Transplante de pulmon

Update on Donor Assessment, Resuscitation, and Acceptance Criteria, Including Novel Techniquesç Non ^ Hear t- Beating Donor Lung Retrieval and Ex Vivo Donor Lung Per fusion
Jonathan C. Yeung, MDa, Marcelo Cypel, MDa, Thomas K.Waddell, MDa, Dirk van Raemdonck, MDb, Shaf Keshavjee, MDa,*
KEYWORDS
 Lung transplantation  Non-heart beating donor  Ex vivo lung perfusion  Donor assessment  Donorresuscitation

Lung transplantation has seen increasing success as a therapy that improves the quality and quantity of life for selected patients who have end-stage lung disease.1 Only a minority of patients, however, can benefit because of the lack of acceptable donor organs. The largest source of donor organs is from donations after neurologic determination of death (DNDDs). Unfortunately,because of injuries acquired during the process of brain death, the average organ procurement rate remains disappointing. United Network for Organ Sharing data reveal that only 2489 individual lungs were

transplanted from 8089 deceased donors in 2007.2 As a comparison, 11,752 individual kidneys were transplanted from that same pool of organ donors. This lack of donor organs has been the impetusfor the search for alternative donor sources. A common strategy to maximize use of DNDD lungs has been to transplant extended criteria donor organs (ie, those organs that fall outside of International Society for Heart and Lung Transplantation [ISHLT] standard criteria but still believed to be transplantable).3 Some transplant programs have begun to explore the use of circulation-arrested

a

bToronto Lung Transplant Program, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada The Lung Transplant Program, University Hospital Gasthuisberg, UZ Gasthuisberg, Herestraat 49, Leuven 3000, Belgium * Corresponding author. Division of Thoracic Surgery, Toronto General Hospital, 200 Elizabeth Street, 9N-947, Toronto, ON, Canada. E-mail address: shaf.keshavjee@uhn.on.ca (S.Keshavjee).

Thorac Surg Clin 19 (2009) 261–274 doi:10.1016/j.thorsurg.2009.02.006 1547-4127/09/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.

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Yeung et al
donors, so called non–heart-beating donors (NHBDs) or donors after cardiac death,4,5 as alternative sources for lungs. Because most patients succumb as a result of cardiac arrest, the use ofNHBDs could open a new pool of donor organs of such magnitude that ultimately the entire demand could be met. A major problem with the use of extended criteria donor organs and NHBDs is the difficulty in assessing which lungs can be used safely. The urgency during the retrieval of lungs from NHBDs compounds this difficulty.6 This article focuses on DNDD and NHBD lung criteria, assessment,preservation, retrieval, and the possible role of ex vivo lung perfusion (EVLP). evaluation is imprecise and approximately 11% to 57% of lungs go on to primary graft dysfunction (PGD) of varying severity, some of which may be the result of unrecognized donor injury.8 As a consequence, transplant clinicians remain conservative when choosing lungs for fear of potential PGD. It is estimated that 40% ofrejected donor lungs could be used safely if more detailed and accurate evaluation were available to identify these lungs.9

NON^HEART-BEATING DONORS
At the First International Workshop on NHBD, held in Maastricht, the Netherlands, in 1995, four types of donors were identified, the so-called Maastricht categories.10 Categories I (dead on arrival) and II (unsuccessful resuscitation) comprise theuncontrolled donors. Categories III (awaiting cardiac arrest) and IV (cardiac arrest in brain-dead donors) include the controlled donors (see Box 1). The first clinical lung transplantation, performed by James Hardy in 1963,11 used a lung from a NHBD who died from a myocardial infarction. At that time, use of a NHBD was a necessity, as the concept of brain death was not yet legally established. Once...