Related Experiment Video
Updated: Aug 17, 2025
Lung Rapid Recovery Procurement Combined with Abdominal Normothermic Regional Perfusion in Controlled Donation after Circulatory Death
Published on: August 15, 2022
Prioritizing direct heart procurement in organ donors after circulatory death does not jeopardize lung transplant
Stefan Schwarz1, Johannes Gökler2, Roxana Moayedifar2
1Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
Insights
Controlled donation after circulatory death (cDCD) heart procurement may delay lung ventilation, increasing warm ischemic time. However, lung transplant outcomes remain unaffected, making simultaneous heart and lung procurement acceptable.
Area of Science:
- Transplantation Medicine
- Organ Procurement
- Cardiopulmonary Surgery
Background:
- Controlled donation after circulatory death (cDCD) is standard for liver, kidney, and lung transplants.
- Innovations in ex vivo heart preservation enable acceptance of cDCD heart allografts.
- cDCD procedures require modifications due to the heart's limited tolerance to warm ischemia, potentially impacting lung allograft function.
Purpose of the Study:
- To evaluate the impact of prioritizing cDCD heart explantation on subsequent lung allograft function and transplant outcomes.
- To compare post-lung transplant outcomes between lungs procured with concurrent heart procurement versus lungs procured alone.
Main Methods:
- Retrospective analysis of 56 cDCD lung transplants performed between 2012 and February 2022.
- Comparison of a heart+lung procurement group (n=7) with a lung-only procurement group (n=49).
- Analysis of procedural times, primary graft dysfunction (PGD), mechanical ventilation duration, ICU stay, and early survival.
Main Results:
- Heart+lung procurement involved significantly longer times from circulatory arrest to lung perfusion and skin incision to lung perfusion.
- No significant differences were observed in PGD grades at 0, 24, 48, or 72 hours post-transplant between the groups.
- Mechanical ventilation duration, ICU stay, and hospital stay were comparable, with low in-hospital mortality in both groups.
Conclusions:
- Prioritized cDCD heart explantation leads to delayed lung ventilation and increased warm ischemic time.
- Despite longer ischemic times, lung transplant outcomes within the first year are not negatively impacted.
- cDCD organ procurement prioritizing heart perfusion and explantation is a viable and acceptable approach.
Background:
Controlled donation after circulatory death (cDCD) has become a standard in liver, kidney, and lung transplantation (LTx). Based on recent innovations in ex vivo heart preservation, heart transplant centers have started to accept cDCD heart allografts. Because the heart has very limited tolerance to warm ischemia, changes to the cDCD organ procurement procedures are needed. These changes entail delayed ventilation and prolonged warm ischemia for the lungs. Whether this negatively impacts lung allograft function is unclear.
Methods:
A retrospective analysis of cDCD lungs transplanted between 2012 and February 2022 at the Medical University of Vienna was performed. The heart + lung group consisted of cases in which the heart was procured by a cardiac team for subsequent normothermic ex vivo perfusion. A control group (lung group) was formed by cases where only the lungs were explanted. In heart + lung group cases, the heart procurement team placed cannulas after circulatory death and a hands-off time, collected donor blood for ex vivo perfusion, and performed rapid organ perfusion with Custodiol solution, after which the heart was explanted. Up to this point, the lung procurement team did not interfere. No concurrent lung ventilation or pulmonary artery perfusion was performed. After the cardiac procurement team left the table, ventilation was initiated, and lung perfusion was performed directly through both stumps of the pulmonary arteries using 2 large-bore Foley catheters. This study analyzed procedural explant times, postoperative outcomes, primary graft dysfunction (PGD), duration of mechanical ventilation, length of intensive care unit (ICU) stay, and early survival after LTx.
Results:
A total of 56 cDCD lungs were transplanted during the study period. In 7 cases (12.5%), the heart was also procured (heart + lung group); in 49 cases (87.5%), only the lungs were explanted (lung group). Basic donor parameters were comparable in the 2 groups. The median times from circulatory arrest to lung perfusion (24 minutes vs 13.5 minutes; P = .002) and from skin incision to lung perfusion (14 minutes vs 5 minutes; P = .005) were significantly longer for the heart + lung procedures. However, this did not affect post-transplantation PGD grade at 0 hours (P = .851), 24 hours (P = .856), 48 hours (P = .929), and 72 hours (P = .874). At 72 hours after transplantation, none of the lungs in the heart + lung group but 1 lung (2.2%) in lung group was in PGD 3. The median duration of mechanical ventilation (50 hours vs 41 hours; P = .801), length of ICU stay (8 days vs 6 days; P = .951), and total length of hospital stay (27 days vs 25 days; P = .814) were also comparable in the 2 groups. In-hospital mortality occurred in only 1 patient of the lung group (2.2%).
Conclusions:
Although prioritized cDCD heart explantation is associated with delayed ventilation and significantly longer warm ischemic time to the lungs, post-LTx outcomes within the first year are unchanged. Prioritizing heart perfusion and explantation in the setting of cDCD procurement can be considered acceptable.
