Commentary: Who should be using ex vivo lung perfusion?

Central MessageEVLP expands donor pools by increasing evaluation and use of marginal grafts. Measurements and mechanisms to ensure quality of a low volume, highly specialized procedure remain to be determined.See Article page XXX. EVLP expands donor pools by increasing evaluation and use of marginal grafts. Measurements and mechanisms to ensure quality of a low volume, highly specialized procedure remain to be determined. See Article page XXX. The use of ex vivo lung perfusion (EVLP) has revolutionized lung transplantation (LTx) by allowing greater organ preservation time, improved operating room logistics, and use of marginal grafts that may not otherwise be transplanted.1Mansour D. Roberts S. Lee M. Shukrallah B. Whitson B.A. The role of ex-vivo lung perfusion (EVLP) in lung transplantation.in: Nistor C.E. Tsui S. Kırali K. Ciuche A. Aresu G. Kocher G.J. Thoracic Surgery: Cervical, Thoracic and Abdominal Approaches. Springer International Publishing, 2020: 977-986https://doi.org/10.1007/978-3-030-40679-0_86Crossref Scopus (1) Google Scholar, 2Cypel M. Yeung J.C. Liu M. Anraku M. Chen F. Karolak W. et al.Normothermic ex vivo lung perfusion in clinical lung transplantation.N Engl J Med. 2011; 364: 1431-1440https://doi.org/10.1056/NEJMoa1014597Crossref PubMed Scopus (771) Google Scholar, 3Halpern S.E. Kesseli S.J. Au S. Krischak M.K. Olaso D.G. Smith H. et al.Lung transplantation after ex vivo lung perfusion versus static cold storage: an institutional cost analysis.Am J Transplant. 2022; 22: 552-564https://doi.org/10.1111/ajt.16794Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Although the use of EVLP has become more widespread within the past decade, not all transplant centers utilize the technology, with some being slower than others to implement it. Some barriers relate to the infrastructure and expertise that are required to develop an EVLP program. The degree to which these are present at a transplant center may lead to differences in outcomes when using the technology.4Van Raemdonck D.V. Ceulemans L.J. Van Beersel D.V. Neyrinck A. Current achievements and future applications of ex vivo lung perfusion; where do we go from here?.J Thorac Cardiovasc Surg. 2023; 165: 920-924https://doi.org/10.1016/j.jtcvs.2022.06.019Abstract Full Text Full Text PDF Scopus (1) Google Scholar Chen and colleagues5Chen Q. Malas J. Krishnan A. Limited cumulative experience with ex-vivo lung perfusion is associated with inferior outcomes after lung transplantation.J Thorac Cardiovasc Surg. 2023; XXX (X-XX)Google Scholar evaluated the influence that transplant center experience with EVLP may have on LTx outcomes. They assessed the clinical outcomes of 41 transplant centers in the United States that utilize the technology. After stratifying the centers into high and low users of EVLP, the authors found that lung recipients at low-volume centers (<15 EVLP transplants over 4 years) had significantly worse 1-year adjusted rates of survival after transplant. They demonstrated that the low-volume center recipients had significantly worse 1-year survival when receiving EVLP donor lungs compared with when the same centers used non-EVLP lungs. On the contrary, higher-volume EVLP centers had comparable outcomes between their non-EVLP and EVLP LTx procedures. The results of this study are consistent with prior work demonstrating that transplant center volume, and thus experience, is directly associated with LTx outcomes. One study demonstrated that LTx centers that perform more than 33 cases annually had greater 1-year survival rates compared with those that do not.6Yang Z. Subramanian M.P. Yan Y. Meyers B.F. Kozower B.D. Patterson G.A. et al.The impact of center volume on outcomes in lung transplantation.Ann Thorac Surg. 2022; 113: 911-917https://doi.org/10.1016/j.athoracsur.2021.03.092Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Additionally, Kilic and colleagues7Kilic A. George T.J. Beaty C.A. Merlo C.A. Conte J.V. Shah A.S. The effect of center volume on the incidence of postoperative complications and their impact on survival after lung transplantation.J Thorac Cardiovasc Surg. 2012; 144 (discussion 1508-9. https://doi.org/10.1016/j.jtcvs.2012.08.047): 1502-1508Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar showed that higher-volume transplant centers have lower rates of postoperative complications and a greater ability to rescue patients who go on to develop complications. The authors should be commended for this important work that comes at a time when the cost–benefit ratio of EVLP is highly debated. One high-volume, single-center analysis showed that using EVLP donor lungs was associated with higher index hospitalization costs despite similar clinical outcomes compared with non-EVLP standard criteria donor lungs.3Halpern S.E. Kesseli S.J. Au S. Krischak M.K. Olaso D.G. Smith H. et al.Lung transplantation after ex vivo lung perfusion versus static cold storage: an institutional cost analysis.Am J Transplant. 2022; 22: 552-564https://doi.org/10.1111/ajt.16794Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar The findings in Chen and colleagues’5Chen Q. Malas J. Krishnan A. Limited cumulative experience with ex-vivo lung perfusion is associated with inferior outcomes after lung transplantation.J Thorac Cardiovasc Surg. 2023; XXX (X-XX)Google Scholar study suggest that there might be an even greater discrepancy in index hospitalization costs at low-volume centers. However, can we put a price on successfully using a lung that otherwise would have been discarded? This study raises the question of how to ensure quality for all LTx centers when using new technologies and whether or not low-volume centers may benefit more from high-volume, third-party EVLP vendors. It is also worth noting that the low-volume cohort used more lungs from donor after cardiac death and extended criteria donors, which when compared with standard criteria donors, have been shown to have worse transplant outcomes following EVLP.8Loor G. Warnecke G. Villavicencio M.A. Smith M.A. Kukreja J. Ardehali A. et al.Portable normothermic ex-vivo lung perfusion, ventilation, and functional assessment with the Organ Care System on donor lung use for transplantation from extended-criteria donors (EXPAND): a single-arm, pivotal trial.Lancet Respir Med. 2019; 7: 975-984https://doi.org/10.1016/S2213-2600(19)30200-0Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar,9Warnecke G. Van Raemdonck D. Smith M.A. Massard G. Kukreja J. Rea F. et al.Normothermic ex-vivo preservation with the portable Organ Care System lung device for bilateral lung transplantation (INSPIRE): a randomised, open-label, non-inferiority, phase 3 study.Lancet Respir Med. 2018; 6: 357-367https://doi.org/10.1016/S2213-2600(18)30136-XAbstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar Additionally, the improved EVLP outcomes in the higher-volume cohort may be partially explained by greater transplant center experience through higher volume of non-EVLP lung transplants. Nevertheless, the authors make a compelling argument to consider transplant experience and infrastructure when deciding to utilize EVLP. Further work is needed to elucidate the best strategy on how to safely expand the use of EVLP without compromising posttransplant outcomes. Limited cumulative experience with ex vivo lung perfusion is associated with inferior outcomes after lung transplantationThe Journal of Thoracic and Cardiovascular SurgeryPreviewEx vivo lung perfusion (EVLP) allows for prolonged preservation and evaluation/resuscitation of donor lungs. We evaluated the influence of center experience with EVLP on lung transplant outcomes. Full-Text PDF