Limited cumulative experience with ex vivo lung perfusion is associated with inferior outcomes after lung transplantation.

OBJECTIVE: Ex vivo lung perfusion (EVLP) allows for prolonged preservation and evaluation/resuscitation of donor lungs. We evaluated the influence of center experience with EVLP on lung transplant outcomes. METHODS: We identified 9708 isolated, first-time adult lung transplants from the United Network for Organ Sharing database (March 1, 2018-March 1, 2022), 553 (5.7%) involved using donor lungs after EVLP. Using the total volume of EVLP lung transplants per center during the study period, centers were dichotomized into low- (1-15 cases) and high-volume (>15 cases) EVLP centers. RESULTS: Forty-one centers performed EVLP lung transplants, including 26 low-volume and 15 high-volume centers (median volume, 3 vs 23 cases; P < .001). Recipients at low-volume centers (n = 109) had similar baseline comorbidities compared with high-volume centers (n = 444). Low-volume centers used numerically more donation after circulatory death donors (37.6 vs 28.4%; P = .06) and more donors with Pao2/Fio2 ratio <300 (24.8 vs 9.7%; P < .001). After EVLP lung transplants, low-volume centers had worse 1-year survival (77.8% vs 87.5%; P = .007), with an adjusted hazard ratio of 1.63 (95% CI, 1.06-2.50, adjusting for recipient age, sex, diagnosis, lung allocation score, donation after circulatory death donor, donor Pao2/Fio2 ratio, and total annual lung transplant volume per center). When compared to non-EVLP lung transplants, 1-year survival of EVLP lung transplants was significantly worse at low-volume centers (adjusted hazard ratio, 2.09; 95% CI, 1.47-2.97) but similar at high-volume centers (adjusted hazard ratio, 1.14; 95% CI, 0.82-1.58). CONCLUSIONS: The use of EVLP in lung transplantation remains limited. Increasing cumulative EVLP experience is associated with improved outcomes of lung transplantation using EVLP-perfused allografts.

Impact of minimally invasive lung transplantation on early outcomes and analgesia use: A matched cohort study.

BACKGROUND: Minimally invasive (MI) approaches to lung transplantation (LTx) offer the prospect of faster recovery compared to traditional incisions, however, little data exist describing the impact of surgical technique on early outcomes and analgesia use. METHODS: A prospectively maintained institutional registry identified 170 patients who underwent LTx between January, 2017 and June, 2022. Post-COVID acute respiratory distress syndrome, repeat, and multiorgan transplants were excluded (n = 27) leaving 37 MILTx and 106 traditional LTx patients. Propensity score matching by age, sex, body mass index, diagnosis, lung allocation score, double vs. single lung, hypertension, diabetes, and hospitalization status created 37 pairs. RESULTS: Before matching, MILTx patients were more often male (70% vs 43%) and more likely to receive grafts from younger (31 vs 42 years), circulatory death donors (19% vs 6%) compared with traditional LTx patients (all p < 0.05). After matching, there were no differences in graft warm ischemia or operative duration (both p > 0.05). Postoperatively, MILTx experienced shorter intensive care unit (ICU) (4.3 [IQR 3.1-5.5] vs 8.2 [IQR 3.7-10.8] days) and hospital lengths of stay (LOS) (13 [IQR 11-15] vs 17 [IQR 12-25] days) (both p < 0.05). Among patients surviving to discharge, MILTx patients required fewer opioid prescriptions at discharge (38% vs 66%, p = 0.008) and had improved pulmonary function at 3 months (Forced expiratory volume in 1 second 82 [IQR 72-102] vs 77 [IQR 52-88]% predicted; forced vital capacity 78 [IQR 65-92] vs 70 [IQR 62-80]% predicted] (both p < 0.05). CONCLUSION: Minimally invasive LTx techniques demonstrate potential advantages over traditional approaches, including reduced ICU and hospital LOS, lower opioid use on discharge, and improved early pulmonary function.

Consensus Statement: Technical Standards for Thoracoabdominal Normothermic Regional Perfusion.

BACKGROUND: Thoracoabdominal normothermic regional perfusion (TA-NRP) has emerged as a powerful technique for optimizing organ procurement from donation after circulatory death donors. Despite its rapid adoption, standardized guidelines for TA-NRP implementation are lacking, prompting the need for consensus recommendations to ensure safe and effective utilization of this technique. METHODS: A working group composed of members from The American Society of Transplant Surgeons, The International Society of Heart and Lung Transplantation, The Society of Thoracic Surgeons, and The American Association for Thoracic Surgery was convened to develop technical guidelines for TA-NRP. The group systematically reviewed existing literature, consensus statements, and expert opinions to identify key areas requiring standardization, including predonation evaluation, intraoperative management, postdonation procedures, and future research directions. RESULTS: The working group formulated recommendations encompassing donor evaluation and selection criteria, premortem testing and therapeutic interventions, communication protocols, and procedural guidelines for TA-NRP implementation. These recommendations aim to facilitate coordination among transplant teams, minimize variability in practice, and promote transparency and accountability throughout the TA-NRP process. CONCLUSIONS: The consensus guidelines presented herein serve as a comprehensive framework for the successful and ethical implementation of TA-NRP programs in organ procurement from donation after circulatory death donors. By providing standardized recommendations and addressing areas of uncertainty, these guidelines aim to enhance the quality, safety, and efficiency of TA-NRP procedures, ultimately contributing to improved outcomes for transplant recipients.

Consensus Statement: Technical Standards for Thoracoabdominal Normothermic Regional Perfusion.

BACKGROUND: Thoracoabdominal normothermic regional perfusion (TA-NRP) has emerged as a powerful technique for optimizing organ procurement from donation after circulatory death donors. Despite its rapid adoption, standardized guidelines for TA-NRP implementation are lacking, prompting the need for consensus recommendations to ensure safe and effective utilization of this technique. METHODS: A working group composed of members from The American Society of Transplant Surgeons, The International Society of Heart and Lung Transplantation, The Society of Thoracic Surgeons, and The American Association for Thoracic Surgery was convened to develop technical guidelines for TA-NRP. The group systematically reviewed existing literature, consensus statements, and expert opinions to identify key areas requiring standardization, including predonation evaluation, intraoperative management, postdonation procedures, and future research directions. RESULTS: The working group formulated recommendations encompassing donor evaluation and selection criteria, premortem testing and therapeutic interventions, communication protocols, and procedural guidelines for TA-NRP implementation. These recommendations aim to facilitate coordination among transplant teams, minimize variability in practice, and promote transparency and accountability throughout the TA-NRP process. CONCLUSIONS: The consensus guidelines presented herein serve as a comprehensive framework for the successful and ethical implementation of TA-NRP programs in organ procurement from donation after circulatory death donors. By providing standardized recommendations and addressing areas of uncertainty, these guidelines aim to enhance the quality, safety, and efficiency of TA-NRP procedures, ultimately contributing to improved outcomes for transplant recipients.