One thousand cases of ex vivo lung perfusion for lung transplantation: A single-center experience

Shaf Keshavjee; Andrew T Sage; Thomas Borrillo; Jonathan C Yeung; Deween Piyasena; Elliot Wakeam; Laura Donahoe; Thomas K Waddell; Marc de Perrot; Andrew Pierre; Sharaniyaa Balachandran; Rasheed Ghany; Aadil Ali; Kazuhiro Yasufuku; Marcelo Cypel

doi:10.1016/j.jtcvs.2025.08.036

One thousand cases of ex vivo lung perfusion for lung transplantation: A single-center experience

J Thorac Cardiovasc Surg. 2025 Sep 3:S0022-5223(25)00738-X. doi: 10.1016/j.jtcvs.2025.08.036. Online ahead of print.

Authors

Affiliations

¹ Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada. Electronic address: shaf.keshavjee@uhn.ca.
² Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.
³ Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada.
⁴ Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

PMID: 40912632
DOI: 10.1016/j.jtcvs.2025.08.036

Abstract

Objectives: The study objectives were to report the impact of ex vivo lung perfusion on lung transplantation practices and clinical outcomes. This study presents the largest single-center ex vivo lung perfusion experience to date, highlighting how ex vivo lung perfusion has transformed clinical lung transplantation with expansion of donor access, program growth, and the safe use of extended criteria donor lungs.

Methods: We conducted a retrospective analysis of 1000 consecutive ex vivo lung perfusion procedures performed between 2008 and 2024 at University Health Network's Toronto General Hospital. Donor lungs were evaluated using the standardized normothermic acellular Toronto ex vivo lung perfusion technique. We analyzed donor and recipient demographics, procedural characteristics, transplant rates, and post-transplant outcomes.

Results: Of 1000 ex vivo lung perfusion procedures, approximately 65% of lungs were accepted for transplant. These grafts accounted for 659 lung transplants, representing 29% of all transplants performed during the study period. Ex vivo lung perfusion volume grew steadily and contributed to an overall increase in transplant activity. The use of moderate- and high-risk donor lungs, including those after circulatory death, increased over time. In concordance with these shifts, median ischemia time increased from 224 to 414 minutes, and the proportion of cases achieving a final ΔpO₂ 400 mm Hg or greater on ex vivo lung perfusion declined from 68% to 52%. Post-transplant outcomes including intensive care unit duration, time to extubation, primary graft dysfunction, and overall survival were not significantly different between ex vivo lung perfusion and non-ex vivo lung perfusion lung recipients.

Conclusions: Ex vivo lung perfusion has emerged as a safe, effective, and scalable platform for donor lung evaluation. Its integration into clinical practice has supported broader donor organ use and excellent patient outcomes, while laying the foundation for continued innovation in lung transplantation.

Keywords: donation after circulatory death; donor lung assessment; ex vivo functional parameters; ex vivo lung perfusion; extended criteria donors; lung transplantation; organ use rate; survival.