There exists a chronic shortage of donor organs in

Lung Transplantation and Donation After Cardiac Death: A Single Center Experience Varun Puri, MD, Masina Scavuzzo, RN, BSN, Tracey Guthrie, RN, Ramsey Hachem, MD, Alexander S. Krupnick, MD, Daniel Kreisel, MD, PhD, G. Alexander Patterson, MD, and Bryan F. Meyers, MD, MPH Departments of Surgery and Medicine, Washington University, St. Louis, Missouri Background. Lung donation after cardiac death (DCD) can enlarge the donor pool. Single-center reports have shown comparable outcomes after lung transplantation using conventional donors versus DCD in small numbers of patients. Methods. We performed a retrospective review of DCD experience at a single lung transplant program using a prospective database. Results. Between January 2003 and April 2008, 293 lung transplantations were performed, including 11 bilateral transplantations (3.7%) using DCD lungs. Similar criteria were used to assess donor quality. The hospital mortality for DCD recipients was 2 of 11 (18%) and overall mortality was 4 of 11 (36%) by 18 months of follow-up. Seven DCD patients (64%) are alive with a median follow-up of 32 months. The DCD group was comparable to the control group in age and ischemic times. The 4 deaths, when compared with 7 DCD survivors, had longer ischemic time (293 minutes versus 232 minutes) and a higher incidence of nonlocal donors (3 of 4 versus 1 of 7). Conclusions. At our center, early outcomes after DCD lung transplantations are somewhat inferior to those of series from other centers but approach national averages for conventional lung transplantation. Thus, DCD lung transplantation has the potential to increase the donor pool but must be offered cautiously. (Ann Thorac Surg 2009;88:1609 15) 2009 by The Society of Thoracic Surgeons There exists a chronic shortage of donor organs in thoracic transplantation. Over the last decade, many strategies have been introduced to mitigate this deficit. Using marginal donors may increase the number of transplantations performed, but possibly at the expense of decreased posttransplant survival. Experimental evidence exists to validate the use of nonheart-beating donors for lung transplantation [1 6]. It has been shown in experiments that lungs and their vascular function can be safely preserved for as long as 24 hours [7, 8]. The gas-exchange system of the lungs can tolerate 1 hour of warm ischemia after circulatory arrest while still maintaining its functional integrity [2, 9], and the pulmonary artery can withstand warm ischemia for 3 hours after death without impairment of endotheliumdependent relaxation or vascular smooth muscle function [10]. Additionally, mere topical cooling of nonventilated lungs gives excellent preservation for 12 to 24 hours [11]. De Antonio and colleagues [12] published the initial clinical report of 17 patients when their group began offering lungs obtained from uncontrolled nonheartbeating donors to patients in 2002 after a preclinical study Accepted for publication June 4, 2009. Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26 28, 2009. Address correspondence to Dr Meyers, Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Queeny Tower, 3108, One Barnes-Jewish Hospital Plaza, St. Louis, MO 63110; e-mail: meyersb@wudosis. wustl.edu. had shown the functional and histologic viability of these grafts [13]. The lung transplant community has been slow to adopt donation after cardiac death (DCD), primarily because of the concern that increased warm ischemia might produce organ injury and graft dysfunction. This concern has resulted in only a handful of publications describing the clinical results of lung transplantation using DCD [12, 14 18], and no single center has a large experience. A recent paper summarized the US DCD lung transplantation experience from the UNOS database [19]. Looking at our own experience, our impression was that our results differed and were not entirely captured by the United Network for Organ Sharing database, leading to the present publication. Material and Methods The DCD Program We started our lung transplantation program in 1988 and incorporated DCD for lung transplantation in 2003. The Maastricht workshop identified categories of donors that could be considered for donation after cardiac death [20]. Category 1 donors are dead on arrival, and category 2 donors are those who undergo unsuccessful resuscitation. Category 3 encompasses donors awaiting cardiac arrest/cessation of futile treatment, and category 4 involves cardiac arrest in a brain dead donor. For the purpose of the program, only Maastricht 3 donors were considered [20]. 2009 by The Society of Thoracic Surgeons 0003-4975/09/$36.00 Published by Elsevier Inc doi:10.1016/j.athoracsur.2009.06.039

1610 PURI ET AL Ann Thorac Surg LUNG TRANSPLANTATION AND DONATION AFTER CARDIAC DEATH 2009;88:1609 15 Table 1. Criteria for Evaluation of Potential Lung Donors Age less than 55 years No history of pulmonary disease Normal serial chest radiograph Adequate gas exchange: PaO 2 more than 300 mm Hg; FIO 2 1.0; positive end-expiratory pressure 5 cm H 2 O Normal bronchoscopic examination Negative serologic screening for hepatitis B and human immunodeficiency virus Recipient matching for ABO blood group Size matching At our program, the criteria for evaluation of DCD donors were similar to those for conventional donors, and are outlined in Table 1. Donor lungs were considered local when they originated within the St. Louis metropolitan area and could be transported by ground transportation to our hospital. Other lungs from outside our region and for which air travel was required were classified as distant donor lungs. We considered both local and distant donors for DCD donations if the expected flight time was less than 60 minutes. Another classification system labels the lungs as either ideal or marginal based on important clinical characteristics of the donor. The key elements of this classification are reported in Table 2. Marginal donors, as characterized by this system, were not considered suitable for DCD lung procurement. There was a conscious attempt to use the DCD lungs for recipients considered to be at baseline risk for perioperative complications. As a result, recipients with emphysema, cystic fibrosis, and bronchiectasis were considered for the procedure, whereas recipients with pulmonary hypertension and pulmonary fibrosis were not. Patients with previous chest surgery or pleurodesis were excluded owing to unpredictable explant procedures. The entire lung transplant team, including surgeons, transplant pulmonologists, and transplant coordinators, was briefed at the initiation of the program and periodically thereafter. The DCD Procedure Appropriate consents were obtained from next of kin and the donor brought to the operating room. There, the donor was extubated and death pronounced at cessation of cardiac activity. After a 5-minute interval, the transplant procurement team was allowed into the operating room. Heparin was administered, the donor reintubated, and a bronchoscopy was performed. Expeditious sternotomy was followed by topical lung cooling with ice. Pulmonary arterial cannulation was performed, and subsequent lung preservation with Perfadex (Vitrolife, Goteborg, Sweden), lung recovery, and transplantation followed standard practice [21]. A retrograde pulmonary venous flush was routinely performed to remove any pulmonary emboli. Cold ischemic times were defined as time from initiation of antegrade pulmonary flush to time of reperfusion of the lungs. For each case of bilateral lung transplantation, this was the average of the cold ischemic time for both lungs. Postoperative Management The postoperative management was identical to that provided to a standard lung transplant patient, with emphasis on maintaining a low central venous pressure (less than 7 cm H 2 O) and weaning from mechanical ventilation as permitted. The patients were generally extubated within 24 hours if PaO 2 /FiO 2 was more than 200. Primary graft dysfunction was defined and managed per standard guidelines [22]. Immunosuppression therapy, surveillance, antibiotic prophylaxis, and diagnosis of bronchiolitis obliterans were no different than that used for conventional transplant recipients. Statistics Retrospective review of the DCD experience at a single lung transplant program using a prospective database between January 2003 and April 2008 was performed. Approval for the study was obtained from the Institutional Review Board, and need for individual consent was waived owing to the minimal risk of this retrospective review. Data are expressed as means unless otherwise stated. Descriptive statistics are presented because small numbers preclude meaningful statistical comparisons between the groups. Results Between January 2003 and April 2008, 293 lung transplants were performed at our program. There were 275 double lung transplants, 5 bilateral lobar transplants, and 13 single lung transplants. Five of the operations were retransplantation operations for bronchiolitis obliterans syndrome or primary graft dysfunction (PGD). We received 63 offers for DCD lung donors during the study period, and performed 11 bilateral transplants using DCD lungs. The 52 DCD offers that were rejected did not meet standard guidelines for evaluation of donors outlined in Table 1. The baseline characteristics and outcomes of the transplants from conventional donors and DCD donors are shown in Table 3. The diagnoses in DCD recipients were as follows: emphysema 9, cystic fibrosis 1, and bronchiectasis 1. The hospital mortality for DCD recipients was 2 of 11 (18%), with a mortality of 4 of 11 (36%) at 18 months of follow-up. Both the perioperative deaths exhibited grade 3 primary graft dysfunction and died of septic complications at 27 and 51 days. The 2 delayed DCD deaths were due to metastatic lung cancer, likely from explanted native lungs (13 months), and chronic respiratory failure with recurrent pneumonia Table 2. Characteristics of Marginal Lung Donors Age more than 55 years Smokers with more than 20 pack-year history Infiltrate on chest radiograph PaO 2 less than 300 mm Hg; FiO 2 1.0; positive end-expiratory pressure 5 cm H 2 O Purulent secretions on bronchoscopy Inhalational drug abuse

Ann Thorac Surg PURI ET AL 2009;88:1609 15 LUNG TRANSPLANTATION AND DONATION AFTER CARDIAC DEATH 1611 Table 3. Characteristics and Outcomes of Patients Undergoing Lung Transplantation During Study Period Characteristic Transplants From Brain-Dead Donors Transplants From Donations After Cardiac Death Number 282 11 Donor characteristics Mean age, years 28 12.5 36 13.3 Distant donors 201/282 (71%) 4/11 (37%) Best PaO 2 /FiO 2, mean 473.3 68 mm Hg 487.1 82 mm Hg Recipient/transplant characteristics Mean age, years 48.3 13.1 53.9 11.9 Body mass index, kg/m 2 22.6 3.9 21.6 4.2 Diagnoses COPD 110 (39%) 9 (81%) Pulmonary fibrosis 47 (17%) 0 (0%) Cystic fibrosis 62 (22%) 1 (9%) Other 63 (22%) 1 (9%) Median NYHA class 3 3 Mean ischemic time, minutes 266 254 Double lung transplant 269/282 (95.4%) 11/11 (100%) Recipient outcome Need for ECMO 6/282 (2%) 2/11 (18%) Perioperative death 11/282 (3.9%) 2/11 (18%) Primary graft dysfunction grade 3 35/191 (18%) a 4/11 (36%) Median follow-up, months 29 18 Best FEV 1, % predicted 96 24 95 20 a Missing data. COPD chronic obstructive pulmonary disease; ECMO extracorporeal membrane oxygenation; FEV 1 % forced expiratory volume in 1 second as percent of predicted; NYHA New York Heart Association. (18 months). Both these patients exhibited grade 3 PGD after implantation. Of the 11 patients undergoing lung transplantation from DCD donors, 7 patients achieved intermediate-term survival (more than 18 months). The median follow-up in this population is now 32 months. The comparative characteristics and outcomes of survivors and nonsurvivors in the DCD group are shown in Table 4. The clinical outcomes and intermediate-term clinical follow-up of the 11 patients undergoing DCD lung transplantation are summarized in Table 5. Table 4. Characteristics and Outcomes of Patients Undergoing Lung Transplantation From Donors After Cardiac Death (DCD) DCD Long-Term Survivors DCD Nonsurvivors Number 7 4 Donor characteristics Mean age, years 34.6 15.4 38.5 10.2 Distant donors 1/7 (14%) 3/4 (75%) PaO 2 /FiO 2 500 89 mm Hg 464 74 mm Hg Recipient/transplant characteristics Mean age, years 52 15 57.3 6.3 Body mass index 21.8 4.6 21.3 4.6 NYHA class (median) 3 3 Mean ischemic time (min) 232 293 Recipient outcome Need for ECMO 0/7 (0%) 2/4 (50%) Primary graft dysfunction grade 3 0/7 (0%) 4/4 (100%) Renal failure 1/7 (14%) 4/4 (100%) Median follow-up (months) 32 7 ECMO extracorporeal membrane oxygenation; NYHA New York Heart Association.

1612 PURI ET AL Ann Thorac Surg LUNG TRANSPLANTATION AND DONATION AFTER CARDIAC DEATH 2009;88:1609 15 Table 5. Clinical Outcomes of Patients Undergoing Lung Transplantation From Donors After Cardiac Death (DCD) Follow-Up (Months) Outcome Current BOS Status Current/Last Rejection Grade Best FEV 1 % Three-Month FEV 1 % Airway Complication Early Clinical Issues Mean Cold Ischemic Time (Min) Age (Years) Recipient No. 1 49 199 None No 81 81 A0B0 1 65 Alive 2 21 190 None No 87 87 A0B1 0 66 Alive 3 59 335 PGD, ECMO, No NA NA A0B0 NA 18 Recurrent pneumonia, died 4 53 252 None No 103 105 A0B0 0 36 Alive No 59 59 A0B0 NA 13 Died of NSCLC 5 55 351 PGD, DVT, 6 60 177 None No 102 118 A0B0 0 24 Alive 75 75 A1B0 1 20 Alive 7 63 225 Pneumonia Yes, required sleeve RUL No NA NA A0B0 NA 1 Died of sepsis 8 50 280 PGD, fungal pneumonia, No 64 73 A0B0 3 16 Alive 9 63 278 Empyema, 10 55 264 None No 108 110 A0B0 0 5 Alive 11 65 210 PGD, ECMO, No NA NA A3B2 NA 0 Died of sepsis BOS bronchiolitis obliterans syndrome; DVT deep vein thrombosis; ECMO extracorporeal membrane oxygenation; NA not available; NSCLC nonsmall-cell lung cancer; PGD primary graft dysfunction; RUL right upper lobectomy. Comment Donation after cardiac death lung transplantation is infrequently performed in the United States and worldwide. During the study period, 11 of 293 lung transplants (3.9%) performed at our center were from DCD donors. In the review of a large UNOS database by Mason and colleagues [19], only 36 of 14,939 lung transplants (0.24%) performed in the United States were from DCD donors [19]. Looking at all the published data, fewer than 100 DCD lung transplantations have been performed worldwide. De Antonio and coworkers [12] have published a series of 17 patients undergoing lung transplantation from Maastricht 1 donors. Their 1-month, 1-year, and 3-year survival was 82%, 69%, and 58%, respectively. The survival figures are lower than what one would expect from modern lung transplant outcomes, but the small numbers make it hard to draw conclusions. From their effort, it is possible that category 1 DCD lung transplantation may provide acceptable outcomes but is quite challenging to introduce and maintain. Thus, we have concentrated our efforts on a Maastricht 3 DCD lung transplantation program. Our DCD perioperative mortality (2 of 11, 18%) is higher than our perioperative mortality from conventional donors (11 of 282, 3.9%) and that seen in outcomes from large databases [19]. Our first perioperative death had a distant donor and relatively long cold ischemic time (335 minutes). She had grade 3 PGD, required prolonged ventilator support, and died of fungal sepsis. Our second perioperative mortality had a local donor and relatively short ischemic time (207 minutes), but severe PGD developed requiring extracorporeal membrane oxygenation (ECMO) support. The patient was weaned from ECMO but died of abdominal sepsis at 27 days. In our series, the 4 intermediate-term deaths had longer ischemic times (293 versus 232 minutes) and were more likely to have a distant donor (3 of 4 versus 1 of 7). The absolute number of patients in our series is small, and any differences may be due to chance. Snell and associates [17] noted a mean overall ischemic time of 443 minutes, and Mason and associates [20] reported an average maximum lung ischemic time of 371 minutes in the DCD cohorts reported by these authors. Both series describe favorable outcomes, and thus we cannot place too much emphasis on the differences in ischemic times in our cohort. The mean ischemic time in our report is the average of the two ischemic times in double lung transplantation, hence apparently lower than the numbers in these two reports. We have avoided the use of DCD lungs for patients with pulmonary hypertension and pulmonary fibrosis and for patients with prior pleurodesis to avoid long and unpredictable explant procedures. This policy favors patients with emphysema, cystic fibrosis, and bronchiectasis who may have lower lung allocation scores and may not get transplanted otherwise. Also, this approach selects a group of patients who are at a baseline risk for complications, avoiding the higher risk population of patients with pulmonary hypertension and pulmonary fibrosis. The 4 deaths were of patients who suffered from significant perioperative morbidity, with 2 of them requiring

Ann Thorac Surg PURI ET AL 2009;88:1609 15 LUNG TRANSPLANTATION AND DONATION AFTER CARDIAC DEATH 1613 ECMO support for severe PGD. All 4 also had. Of the 7 survivors, only 1 had that did not require dialysis. There was 1 major airway complication of the 22 anastomoses at risk. The patient required a sleeve right upper lobectomy and has done well since. Our airway complication rate of less than 5% is similar or favorable to that of published data [23]. The incidence of grade 3 PGD is 36% in the DCD group and 18% in our general transplant cohort (Table 4). This difference may be due to chance as the numbers in the DCD group are small. Snell and colleagues [17] describe an incidence of 13% PGD grade 3 in their DCD population whereas deantonio and colleagues [12] noted an incidence of 29%. It is suspected that warm ischemia may contribute to the incidence of PGD in the DCD population, but the precise nature of the impact is not clear with the limited clinical data available. Snell and colleagues [17] have demonstrated excellent short-term results from their series of 8 DCD Maastricht 3 lung transplants, with no perioperative mortality and 1 patient requiring perioperative use of ECMO for grade 3 PGD. Another recent paper [19] summarizes the North American experience from the UNOS database looking at 36 patients with an excellent survival of 87% at 24 months in DCD lung transplantation. Reviewing our own patients and comparing them to the published UNOS database results, which should be inclusive of data from all US transplant centers [19], 2 of our intermediate-term deaths (51 days and 13 months) were not captured by the UNOS database. Our own 1-year survival of 81% and 2.5-year survival of 63% are closer to the outcomes seen for conventional bilateral lung transplantation in the International Society for Heart and Lung Transplantation registry (83% 1-year survival, 67% 3-year survival) [24]. In the context of DCD, there is no clear consensus on the definition of warm ischemia. Oto and colleagues [14] defined it as the interval between cessation of cardiac output and the time to antegrade pulmonary artery flush. In addition, there is a second period of warm ischemic time during implantation: the time from the removal of the lung from the cold preservative to the time of restoration of blood flow to the graft lung. It is generally recommended that the initial warm ischemia not exceed 60 minutes [17]. Although we did not formally record warm ischemic time in our database, every procurement involved withdrawal of support in the operating room, and there were no instances of prolonged cardiac activity after extubation. It is likely that our initial warm ischemic times were in the 20- to 45-minute range. Our series has obvious limitations. It is a single-center, retrospective review of a relatively small patient population. Also, we do not have recorded data for warm ischemic times. Still, because our data add to a growing body of literature about DCD lung transplantation, which can increase the donor pool, we believed it would be of interest to the lung transplant community. In conclusion, our patient outcomes for DCD lung transplantation show acceptable survival in the intermediate term. Hence, DCD lung transplantation has been shown to be an additive influence on the number of patients undergoing lung transplantation [17] and may continue to be cautiously offered as part of a lung transplant program. References 1. Egan TM. Non-heart beating donors in thoracic transplantation. J Heart Lung Transplant 2004;23:3 10. 2. Egan TM, Lambert CJ, Reddick RL, Ulicny KS, Keagy BA, Wilcox BR. A strategy to increase the donor pool: the use of cadaver lungs for transplantation. Ann Thorac Surg 1991;52: 1113 21. 3. Shimada K, Kondo T, Handa M, et al. The possibility of lung transplantation from non-heart-beating donors: experimental study in a canine model. Transplant Proc 1994;26:880 1. 4. Buchanan SA, DeLima NF, Binns OAR, et al. Pulmonary function after non-heart-beating lung donation in a survival model. Ann Thorac Surg 1995;60:38 46. 5. Greco R, Cordovilla G, Sanz E, et al. Warm ischemic time tolerance after ventilated non-heart-beating lung donation in piglets. Eur J Cardiothorac Surg 1998;14:319 25. 6. Wierup P, Andersen C, Janciauskas D, Bolys R, Sjoberg T, Steen S. Bronchial healing, lung parenchymal histology, and blood gases one month after transplantation of lungs topically cooled for 2 hours in the non-heart-beating cadaver. J Heart Lung Transplant 2000;19:270 6. 7. Steen S, Kimblad PO, Sjöberg T, Lindberg L, Ingemansson R, Massa G. Safe lung preservation for twenty-four hours with Perfadex. Ann Thorac Surg 1994;57:450 7. 8. Ingemansson R, Massa G, Pandita R, Sjöberg T, Steen S. Perfadex is superior to Euro-Collins solution regarding 24- hour preservation of vascular function. Ann Thorac Surg 1995;60:1210 4. 9. Van Raemdonck DEM, Jannis NCP, De Leyn PRJ, Flameng WJ, Lerut TE. Warm ischemic tolerance in collapsed pulmonary grafts is limited to 1 hour. Ann Surg 1998;228:788 96. 10. Bolys R, Ingemansson R, Sjöberg T, Steen S. Vascular function in the cadaver up to six hours after cardiac arrest. J Heart Lung Transplant 1999;18:582 6. 11. Steen S, Sjöberg T, Ingemansson R, Lindberg L. Efficacy of topical cooling in lung preservation: is a reappraisal due? Ann Thorac Surg 1994;58:1657 63. 12. de Antonio DG, Marcos R, Laporta R, et al. Results of clinical lung transplant from uncontrolled non-heart-beating donors. J Heart Lung Transplant 2007;26:529 34. 13. Varela A, Gámez P, Núñez JR, Río F, Calatayud J. Preclinical experience in transplant with lung obtained from non heart beating donors. J Heart Lung Transplant 2003;22(Suppl):112. 14. Oto T, Levvey B, McEgan R, et al. A practical approach to clinical lung transplantation from a Maastricht category III donor with cardiac death. J Heart Lung Transplant 2007;26: 196 9. 15. Steen S, Ingemansson R, Budrikis A, Bolys R, Roscher R, Sjoberg T. Successful transplantation of lungs topically cooled in the non-heart-beating donor for 6 hours. Ann Thorac Surg 1997;63:345 51. 16. Steen S, Liao Q, Wierup PN, Bolys R, Pierre L, Sjoberg T. Transplantation of lungs from non-heart-beating donors after functional assessment ex vivo. Ann Thorac Surg 2003; 76:244 52. 17. Snell GI, Levvey BJ, Oto T, et al. Early lung transplantation success utilizing controlled donation after cardiac death donors. Am J Transplant 2008;8:1282 8. 18. Mason DP, Murthy SC, Gonzalez-Stawinski GV, et al. Early experience with lung transplantation using donors after cardiac death. J Heart Lung Transplant 2008;27:561 3. 19. Kootstra G. Statement on non-heart-beating donor programs. Transplant Proc 1995;27:2965E. 20. Mason DP, Thuita L, Alster JM, et al. Should lung transplantation be performed using donation after cardiac death? The United States experience. J Thorac Cardiovasc Surg 2008;136: 1061 6.

1614 PURI ET AL Ann Thorac Surg LUNG TRANSPLANTATION AND DONATION AFTER CARDIAC DEATH 2009;88:1609 15 21. Puri V, Patterson GA. Adult lung transplantation: technical considerations. Semin Thorac Cardiovasc Surg 2008;20:152 64. 22. Christie JD, Carby M, Bag R, Corris P, Hertz M, Weill D. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction part II: definition. A consensus statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2005;24:1454 9. 23. Moreno P, Alvarez A, Algar FJ, et al. Incidence, management and clinical outcomes of patients with airway complications following lung transplantation. Eur J Cardiothorac Surg 2008;34:1198 205. 24. International Society for Heart and Lung Transplantation registry. Available at: http://www.ishlt.org/registries/ quarterlydatareportresults.asp?organ LU&rptType tx_p_surv&continent 4. Accessed December 27, 2008. DISCUSSION DR SETH D. FORCE (Atlanta, GA): That was a great presentation from an outstanding transplant program. I have a couple questions. Number one, what is your cutoff for how long you will allow once a donor is extubated to the time of cardiac death that you will take the lungs? DR PURI: Sixty minutes. We use the standard DCD evaluation tool to predict the probability of this. DR FORCE: Did you go back and look at that time in any of the patients who did poorly to see if it was closer to the 60 or to the 20 or 15 minutes? DR PURI: Of the 11 patients, we have warm ischemic times recorded in 6. In all of them, the ischemic times are between 15 and 35 minutes. For the remaining 5 patients since it s a very small patient population, everyone remembers these patients quite well in none of them was prolonged cardiac activity observed after extubation. So our warm ischemic times were not a problem. DR FORCE: Just two more quick questions. Number one, when I was at Barnes, the method of procuring for DCD donors was just to wait and do it in the standard fashion once the heart had stopped. Other authors have proposed putting in chest tubes as soon as the patient is extubated and irrigating with cold saline. Have you changed your techniques to try to reduce the incidence the primary graft dysfunction? DR PURI: No. It is still similar to what you had observed when you were there. It s fairly similar to conventional lung transplantation procurement technique. And since the warm ischemic times are low as we see, I don t think it would make a difference. I believe the experience that you re referring to is D Antonio s paper from the 2007 Journal of Heart and Lung Transplantation in Maastricht I and II donors in which they used this protocol and irrigated the thoracic cavity with the cold saline. Also some other programs are implementing a Maastricht III donor program in which they withdraw support in the intensive care unit. That would possibly increase warm ischemic times. DR FORCE: My final question is for the chairs as well as you. I read a lot of abstracts and papers on DCD donors. I do not get a lot of offers for DCD donors. These patients are usually in the hospital for a long time. They develop multiple complications, pneumonias. And my thought has always been whenever I read an abstract, is this really going to increase the lung donor population that much? You ve mentioned other strategies that I think are much more likely to. I want to get your thoughts. I mean, I m always happy to use a DCD donor. I haven t done one in 5 years just because I haven t gotten a suitable donor. DR JOSHUA R. SONETT (New York, NY): I think this paper is excellent because it introduces a word of caution in regard to a new technique that is very exciting and especially being used more commonly. At Columbia, we ve just done 2 DCD donors mostly because in this early phase, as with St Louis, We have been very picky in regard to the donors. We have limited it to 20- to 30-year-olds, limited ischemic time, with less travel. But I think as we become more comfortable with the technique we may be able to add 6% or 10% to the donor pool, and it will really help. We may just have to be careful not to push the envelope too hard as this paper shows. Now, let me ask you. What are your criteria now? Have you changed at all because you looked at it? Which ones would you take versus not take for DCD donors? DR PURI: Before I answer that, do you mind if I add two pieces of data to Dr Force s question. We have received about 63 offers in this period of time, of which we have accepted 11 DCD lungs. And Dr Snell from Australia has shown that it has increased their annual transplantation numbers using DCD by about between 10% and 15%. Now, for criteria, we haven t really changed our criteria because they were fairly strict to start with. I do believe that of the 2 the patients who died with primary graft dysfunctions, 1 of them was likely related to chance. The other had significantly prolonged ischemic times. And others have shown that in their limited DCD experience, these patients do quite well. I m privy to some data from the University of Wisconsin, which are going to be published or presented to the AATS by Dr DeOliveira, and his numbers are better than ours. So I do think that experienced lung transplant programs should proceed cautiously with this, but again, maintaining very tight controls over the quality of the donor organ and taking it from patients that are safe. DR MICHAEL S. MULLIGAN (Seattle, WA): Liver and kidney programs are backing away from this. You re going to see the DCD numbers go down for 2009. The cautionary notes about biliary strictures and problems with timing of withdrawal are big. Your protocol appears to be in line with what we arrived at the Consensus Conference in Chicago 3 years ago, but I think I would add some practical notion to what Seth is asking. I would only do local DCD donors. I think you can take that away from this. And I think you need to put your most experienced team in the field to do this. If you put a junior fellow out in the field and ask him to flounder around with an abdominal surgeon who wants to vent in the chest, as is the routine with DCD abdominal donation, you re going to get into problems. So it needs to be very tight, and you should have a very low threshold for walking away. Having an attending in the field will assist that. Having a resident who is reluctant to make that decision and stop the transplant process at his discretion may lead you to carry that momentum forward when you would rather arrest it.

Ann Thorac Surg PURI ET AL 2009;88:1609 15 LUNG TRANSPLANTATION AND DONATION AFTER CARDIAC DEATH 1615 DR BRYAN FITCH MEYERS (St. Louis, MO): Those are good points, and you also might even consider the notion of additional consent when you use a DCD donor. We have to do additional consents now for donors who are considered socially high risk donors. This DCD situation is another example of when the donor is distinct from the rest of the donor pool and might require extra caution and explanation to the potential recipient. DR SONETT: I think it s a requirement, actually, for CMS. You need to separately consent for anything out of the norm, and certainly DCD is out of the norm. The Society of Thoracic Surgeons: Forty-Sixth Annual Meeting Mark your calendars for the Forty-Sixth Annual Meeting of The Society of Thoracic Surgeons (STS) to be held at the Greater Fort Lauderdale-Broward County Convention Center, Fort Lauderdale, Florida, from January 25 27, 2010. The meeting is open to all physicians, residents, fellows, engineers, perfusionists, physician assistants, nurses, or other interested individuals. Meeting attendees will be provided with the latest scientific information for practicing cardiothoracic surgeons. Attendees will benefit from traditional Abstract Presentations, as well as Surgical Forums, Breakfast Sessions, Surgical Motion Pictures, and Wet Lab sessions. Parallel sessions on Monday and Tuesday will focus on specific subspecialty interests. An advance program with a registration form, hotel reservation information, and details regarding spouse/ guest activities will be mailed to STS members this fall. Nonmembers may contact the Society s secretary, Douglas E. Wood, MD, to receive a copy of the advanced program; however, detailed meeting information will be available on the STS website at www.sts.org. Douglas E. Wood, MD Secretary The Society of Thoracic Surgeons 633 N. Saint Clair St, Suite 2320 Chicago, IL 60611-3658 Telephone: (312) 202-5800 Fax: (312) 202-5801 email: sts@sts.org website: www.sts.org 2009 by The Society of Thoracic Surgeons Ann Thorac Surg 2009;88:1615 0003-4975/09/$36.00 Published by Elsevier Inc