Lung Rapid Recovery Procurement Combined with Abdominal Normothermic Regional Perfusion in Controlled Donation after Circulatory Death

Multi-organ recovery for controlled donation after cardiac death donors is a challenge. This method increases the complexity of the whole procedure, but it offers better results for the recipients. This method minimizes the ischemic damage produced by hypotension and cardiac arrest after the withdrawal of life-sustaining therapy in donors.

To begin, intravenously administer a bolus of Heparin to the donor. Then prepare a sterile instrumentation table with all the necessary equipment, the electrocautery, and the suction system. Prepare a surgical field on the selected groin with disinfectant solution and sterile drapes.

Make an eight to 10 centimeter longitudinal incision with a number 23 blade, and control the bleeding with electrocautery and Ligaclips. Separate the wound edges with a retractor, and proceed with dissection to expose the femoral artery and vein. Embrace femoral vessels with a silk strand to control the bleeding.

Select the appropriate cannula diameters according to the vessel sizes as described in the text manuscript. Cannulate the femoral vein, introducing first a metal wire as a guide, followed by progressive dilators to finally introduce the cannula. Proceed similarly with the femoral artery using a double lumen cannula.

Cut off a 10 centimeter piece of the ECMO input line. Insert a straight connector with a lure lock with a three-way stopcock assembled at one end of the piece, and connect the other end to the arterial cannula. Purge the ECMO lines.

Employ an irrigation paired with saline to fill the lines while connecting with cannulas. Connect the output ECMO line to the venous cannula and the input ECMO line to the straight connector with the three-way stopcock previously assembled to the arterial cannula. The three-way stopcock can be used for purging the system.

Keep the ECMO lines clamped. Fix both cannulas to the groin with size one silk sutures to avoid displacement during transfer. Placer a monitored pressure line in the femoral artery cannula and the donor's left radial artery.

Next, initiate the aortic occlusion balloon placement by taking the distance between the xiphoid process of the donor and the distal end of the arterial cannula as a reference to determine the length of the catheter to be inserted to reach the thoracic descending aorta. Set a reference mark in the balloon with a silk suture or a marker. Introduce a metal wire guide through the free lumen of the femoral artery cannula.

Continue with the catheter guided by the metal wire, and introduce it until the referenced mark. Confirm the correct position of the occlusion balloon. Check the correct function of the occlusion balloon by filling it with saline for four to five seconds using a 50 cubic centimeter cone syringe.

Confirming that the arterial pressure from the femoral cannula disappears, while the pressure from the left radial artery is maintained. To perform a median sternotomy, proceed with a median vertical skin incision from the suprasternal notch to the tip of the xiphoid process. Extend the incision to the pectoral fascia and sternal periosteum using electrocautery.

Divide the interclavicular ligament and create a plane by finger dissection behind the sternum, both at the level of the suprasternal notch and the xiphoid process. Divide the sternum with an electric saw. Place a sternal retractor and open it carefully, releasing the pericardium from the posterior surface of the sternum.

Control any bleeding point with electrocautery. At the same time, ventilate the donor with 100%oxygen and a positive and expiratory pressure of five centimeter water. For bronchoscopy, introduce a flexible bronchoscope through the endotracheal tube.

Open both the pleural cavities by longitudinal incisions in the mediastinal pleura. If any errors are encountered while examining the supra-aortic vessels with the occlusion balloon, retract the left lung medially to expose and clamp the thoracic aorta as low as possible under direct vision. Examine the lungs by performing visual and palpatory assessments, inspecting for bullae, contusion, atelectasis, pneumonia, and occult tumors.

Deliver one liter of four degree Celsius saline in both pleural cavities. Reduce the inspired fraction of oxygen to 50%Open the pericardium with an inverted T incision. Retract laterally the edges of the pericardium with 2-0 silk sutures fixed to the skin with mosquito forceps to expose the heart structures.

Place a 4-0 polypropylene purse-string suture on the main pulmonary artery below the bifurcation. Perform an arteriotomy with a number 11 blade, and dilate with curved mosquito forceps. Cannulate the pulmonary artery with a right angled, straight cannula clamped at the end.

Connect the pulmonary artery cannula to the irrigation system line, assembling a straight connector with a lure lock and a three-way stopcock. Connect the irrigation system to the lung preservation solution and purge the lines. Start flushing 50 to 60 milliliters per kilogram of cold preservation solution in an antegrade fashion.

Start flushing 500 micrograms of prostaglandin diluted in 100 milliliters of saline at the same time through the three-way stopcock. Open the left atrium directly to allow free drainage. If areas of atelectasis are found, recruit them with short inspiratory holds at 25 to 30 centimeter water pressure.

Once preservation is finished, remove the pulmonary artery cannula, and announce to the rest of the team the intention to clamp the cava vein and start heart excision. Place a cross clamp in the inferior cava vein, making sure there is enough stump for the liver. Ligate and divide the inferior cava vein with a number three silk strand.

Tie and divide the femoral superior cava vein from caudal to azygous with a number three silk strand. Secure the distal stump with a clamp. Leave the clamps remaining in the surgical field, being careful not to remove them by accident, as otherwise, the ECMO device and ARNP will be compromised.

Excise the rest of the heart in a standard function. After heart excision, remove the lungs following the same procedure as with brain death donors. Divide the inferior pulmonary ligaments, open the posterior pericardium, and expose the esophagus.

Free the posterior mediastinal attachments of the lung with blunt dissection, ensuring cautious hemostasis. Dissect the pulmonary arteries away from the aorta. Isolate the trachea above the carina and pass a TA stapler around.

Inflate the lungs to 50 to 60%of the tidal volume before withdrawing the endotracheal tube and dividing the trachea. Remove any remaining attachments and extract the lung block from the donor. Carefully check the thoracic cavity to detect any bleeding points, since continuous blood loss may decrease the pump flow.

The percentage of patients with interstitial lung disease was the highest, followed by chronic obstructive pulmonary disease, and bronchiectasis. Most recipients had a smoking history. Only 16.7%had systemic hypertension and 10%had diabetes mellitus.

Pulmonary hypertension was present in 14 recipients. One recipient needed intraoperative extracorporeal life support during surgery with ECMO. The median cold ischemic time was 292.5 minutes for the first graft and 405 minutes for the second.

There were no intraoperative deaths. Two recipients needed postoperative ECMO support due to primary graft dysfunction. The median time for postoperative intubation was 24 hours.

ICU stay was 3.1 days and hospital stay was 18.9 days. Acute cellular rejection in the first three weeks was present in 12 recipients. There was no hospital mortality and 30 day survival was 100%The key points in this method are pre-mortem interventions, cannulation, aortic occlusion balloon placement, and the measures to avoid volume loss and pump flow during lung preservation and procurement.

This method has been applied to pediatric donors with an increased rate of grafts utilization and excellent recipients survival.