Ann Thorac Surg 2007;83:2194-2195
© 2007 The Society of Thoracic Surgeons
New Technology
Invited commentary
James S. Allan, MD
Division of Thoracic Surgery, Massachusetts General Hospital, 55 Fruit St, Blake 1570, Boston, MA 02114
(Email: jallan{at}partners.org).
Steen and colleagues [1] present a case of successful delayed lung transplantation using a donor graft that was ostensibly suboptimal on initial evaluation. Most notable are the use of an ex vivo perfusion system to assess the graft and an extended (overnight) period of cold preservation using a technique, which they have termed topical (extracorporeal membrane oxygenation) ECMO.
In this case, a different team harvested both lungs from a brain-dead donor secondary to closed head trauma. The donor had bilateral pulmonary contusions (right worse than left) and some retained clot within the airways bilaterally. As expected, the arterial oxygen tension of the donor was quite low. In an attempt to salvage this graft, Steen and colleagues [1] performed three key interventions ex vivo. First, the right lung was discarded due to the extent of contusion and hemorrhage. Second, the airways were suctioned clear. Third, atelectasis was removed by a transient increase in positive end-expiratory pressure. It would have been ideal if these last two interventions had been done in vivo by the donor management team prior to the procurement, but the authors are to be commended for their efforts in salvaging this organ. Also, one should keep in mind the option of obtaining blood gases directly from the pulmonary veins at the time of procurement, when there is suspicion that the function of the right and left lungs is disparate.
After these interventions, the optimized left lung was assessed by ex vivo perfusion and was found to be acceptable, clearly demonstrating the utility of this technique as an assessment tool. Whether the brief period of ex vivo perfusion served a resuscitative purpose is debatable.
Finally, the authors maintained graft viability after overnight cold storage, in which the static lung was immersed in (but not perfused with) an oxygenated, normocapnic blood-based perfusate. Although further controlled studies are needed to determine whether topical ECMO storage can prolong graft ischemic time, this case demonstrates a novel approach that could be of considerable future benefit in the field of lung transplantation.
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References
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- Steen S, Ingemansson R, Eriksson L, et al. First human transplantation of a nonacceptable donor lung after reconditioning ex vivo Ann Thorac Surg 2007;83:2191-2195.[Abstract/Free Full Text]
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First Human Transplantation of a Nonacceptable Donor Lung After Reconditioning Ex Vivo
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Ann. Thorac. Surg. 2007 83: 2191-2194.
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