Breathing New Life Into Donation After Circulatory Death (DCD) Lung Transplantation: The Role of Machine Perfusion

Lung transplantation (LTx) is a life-saving procedure for patients with end-stage pulmonary disease, but the shortage of suitable donor lungs remains a critical barrier. Traditionally, lungs from donors after brain death (DBD) have been preferred, though the growing presence of donation after circulatory death (DCD) is a viable solution to expand the donor pool. However, DCD lungs present unique challenges, primarily due to exposure to warm ischemia, higher aspiration risk, hurried evaluation, and the lack of real-time viability assessment. Additionally, many donor hospitals and organ procurement organizations (OPOs) impose limitations on certain pre-mortem interventions, such as restrictions on aggressive lung recruitment, a potential barrier to improvement of lung function, and bronchoscopy, which can reduce the willingness of transplant centers to accept lung offers. This review examines the impact of modern preservation methods, particularly machine perfusion (MP) technologies such as ex vivo lung perfusion (EVLP) and the Organ Care System (OCS), on DCD lung transplantation outcomes. MP technologies allow for the preservation, assessment, and reconditioning of DCD lungs, significantly improving their viability and transplantation success rates. Studies indicate that MP can reduce the risks of ischemia-reperfusion injury (IRI), enhance graft function, and increase lung utilization without compromising short-term or long-term survival outcomes. Despite this, the implementation of MP faces challenges related to logistical coordination, cost-effectiveness, and protocol variability. With that said, the growing body of evidence suggests that MP can help to overcome the traditional limitations of DCD lungs, thus expanding the donor pool and improving transplant outcomes.