Name: lung rapid recovery procurement combined with abdominal normothermic regional perfusion in controlled donation after circulatory death
Uploaded: 2022-08-15T14:00:00
Description: Watch this Scientific Journal Video about Lung Rapid Recovery Procurement Combined with Abdominal Normothermic Regional Perfusion in Controlled Donation after Circulatory Death at JoVE.com

The authors acknowledge all the members involved in the Lung Transplant Program at University Hospital Marqu&#233;s de Valdecilla.

These interventions are undertaken at the bedside in the intensive care unit (ICU). This protocol follows the guidelines of the University Hospital Marqu&#233;s de Valdecilla ethics committee and is in accordance with the Spanish legal framework regarding donation procedures. Informed consent was obtained from next of kin for video recording of the procedures for research. cDCD is considered in patients with catastrophic brain damage or a terminal heart or a neurodegenerative disease for whom the decision to withdraw lif...

Though the use of simultaneous lung cold perfusion with ARNP in cDCD was first published in 2014, very few experiences have been described for this25,26,29. Moreover, the utilization of cDCD lungs, regardless of the technique used, remains low in most countries.
The critical steps within this protocol are the use of premortem interventions; a specific methodology to ensure coronary and cerebral perfus...

Donation after circulatory death (DCD) started in Spain with uncontrolled donors. In 1996, the first national consensus document on DCD was published as a guide for the practice of uncontrolled donation after circulatory death1 (uDCD), also setting a moratorium on controlled donation after circulatory death (cDCD). In 2012, a new consensus emerged establishing the basis and the legislative framework for the practice of both uDCD and cDCD2. Currently, Spain is one of the most active countries in DCD, reaching the highest rate of donors after circulatory death in the world3. This type of donor represented nearly 35% of the total donors in 2021 in the country, with a marked decrease in uDCD and donors being exclusively cDCD4.
Organ procurement in cDCD is commonly performed using the super-rapid recovery technique5. After the declaration of death and when the non-touch period has elapsed, a rapid sternotomy and laparotomy is performed. The abdominal aorta and pulmonary artery are cannulated and flushed with cold perfusion solutions to preserve the abdominal and thoracic organs, plus topical cooling is conducted before retrieval6. In this situation, cDCD is characterized by the unpredictable consequences of warm ischemia,&#160;after the withdrawal of life-sustaining therapy. The ischemic damage during this period of agonic hypotension and progressive hypoxia, followed by the non-touch period after cardiac arrest, is further exacerbated by the later period of cold ischemia7. This combination of warm and cold ischemia seems to be detrimental, especially to abdominal grafts8,9,10,&#160;generating more reluctance among professionals in the use of these organs from cDCD donors.
To minimize these risks, an in situ preservation model, based on previous experiences from Spanish teams working in uCDC11,&#160;has been developed with growing interest. The use of extracorporeal membrane oxygenation (ECMO) systems to restore blood flow after death and before graft recovery can reverse the metabolic deviations resulting from ischemia and restore cellular physiology12. Abdominal normothermic regional perfusion (ANRP) can improve the quality of ischemic-damaged organs in cDCD13. Organ function can be assessed and improved, allowing a better selection of abdominal grafts for transplantation.
Recent international multicenter experiences provide evidence that ANRP versus the rapid recovery (RR) technique helps overcome traditional limitations in cDCD, reducing rates of post-transplant biliary complications, facilitating successful transplantation of older livers, and improving liver graft survival14,15. In kidneys, it seems to improve short-term outcomes with a lower delayed graft function and higher 1 year graft survival rates16. With this evidence, ANRP in cDCD has gained advantages over the rapid recovery technique for abdominal graft procurement and is now applied in several European countries and other parts of the world17,18.
The use of lungs from cDCD donors, however, was promptly adopted worldwide. A lung functional warm ischemic time of up to 60 min does not seem to affect survival19. In the last decade, several centers and multi-institutional experiences have reported outcomes after lung transplant from cDCD comparable to those from DBD20,21. The RR technique is the routine method for lung procurement: lungs are cooled topically and removed after being flushed with cold preservation solution22.
The first experiences combining ANRP and RR of lungs in cDCD were reported by two United Kingdom groups23,24. Years later, a variation of this technique adding premortem interventions was published25. Results present this dual procurement technique as safe and effective for both abdominal and thoracic grafts26. Obviously, the donation procedure becomes more complex. It requires technological and human resources, sufficient organizational capabilities, and has a higher economic cost. All of this may discourage professionals from starting a program. The aim of this study is to present a protocol especially focused on premortem interventions, cannulation, and aortic occlusion balloon placement, with tips and tricks learned from experience, and comment the different technical details to consider during lung retrieval when ARNP is used. At present, in the Center, cDCD donors have become the main source of grafts for thoracic and abdominal transplantation.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Vial 5 mL Heparin 1000 UI/mL</td>
			<td>ROVI</td>
			<td></td>
			<td>For donor heparinization</td>
		</tr>
		<tr>
			<td>ECMO KIT (MATERIALS FOR CANNULATION)</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Artery pressure lines</td>
			<td>BEXEN MEDICAL</td>
			<td>137.15</td>
			<td>Artery pressure line por radial artery and femoral cannula</td>
		</tr>
		<tr>
			<td>Bandage scissors</td>
			<td>SURGIMEDIC</td>
			<td>BC-881R</td>
			<td>Shear to cut ECMO lines</td>
		</tr>
		<tr>
			<td>Bio-medicus Venous cannula 21 Fr (7.0 mm) x 27.5 in (69.9 cm)</td>
			<td>MEDTRONIC</td>
			<td>96670-121</td>
			<td>Venous cannula</td>
		</tr>
		<tr>
			<td>Clhorhexidine solution 2%</td>
			<td></td>
			<td></td>
			<td>Disinfectant solution</td>
		</tr>
		<tr>
			<td>ECMO device Maquet Rotaflow</td>
			<td>Maquet, Rasttat, Germany</td>
			<td></td>
			<td>ECMO system</td>
		</tr>
		<tr>
			<td>Electrocautery handle</td>
			<td>DEXTRO</td>
			<td>SW12200</td>
			<td></td>
		</tr>
		<tr>
			<td>EndoReturn Arterial Cannula Kit&#160; 21-23F</td>
			<td>Edwards Lifesciences</td>
			<td>ER21B, ER23B</td>
			<td>Arterial cannula with a doble lumen to ECMO connection and to introduce aortic oclussion balloon</td>
		</tr>
		<tr>
			<td>Ethicon LigaClip med/short 20 titanium medium</td>
			<td>ETHICON</td>
			<td>MCS30</td>
			<td>Ligaclips for control bleeding during groin dissection</td>
		</tr>
		<tr>
			<td>Ethicon LigaClip med/short 20 titanium small</td>
			<td>ETHICON</td>
			<td>MCS20</td>
			<td>Ligaclips for control bleeding during groin dissection</td>
		</tr>
		<tr>
			<td>Insertion Kit Bio-medicus 180cm</td>
			<td>MEDTRONIC</td>
			<td>96551</td>
			<td>Insertion Kit for ECMO cannulas, with catheter, metal wire guide and dilators</td>
		</tr>
		<tr>
			<td>Irrigation pear</td>
			<td>MEDLINE</td>
			<td>DYNDE 20125</td>
			<td>Pear to be filled with saline and purge ECMO lines at the site of connection with cannulas</td>
		</tr>
		<tr>
			<td>Luer cone syringe 50cc</td>
			<td>CARDIONATUR</td>
			<td>60ML</td>
			<td>Syringe filled with saline to fill occlusion balloon</td>
		</tr>
		<tr>
			<td>Mersilk no 1, LR-60 CONV , 75 cm</td>
			<td>ETHICON</td>
			<td>W562H</td>
			<td>Silk curved suture for ECMO cannulas fixation</td>
		</tr>
		<tr>
			<td>Prolene 4/0</td>
			<td>ETHICON</td>
			<td>W8355</td>
			<td>polypropylene suture for purse string in femoral vessels or vascular suture</td>
		</tr>
		<tr>
			<td>Prolene 5/0 , 60 cm</td>
			<td>ETHICON</td>
			<td>8325</td>
			<td>polypropylene suture for vascular suture</td>
		</tr>
		<tr>
			<td>Prolene 5/0, 90 cm</td>
			<td>ETHICON</td>
			<td>8720</td>
			<td>polypropylene suture for vascular suture</td>
		</tr>
		<tr>
			<td>Reliant Stent Graft Balloon Catheter&#160;12F</td>
			<td>Medtronic, Ireland</td>
			<td>AB46</td>
			<td>Aortic occlusion balloon introduced through femoral artery. It is used as an endoclamp</td>
		</tr>
		<tr>
			<td>Scalpel blade no 11</td>
			<td>INTRAVEN</td>
			<td>150011</td>
			<td></td>
		</tr>
		<tr>
			<td>Scapel blade no 23</td>
			<td>INTRAVEN</td>
			<td>150023</td>
			<td></td>
		</tr>
		<tr>
			<td>Silicone tube</td>
			<td>IBERHOSPITEX</td>
			<td>0027224-P</td>
			<td>Silicone tube to connect suction system</td>
		</tr>
		<tr>
			<td>Sofsilk braided silk no 1 strands</td>
			<td>COVIDIEN</td>
			<td>L-12</td>
			<td>Silk strand for ligation or bleeding control</td>
		</tr>
		<tr>
			<td>Sofsilk braided silk no 3 strands</td>
			<td>COVIDIEN</td>
			<td>L-115</td>
			<td>Silk strand for ligation or bleeding control</td>
		</tr>
		<tr>
			<td>straight connector 3/8&#34;x3/8&#34; with Luer lock</td>
			<td>ANDOCOR</td>
			<td>04CS0022</td>
			<td>Piece to connect arterial cannula with ECMO line and the three way stop-cock for pressure line and blood sampling</td>
		</tr>
		<tr>
			<td>Surgical pads pack</td>
			<td>TEXPOL</td>
			<td>146500</td>
			<td></td>
		</tr>
		<tr>
			<td>Surgical stapler</td>
			<td>COVIDIEN</td>
			<td>8886803712</td>
			<td>Stapler to close surgical wound</td>
		</tr>
		<tr>
			<td>Three-way stopcock</td>
			<td>BD CONNECTA</td>
			<td>394501</td>
			<td>Three way stop-cock to connect farterial cannula with pressure line</td>
		</tr>
		<tr>
			<td>Vessel loop large</td>
			<td>MEDLINE</td>
			<td>VLMAXR</td>
			<td>Vascular loop to embrace femoral artery and vein for bleeding control.</td>
		</tr>
		<tr>
			<td>Vessel loop small</td>
			<td>MEDLINE</td>
			<td>VLMINR</td>
			<td>Vascular loop to embrace femoral artery and vein for bleeding control.</td>
		</tr>
		<tr>
			<td>Yankauer suction terminal 50 V</td>
			<td>DEXTROMEDICA</td>
			<td>349701</td>
			<td>Suction terminal for suction while surgical dissection</td>
		</tr>
		<tr>
			<td>SURGICAL TOOLS FOR CANNULATION</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Adson retractor 20 cm adn 33 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Aortic clamp</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Boyd Scissors 18 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Dissection forceps without jaws 21 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Farabeuf retractor small</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Mayo scissors straight 14 cm and 16 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Metzembaum scissors 18 cm, 20 cm and 23 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Mosquito forceps straigth and curved</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Needle holder 18 cm and 23 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Russ dissection forceps 15 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Scalpel handle no 23 and no 21,&#160; 21 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Surgical Dissector 23 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>MATERIALS FOR LUNG PROCUREMENT</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>10 cc syringe</td>
			<td>BD DISCARDIT</td>
			<td>309110</td>
			<td></td>
		</tr>
		<tr>
			<td>Alprostadil 500 mcgs injectable solution</td>
			<td>PFIZER</td>
			<td></td>
			<td>Prostaglandin injected with lung preservation solution</td>
		</tr>
		<tr>
			<td>Disposable GIA cartridge Steril 6/Ca</td>
			<td>MEDTRONIC</td>
			<td>1141634</td>
			<td></td>
		</tr>
		<tr>
			<td>Disposable GIA stapler 60/3.8 3/Ca</td>
			<td>MEDTRONIC</td>
			<td>2802122</td>
			<td>Stapler for trachea and bronquial division</td>
		</tr>
		<tr>
			<td>Foley catheter 18 Ch Folysil</td>
			<td>Folysil, Coloplast</td>
			<td>AA6118</td>
			<td>urinary catheter employed to canulated pulmonary veins for retrograde perfusion</td>
		</tr>
		<tr>
			<td>Lung preservation solution Perfadex 1000 mL</td>
			<td>Medisan, Uppsala, Sweeden</td>
			<td>19811 ( box of 10 units)</td>
			<td>Lung preservation solution</td>
		</tr>
		<tr>
			<td>Mersilk no 1, LR-60 CONV , 75 cm</td>
			<td>ETHICON</td>
			<td>W562H</td>
			<td>Silk curved suture for pericardium sutures</td>
		</tr>
		<tr>
			<td>Paediatric Venous cannula</td>
			<td>SORIN GROUP</td>
			<td>V132-12</td>
			<td>Cannula used for pulmonary artery cannulation</td>
		</tr>
		<tr>
			<td>Prolene 4/0</td>
			<td>ETHICON</td>
			<td>W8355</td>
			<td>polypropylene suture for purse string in pulmonary artery</td>
		</tr>
		<tr>
			<td>Scalpel blade no 11</td>
			<td>INTRAVEN</td>
			<td>150011</td>
			<td></td>
		</tr>
		<tr>
			<td>Sofsilk braided silk no 1 strands</td>
			<td>COVIDIEN</td>
			<td>L-12</td>
			<td>Silk strand to fix arterial cannula with the tourniquet</td>
		</tr>
		<tr>
			<td>Sofsilk braided silk no 3 strands</td>
			<td>COVIDIEN</td>
			<td>L-115</td>
			<td>Silk strand for vessel ligation</td>
		</tr>
		<tr>
			<td>Sterile bags</td>
			<td></td>
			<td></td>
			<td>To keep and store lungs.</td>
		</tr>
		<tr>
			<td>Straigth connector 1,4&#34;/1,4&#34; with luer lock</td>
			<td>ANDOCOR</td>
			<td>04CS0032</td>
			<td>Piece to connect pulmonary artery arterial cannula with preservation line and the three way stop-cock for prostaglandin</td>
		</tr>
		<tr>
			<td>Three-way stopcock</td>
			<td>BD CONNECTA</td>
			<td>394501</td>
			<td>Three way stop-cock to connect farterial cannula with pressure line</td>
		</tr>
		<tr>
			<td>Uromatic set for irrigation double lead</td>
			<td>MEDISAVE</td>
			<td>TRC4007N</td>
			<td>Irrigation system for lung preservation solution</td>
		</tr>
		<tr>
			<td>Uromatic set for irrigation single lead</td>
			<td>MEDISAVE</td>
			<td>TRC4002</td>
			<td>Irrigation system for lung preservation solution</td>
		</tr>
		<tr>
			<td>SURGICAL TOOLS FOR LUNG PROCUREMENT</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Aortic cross- clamp</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Battery-powered surgical saw</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Cooley vascular clamp</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Dissecting forceps 18 cm and 27,9 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Finochietto sternal retractor</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Metzembaum scissors 20 cm and 23 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Mosquito forceps curved 12,5 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Vascular clamps</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>SURGICAL TOOLS FOR ABDOMINAL ORGAN PROCUREMENT</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Adson articulated retractors</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Allis forceps 16 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Aortic cross-clamps</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Boyd scissors 17 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Castroviejo needle holder</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Cooley Vascular clamps</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Crile forceps curved 18 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Davis retractor 24.5 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>DeBakey dissecting forceps 19.7 cm adn 24.1 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>DeBakey vascular clamps</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Dissecting forceps 18 cm and 27.9 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Duval forceps 23 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Farabeuf retractors</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Kidney Trays 300 cc and 500 cc</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Kocher forceps straigth 18 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Langenbeck retractors 21 cm and 23 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Mayo scissors straigth and curved , 17 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Mosquito forceps straigth and curved, 12.5 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Needle holders 15 cm, 18 cm, 23 cm and 23 cm.</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Pean forceps 16 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Potts scissors 19cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Rochester forceps curved 24 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Rochester forceps straigth 24 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Russ dissection forceps 15 cm and 20 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Scalpel handles</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Senn-mueller retractor 16 cm</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

lung rapid recovery procurement combined with abdominal normothermic regional perfusion in controlled donation after circulatory death

Controlled donation after circulatory death (cDCD) has contributed to increasing donor numbers all over the world. Experiences published in the last years confirm that the outcomes after lung transplantation from cDCD are similar to those from brain death donors; however, the utilization of lungs from asystole donors remains low. Several reasons may be involved: different legal frameworks among countries and centers with different premortem interventions, inadequate lung donor care before procurement, or even poor experience with cDCD procedures and protocols.
Initially, the rapid recovery technique was commonly employed for the procurement of thoracic and abdominal organs in cDCD, but, in the last decade, abdominal normothermic regional perfusion (ANRP) with extracorporeal membrane oxygenation devices has become a useful method to restore blood flow to abdominal organs, allowing their quality improvement and their functional assessment prior to transplantation. This makes the donation procedure more complex and generates doubts about injury to the grafts due to dual temperature.
The aim of this article is to describe a protocol based on a single center experience with Maastricht III donors combining lung cooling rapid recovery in the thorax and abdominal normothermic regional perfusion. Tips and tricks focused on premortem interventions and lung procurement procedure techniques are explained. This may help to minimize the reluctance among professionals to use this combined technique and encourage other donor centers to use it, despite the increased complexity of the procedure.

We performed a descriptive analysis of 30 lung transplants performed at University Hospital Marqu&#233;s de Valdecilla with lungs obtained from cDCD donors in the last 2 years, 2020 and 2021. Donor and recipient demographic characteristics, technical data, postoperative outcomes, and short-term results are presented here. These results are presented as absolute numbers and percentages for categorical variables and as measures of central tendency and dispersion for continuous variables. The Kolmogorov-Smirnov test was use...

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

The protocol combines a lung cooling rapid recovery technique with abdominal normothermic regional perfusion for abdominal graft procurement in controlled asystole donors, which is a safe and useful method to expand the donor pool.

Controlled donation after circulatory death (cDCD) has contributed to increasing donor numbers all over the world. Experiences published in the last years ...

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.

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