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DCD Lung Transplantation: Reflecting on the Past, Showcasing the Present, and Forecasting the Future

Bronwyn Levvey and Greg Snell
Lung Transplant Service
Alfred Hospital
Melbourne, Australia

A highlight of the recent ISHLT 2014 San Diego meeting was a pre-meeting symposium entitled, Global Perspectives on Donation after Cardio-circulatory Determination of Death (DCD) in Lung Transplantation (LTx). A large audience attended, and were subsequently educated (and at times entertained!) about the past, present and future of DCD LTx and ex-vivo lung perfusion (EVLP).

Just over 50 years ago, in 1963, the first successful human LTx was carried out by James Hardy, using lungs retrieved from what we now would classify as a 'controlled' Category III DCD donor. It would be nearly 30 years (1991) before Tom Egan revisited the concept of using 'non-heart-beating-donors (NHBD)' as a potential solution to increase the lung donor pool. Bob Love reported his center's first successful LTx using a 'controlled' NHDB donor lung, at the ISHLT meeting in 1995. Years passed before the LTx world was reanimated by Stig Steen's seminal Lancet article in 2001, describing successful LTx from an 'uncontrolled' NHBD donor, and the first clinical use of EVLP to determine the suitability of the donor lung. The work of these 3 NHBD (or DCD) pioneers has certainly stood the test of time. Over the intervening 5 or so years, up to 2006, only a small number of individuals and their LTx programs had the courage to follow in their footsteps.

Fast forwarding to 2014, global results and trends of DCD LTx were outlined by a multi-national panel of speakers. Without doubt, increasingly over the past 10 years, DCD has added a significant number of quality donor lungs for LTx with consistently excellent results. Widespread adoption of DCD LTx has occurred in some countries including Australia, Belgium, Canada, Netherlands, Spain and the UK. Paradoxically, Sweden and the USA have been slower on the uptake of DCD LTx. And if you are wondering about Switzerland's involvement, don't ask John Dark ... he seems to have a problem with European geography!

International differences in DCD practice and experiences (eg. controlled vs uncontrolled DCD, EVLP vs no EVLP) provided fuel for an entertaining and energetic debate. It was obvious that Bob Love had employed an Australian voice coach to enhance the cultural appeal of his presentation, hoping to win the debate. Greg Snell on the other hand, in typical Australian fashion, 'played the man—not the ball!' The winner was obvious....

The future of DCD LTx is guaranteed. The solid clinical outcomes presented in this Symposium will surely encourage units currently not utilizing DCD to push forward with developing clinical protocols and engaging with their donation networks. It is evident (unless you come from Toronto!) that EVLP is not required to commence a Category III (controlled) DCD LTx program. There is huge potential for Category I & II (uncontrolled) DCD activity, although EVLP is most likely required for lung quality assessment. The Chapel Hill and Madrid 'uncontrolled' DCD experiences provide excellent templates to emulate.

To facilitate capture of contemporary and evolving DCD practices and outcomes, active DCD programs successfully lobbied for the development of a mini DCD LTX Registry. Results are coming to an ISHLT meeting near you soon!

The below picture, taken after the symposium, reveals many of the 'stars' of the DCD LTx Universe. The 2 adjacent pictures represent the 2 pioneering DCD comets (Tom Egan and Stig Steen) who exited at light-speed from the room before they were captured on film!!

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DCD LTx "Stars"

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DCD LTx "Comets"

Disclosure Statement: the authors have no conflicts of interest to report.

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