Commentary: Leveling up the evidence!
2019; Elsevier BV; Volume: 159; Issue: 2 Linguagem: Inglês
10.1016/j.jtcvs.2019.08.011
ISSN1097-685X
Autores Tópico(s)Tracheal and airway disorders
ResumoCentral MessageThere is an increasing body of evidence pointing toward the routine use of ex vivo lung perfusion for marginal donor lungs.See Article page 720. There is an increasing body of evidence pointing toward the routine use of ex vivo lung perfusion for marginal donor lungs. See Article page 720. I read with great interest the article “Outcomes of Marginal Donors for Lung Transplantation After Ex Vivo Lung Perfusion: A Systematic Review And Meta-analysis,” published by Nakajima and colleagues1Tian D. Wang Y. Shiiya H. Sun C.-B. Uemura Y. Sato M. et al.Outcomes of marginal donors for lung transplantation after ex vivo lung perfusion: a systematic review and meta-analysis.J Thorac Cardiovasc Surg. 2020; 159: 720-730.e6Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar in this issue of the Journal. It provides a summary of published evidence comparing outcomes of marginal donor lungs pretreated by ex vivo lung perfusion (EVLP) to outcomes of standard donor lungs preserved by static cold storage. A total of 8 studies with nearly 1200 patients met the inclusion criteria and served as the basis for a meta-analysis. The central message of this work is that EVLP-treated marginal lungs perform equally well as standard donor lungs. To the best of my knowledge this is the first meta-analysis of ex vivo lung perfusion. The fact that this analysis was published in the Journal of Thoracic and Cardiovascular Surgery highlights the high reputation that the Journal currently enjoys in the lung transplant community. Performing EVLP for marginal lungs has 2 major advantages: First, it serves as an additional safety net, allowing lungs to be observed under “near physiologic” conditions for 4 to 6 hours.2Cypel M. Yeung J.C. Machuca T. Chen M. Singer L.G. Yasufuku K. et al.Experience with the first 50 ex vivo lung perfusions in clinical transplantation.J Thorac Cardiovasc Surg. 2012; 144: 1200-1206Abstract Full Text Full Text PDF PubMed Scopus (225) Google Scholar Second, there is emerging evidence that the perfusion itself can improve damaged grafts and render them into a transplantable state.3Aigner C. Slama A. Hötzenecker K. Scheed A. Urbanek B. Schmid W. et al.Clinical ex vivo lung perfusion—pushing the limits.Am J Transplant. 2012; 12: 1839-1847Crossref PubMed Scopus (139) Google Scholar, 4Sage E. Mussot S. Trebbia G. Puyo P. Stern M. Dartevelle P. et al.Lung transplantation from initially rejected donors after ex vivo lung reconditioning: the French experience.Eur J Cardiothorac Surg. 2014; 46: 794-799Crossref PubMed Scopus (84) Google Scholar Especially the first indication—the use of EVLP as a safety net—has lately gained increasing importance. Most transplant centers nowadays accept marginal donor lungs on a routine basis. In the clinical reality, however, it is often unclear how marginal donor lungs can be in order to still to be used safely for transplantation. We have recently shown that organs that had previously been rejected by 2 or more transplant centers for quality reasons can often be used without hampering long-term outcome.5Schwarz S. Muckenhuber M. Benazzo A. Glueck O. Evermann M. Beer L. et al.Outcome after lung transplantation using multiple declined marginal donor lungs.Transplant Int. 2018; 31: 13Google Scholar The use of EVLP to determine the true functional quality of such grafts adds an important tool in the armamentarium of lung transplant surgeons. Another example is the use of donation-after-circulatory-death lungs from donors with a prolonged time between withdrawal of life-sustaining treatment and arrest. Potential graft damage resulting from prolonged warm ischemic times can be examined during EVLP, and often those lungs turn out to be acceptable for transplantation.6Reeb J. Keshavjee S. Cypel M. Successful lung transplantation from a donation after cardiocirculatory death donor taking more than 120 minutes to cardiac arrest after withdrawal of life support therapies.J Heart Lung Transplant. 2016; 35: 258-259Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar The growing evidence of EVLP emphasizes the central place of this technique in contemporary lung transplantation. This meta-analysis performed by the Tokyo group1Tian D. Wang Y. Shiiya H. Sun C.-B. Uemura Y. Sato M. et al.Outcomes of marginal donors for lung transplantation after ex vivo lung perfusion: a systematic review and meta-analysis.J Thorac Cardiovasc Surg. 2020; 159: 720-730.e6Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar is highly relevant. It provides high-level evidence favoring the use of EVLP for marginal donor lungs. Compared with static cold storage, EVLP platforms are extremely costly, but they facilitate the use of organs otherwise lost for the organ pool. Analyses such as that of Nakajima and colleagues1Tian D. Wang Y. Shiiya H. Sun C.-B. Uemura Y. Sato M. et al.Outcomes of marginal donors for lung transplantation after ex vivo lung perfusion: a systematic review and meta-analysis.J Thorac Cardiovasc Surg. 2020; 159: 720-730.e6Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar provide indispensable arguments when discussing the costs of an EVLP program with hospital authorities and management boards. Outcomes of marginal donors for lung transplantation after ex vivo lung perfusion: A systematic review and meta-analysisThe Journal of Thoracic and Cardiovascular SurgeryVol. 159Issue 2PreviewEx vivo lung perfusion (EVLP) is reportedly a useful strategy that permits marginal donor lungs to be evaluated and reconditioned for successful lung transplantation (LTx). This systematic review and meta-analysis was performed to evaluate the outcomes of EVLP conducted for marginal donor lungs. Full-Text PDF Open Archive
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