New Usages of EVLPD Technology in Lung Donation and Transplant

Ex Vivo Lung Perfusion (EVLP) has revolutionized the management of donor organs in lung transplantation by shifting the paradigm from static cold storage to dynamic, normothermic preservation (Nakata et al., 2025). This innovative platform allows "marginal" or extended-criteria donor lungs—which would traditionally be discarded due to neurogenic pulmonary edema, atelectasis, or poor initial arterial blood gas profiles—to be safely isolated in a closed, sterile circuit that mimics physiological ventilation and perfusion (Ahmad et al., 2022; Fisher, n.d.).  

During EVLP management, the allograft is slowly rewarmed to an ambient temperature of 37°C and perfused with a specialized, hyperoncotic solution (such as STEEN Solution) that contains a high concentration of albumin and dextran (Fisher, n.d.; Pan et al., 2018). This high oncotic pressure is highly effective at drawing out interstitial lung water, thereby resolving acute pulmonary edema and significantly improving the organ's oxygenation index (Fisher, n.d.). Concurrently, protective mechanical ventilation is initiated with low tidal volumes (5\text{–}7\text{ mL/kg} of donor ideal body weight) and continuous positive end-expiratory pressure (PEEP) to gently recruit collapsed alveoli without inflicting barotrauma (Nakata et al., 2025; Ragheb, n.d.).   

Throughout the 3-to-6-hour perfusion window, transplant clinicians can continuously monitor real-time physiological metrics—including pulmonary vascular resistance, dynamic lung compliance, and the ratio of arterial oxygen partial pressure to fractional inspired oxygen (\text{P/F ratio})—to objectively verify that the graft meets safe transplantation thresholds, which typically require a stable or improving \text{P/F ratio} greater than 300\text{–}400\text{ mmHg} (Nakata et al., 2025; Pan et al., 2018). Beyond diagnostic evaluation, EVLP serves as an invaluable therapeutic delivery system; clinicians can perform directed bronchoscopy for airway clearance, implement leukocyte filters to deplete donor-derived inflammatory mediators, and administer targeted, high-dose intravascular antibiotics or antivirals directly to the isolated organ without risk of systemic toxicity to a recipient (Ahmad et al., 2022; Ali et al., 2022; Nakajima et al., 2016). Ultimately, this comprehensive management protocol effectively expands the viable donor pool, eliminates geographic transport constraints via portable EVLP devices (such as the TransMedics Organ Care System), and has been shown to match or exceed the short- and long-term post-transplant clinical outcomes of standard, conventionally selected donor lungs (Ahmad et al., 2022; Peer, n.d.).