Donor shortage is a problem that affects the waiting lists of all lung transplantation groups, so it is essential that all sources of potential donors are explored and that donors with expanded criteria (controlled and uncontrolled non-heart beating donors [NHBD], elderly donors and others), live donors and ex vivo perfusion techniques are considered.

Hardy et al.1 performed the first lung transplantation in 1963 using a non-heart beating organ. At the end of the 1990s, Egan et al.2 rekindled interest in non-heart beating lung donation, and Love et al.3 performed the first successful lung transplantation from an NHBD. Since then, this type of donation has become an additional, reliable source of organs in many countries, and has contributed to a significant rise in the number of transplantations with excellent outcomes.4–6

Nowadays, uncontrolled non-heart beating donors have become a reliaty, and has helped to increase the number of lung transplants performed.7,8 In view of this experience, backed up by the work of other groups, our hospital implemented a similar protocol with the aim of procuring NHBD grafts to increase our rate of lung transplantations.

cNHBD protocol used in our hospital can be summarized as follows: after the patient's family has agreed to limitation of therapeutic efforts (LTE), organ donation is proposed. If family agrees, the patient is evaluated as a potential donor, and the same criteria as for brain death donors are applied.9

After all parameters have been examined, a bolus of 1000UI/kg heparin is administered and LTE starts generally in the operating room.

In our hospital, the maximum period between LTE and cardiac arrest (agonal phase) is set at 2h. If the heart does not stop beating during this period, the patient is returned to the intensive care unit. Warm ischemia time (WIT) is defined as the time between a fall in mean blood pressure to below 60mmHg and cold preservation through the pulmonary artery. A maximum of 60min WIT is accepted for the graft to be considered valid.

After asystolia, there is a observation period (5min) and the physician in charge of LTE certifies death. The patient is reintubated, and fibrobronchoscopy is used to ensure than no bronchial aspiration occurred during the agonal phase. At the same time, a median sternotomy is performed, and the pulmonary artery is catheterized for perfusion of a low-potassium dextran solution (Perfadex®). Grafts are inspected in the same manner as brain death donors.

In terms of results, between January 2012 and December 2014, 26 patients were evaluated as possible donors after the family agreed to LTE. Of these, 23 were donors, of whom only 3 met criteria for lung donation. The outcomes of these lung transplant procedures are listed in Tables 1 and 2.

None of our graft recipients developed grade 3 or severe primary graft dysfunction (PGD), and there were no deaths during hospitalization or in the 30-day post-transplant period. Survival at 3 months and 1 year was 100%.

Controlled NHBD has led to a significant worldwide increase in donor numbers, providing PGD and survival outcomes comparable to those achieved with brain death donors.6 In our hospital, the results of the 3 lung transplants perfore with cNHBD were similar to those of other more experienced groups.

The first 2 donors were reevaluated using the ex vivo Organ Care System (OCS® Lung, TransMedics, Inc.). Grafts showed optimal functional and oxygenation parameters. Standard cold preservation was applied in the third case.

A controversial issue in the use of cNHBD is heparinization of the donor before LTE. We prefer to administer heparin before LTE to avoid any risk of pulmonary thromboembolism, including microclots.10 On the other hand, some groups obtain excellent outcomes with the administration of heparin after cardiac arrest.4

In conclusion, we present here the first 3 cases of cNHBD lung transplantation performed in Spain. Our excellent outcomes, added to the international experience, may be used in the implementation of cNHBD protocols in intensive care units throughout the country, with the aim of expanding the lung donor pool.