**3. Lung transplantation procedure**

#### **3.1 Donor selection and operation**

The donor is evaluated for ABO compatibility, size, medical and social history, function, associated pathological findings on CXR or CT scan and bronchoscopic findings. Given the

Lung transplant is indicated for patients with chronic, end-stage lung disease for whom no effective medical therapy is available (4,5). The primary goal of lung transplantation is to provide a survival benefit. Such benefit can be conferred to patients with advanced pulmonary fibrosis, cystic fibrosis and primary pulmonary hypertension. Reports for emphysema are conflicting and for Eisenmenger's syndrome transplant did not find a survival benefit. However, as lung transplantation is a palliative treatment, improvements in quality of life in addition to survival benefit should be used to assess effectiveness of this

A history of malignancy during the past two years, except for skin cancers. In general 5 year

Untreatable advanced disease of another organ system, except the heart, where a heart-lung

Untreatable extra-pulmonary infections, including chronic, active viral hepatitis and HIV

Unreliable social support, medical non-compliance or major psychiatric or psychological

Critical or unstable conditions, such as Extra Corporeal Membrane Oxygenation or

In general referral for transplantation evaluation is recommended when the patient's median survival (50%) is about 2 years or less or New York Heart Association class 3 or 4. Due to the natural history of underlying disease, the referral time will depend on the underlying disease. The waiting period for transplant depends on underlying disease, waiting time, blood group,

The donor is evaluated for ABO compatibility, size, medical and social history, function, associated pathological findings on CXR or CT scan and bronchoscopic findings. Given the

Older age; older patients have less optimal survival following lung transplantation.

**2. Patient selection for lung transplantation** 

**2.1 Indications** 

therapy.

infection.

disorder.

**2.2 Contraindications** 

**2.2.1 Major contraindications** 

Significant chest deformity.

mechanical ventilation.

**2.3 Timing of referral** 

disease free survival is expected (4).

transplantation could be considered.

**2.2.2 Relative contraindications** 

Obesity or malnutrition (BMI>30 or BMI<17).

**3. Lung transplantation procedure** 

**3.1 Donor selection and operation** 

Active substance abuse or use within the past 6 months.

Severely limited functional class with poor rehabilitation potential. Colonization with highly virulent or antibiotic resistant organism.

height of patient and presence of pre-formed antibodies in the recipient.

Mechanical Ventilation except in carefully selected patients Severe or untreated gastroesophageal reflux disease.

improvements in clinical results and shortage of donor organs the generally accepted donor criteria are continually being challenged and expanded. Donor lung selection also depends on subjective assessment at the time of exploration in the operating room and judgment of the donor surgical team (6).

The donor pneumonectomy is approached via a midline sternotomy. The lung is inspected to evaluate its suitability for transplantation by the donor surgical team. Heparin is administered and a pulmonary plegia cannula is inserted into the main pulmonary artery ensuring both main pulmonary arteries are perfused by the cannula. A clamp is placed on the left atrial appendage and the tip of the appendage is excised for free drainage of the pulmonary effluent during the pulmonary plegic infusion. Prostaglandins and pulmonary vasodilators are administered into the main pulmonary artery followed by cold pulmonary plegia that also contains vasodilator medications. The lung is inflated to moderate amount and the trachea is stapled with lung inflated. The lung block is dissected away from the mediastinal structure with the heart or separately after the heart is excised by the 'cardiac' team. Left atrium is divided midway between the confluence of the pulmonary veins and the atrial groove ensuring that an adequate "atrial cuff" will be available with the lungs for implantation. The ligamentum arteriosum is divided toward the descending aorta avoiding injury to the left main pulmonary artery and the entire lung block is dissected away from the descending aorta and esophagus. The lungs are separated from each other at the back table by dividing the left main bronchus with the staples, pulmonary artery at the bifurcation, and left atrium between the right and left pulmonary veins. Retrograde cold flush of the preservation solution is performed through the pulmonary veins before packaging the organs in sterile fashion for transportation to the recipient operating room (8,9).

Satisfactory early and midterm outcomes had been reported with using lung donation after cardiac death expanding potential lung donors (10). Recent exciting developments on normothermic ex-vivo perfusion allowing repair of injured lung and the ability to evaluate function of the lung prior to transplantation has potential benefit of increasing the donor pool even further (11).


Table 1. Established Criteria for Donor Selection
