WHAT IS EVLP?
EVLP stands for ex-vivo lung perfusion. This means that donor lungs are removed from the donor's body (“ex-vivo" is Latin for "outside that which is living”) and put onto a special device that keeps them at the same conditions as in the body.
While on this device, the lungs are also filled (“perfused”) with a nutrient-rich solution that helps prevent them from being damaged.
This gives doctors the chance to look closely at the condition of the lungs, and decide if they can be used for transplantation.
EVLP gives the transplant team more time to evaluate whether the lungs can be used for a transplant.
The EVLP system attempts to mimic the functionality of the body. The donor lungs are attached to a ventilator, pump, and filters. The donor lungs are kept at normal body temperature and perfused.
EVLP makes it possible for organs to be transported over greater distances. This may help hospitals in procuring lungs from donors that are farther away.
WHY IS EVLP NEEDED?
SHORTAGE OF ORGANS THAT MEET "IDEAL" SPECIFICATIONS
Historically, the number of people on the transplant waiting list continues to be much larger than the number of acceptable donors.
Though the number of donors is rising, many donor organs are still not used because they are considered unacceptable.
Data from optn.transplant.hrsa.gov and OPTN/SRTR Annual Report.
LUNGS VERSUS OTHER TRANSPLANTED ORGANS
ONLY 20%
OF AVAILABLE DONOR LUNGS ARE USED FOR TRANSPLANTATION*
*Each year this percentage is increasing due to technological advancements
80%
ARE NOT USED
BY COMPARISON:
70%-80%
of available donor kidneys are used for transplantation
75%
of available donor livers are used for transplantation
30%
of available donor hearts are used for transplantation
WHY ARE ONLY 20% OF DONOR LUNGS USED?
- CONDITION OF DONOR LUNGSLUNGS ARE VULNERABLE AND MAY BECOME DAMAGED
Lungs may become damaged as a result of the donor’s death due to many factors, including:
- ISCHEMIAABSENT OR INSUFFICIENT BLOOD SUPPLY TO LUNGS
- EDEMAEXCESS FLUID IN THE LUNGS
- PNEUMONIAINFLAMMATION OF THE LUNGS CAUSED BY INFECTION
- TRAUMADIRECT INJURY TO THE LUNGS
- LOGISTICAL CHALLENGESLUNGS HAVE SHORT PRESERVATION AND TRANSPORT TIMES
Donated lungs have a short preservation time (the time between lung removal and transplantation) to remain viable. This limits the distance they can be transported for transplantation.
LUNG PRESERVATION TIME
4 hr - 6 hr
Common maximum adult organ preservation times- KIDNEY
24 hr - 36 hr - LIVER8 hr - 12 hr
- HEART4 hr - 6 hr
- DONOR MEDICAL HISTORYONLY A LIMITED NUMBER OF ORGAN DONORS MEET LUNG ACCEPTANCE CRITERIA
Below are some of the characteristics of an ideal donor:
YOUNG DONORS
NO SIGNIFICANT MEDICAL HISTORY
MINIMAL SMOKING HISTORY
GOOD LUNG FUNCTION
- ORGAN MATCHINGINABILITY TO FIND RECIPIENT
Factors that affect the allocation of every donated organ include:
BLOOD TYPE
SIZE
TIME LIMITATIONS
DISTANCE FROM DONOR HOSPITAL
EVLP POTENTIAL
Discover the many benefits that EVLP can offer the field of lung transplantation:
“ [With EVLP] we have been able to utilize some lungs that otherwise would not have been used for transplant.”
EVLP TIMELINE
The idea of ex vivo organ perfusion started over 50 years ago. Transplant programs around the world have contributed to advancing the technology to what is being used today.
FIRST EVLP TRANSPLANT
In Sweden, EVLP is carried out for the first time on a human donor lung. The results of this procedure guide the first successful clinical lung transplantation from a non-heart-beating donor.
INITIALLY REJECTED LUNG
First transplant of a nonacceptable donor lung following EVLP.
TORONTO CLINICAL EXPERIENCE
Clinical trial concludes that transplantation of high-risk donor lungs that are physiologically stable during 4 hours of ex vivo perfusion lead to results similar to those obtained conventionally.
FIRST EVLP TRANSPLANT IN UNITED STATES
First lung transplantation with the application of remote EVLP, wherein the donor lungs are transported from the donor hospital to a center for EVLP and then transported to another hospital for transplantation into the recipient. It is also the first case of lung transplantation in the United States utilizing EVLP for functional optimization leading to successful transplantation.
FUTURE DIRECTION FOR EVLP1
- NEAR-TERM
- Further optimization of EVLP
- EVLP used for scheduling lung transplantations during business hours
- Adaptation for pediatric lung transplantation
- MID-TERM
- EVLP performed in centralized hubs
- Decrease in costs
- LONG-TERM
- EVLP used to enhance donor lungs
EVLP IMPACT
IMPACT OF EVLP ON ORGAN UTILIZATION
EVLP HAS INCREASED THE NUMBER OF TRANSPLANTABLE LUNGS BY 15-20% AT SOME TRANSPLANT CENTERS 2
Review and analysis was performed to evaluate the outcomes of EVLP.
- 1191 PATIENTS
- 8 STUDIES
2 Groups:
16% were patients with EVLP
84% were patients without EVLP
POST TRANSPLANT OUTCOMES WERE SIMILAR
Between EVLP-treated and Standard Lung Transplants
Even though the initial donor lung quality was worse in the EVLP-treated group, there were no significant differences in outcomes between EVLP and non-EVLP groups with respect to:
- amount of time patients were connected to a ventilator after surgery
- extent of artificial life support use
- amount of time patients had to stay in the intensive care unit
- amount of time patients had to stay in the hospital
- 72-hour serious primary graft dysfunction
- 30-day survival
- 1-year survival
REFERENCES:
- Artificial Organs, Volume: 44, Issue: 1, Pages: 12-15, First published: 24 October 2019, DOI: (10.1111/aor.13571).
- Ex Vivo Lung Perfusion: A Key Tool for Translational Science in the Lungs. Tane S., Noda K., Shigemura N. (2017) Chest, 151 (6), pp. 1220-1228.
- Outcomes of marginal donors for lung transplantation after ex vivo lung perfusion: A systematic review and meta-analysis. Tian, Dong et al. The Journal of Thoracic and Cardiovascular Surgery, Volume 159, Issue 2, 720 – 730.e6
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