Post-Ex Vivo Lung Perfusion lung-in-fridge technique

1. Final EVLP Evaluation

* Confirm suitability for transplantation:
* Adequate oxygenation (PaO₂/FiO₂)
* Stable pulmonary vascular resistance (PVR)
* Acceptable lung compliance and airway pressures
* Record all final EVLP parameters (flow, pressure, temperature, gases)

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2. Pre-Weaning Preparation

* Communicate with the surgical team
* Ensure hemodynamic and circuit stability
* Gradually reduce FiO₂ to avoid hyperoxic injury

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3. Controlled Cooling Phase

* Decrease perfusate temperature gradually (37°C → 10–15°C)
* Simultaneously reduce pump flow stepwise
* Maintain low-pressure perfusion to protect endothelium

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4. Ventilation Weaning

* Gradually reduce tidal volume and respiratory rate
* Stop ventilation once lungs are partially deflated
* Apply low-level CPAP (5–10 cmH₂O) to prevent atelectasis

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5. Pulmonary Artery Flush

* Infuse cold preservation solution (e.g., Perfadex) via pulmonary artery
* Ensure effective left atrial venting
* هدف: remove residual blood, metabolites, and inflammatory mediators

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6. De-airing and Circuit Separation

* Carefully de-air pulmonary vasculature
* Clamp pulmonary artery and left atrium
* Disconnect lungs from EVLP circuit under sterile conditions

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7. Lung Inflation Strategy

* Maintain partial inflation:
* FiO₂ ~40–50%
* Low airway pressure
* Clamp or staple the trachea to preserve lung inflation

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8. Sterile Triple-Bag Packaging

* Place lungs in inner sterile bag with cold preservation solution
* Seal and place into second and third sterile bags
* Surround with ice slurry (4°C), avoiding direct ice contact

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9. Cold Storage (“Lung-in-Fridge”)

* Store at 4°C in a transport container
* Prevent mechanical compression or آسیب to lung tissue

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10. Documentation and Handover

* Accurately record:
* End of EVLP time
* Start of second cold ischemic time
* Provide clear handover to transplant team

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11. Interim Monitoring (if delayed implantation)

* Periodically inspect graft (color, edema, integrity)
* Maintain consistent hypothermic conditions

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This technique allows safe transition back to cold preservation after EVLP, optimizing logistics while minimizing ischemia–reperfusion injury and preserving graft quality.

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