length of stay (P = .045). Survival at 3 years was 76.5% (95% CI, 69.2%-84.7%) for the control group, 68.3% (95% CI, 58.9%-79.1%) for the brain-dead donor group, and 60.7% (95% CI, 45.1%-81.8%) for the DCD group (P = .36). At 3-year follow-up, presence observed bronchiolitis obliterans syndrome or quality of life metrics did not differ among the groups. CONCLUSIONS: Although DCD EVLP allografts might not be appropriate to transplant in every candidate recipient, the expansion of their use might afford recipients stagnant on the waitlist a viable therapy.