A 59-year-old man was admitted to the Intensive Care Unit (ICU) with catastrophic brain damage secondary to ischemic stroke established in the territory of the left middle cerebral artery with hemorrhagic transformation.
After four days of ICU admission and in the face of the unfortunate neurological prognosis, it was decided to apply LT a consensual form between the ICU team and the family.
Once established, LT and heparinulation could be due to the possibility of the patient being an organ donor in controlled asystole, the transplant coordinator wasinterviewed with the relatives who showed their wish to donate and signed the informed consent.
After performing the necessary clinical and analytical tests, we proceeded to cannulation of the right femoral artery and vein (AVF type aortic occlusion), as well as the contralateral femoral artery catheter for placement of a femoral catheter.
Once the appropriate NECMO cannulas and the patient's catheter were confirmed, the patient was placed in the operating room where the agreed LT was performed.
After withdrawal of heparin 300 IU/kg i.v. sodium was administered, and 12 minutes later the patient began with hypoperfusion (hypoperfusion five minutes later), another death (real life support less than 60 minutes later).
Thus, the total warm ischemia time (TICT, from withdrawal of life support to the start of cold perfusion or NECMO) was 22 minutes and the warm ischemia time (TICF < 60 mmHg, from the beginning of perfusion.
The evolution of the potential donor during this observation period can be seen in Table 1.
LTs/mmin; life support treatment min: minutes; SBP: systolic blood pressure; DBP: diastolic blood pressure; HR: heart rate; RR: respiratory rate; SpO2: oxygen saturation
As soon as death was confirmed, NECMO (previously swollen contralateral Fogarty balloon) was started with the patient intubated but without initiating ventilation (air turbine).
Subsequently, the thoracic surgeon performed a rapid clamping and, within 7-8 minutes, reviewed the thoracic cavity and thoracic aorta just above the Fogarty catheter.
Immediately after, mechanical ventilation was initiated with an inspired fraction of 100% oxygen (FiO2), positive end-tidal pressure (ESEP) of 5 and 12 breaths/minute.
The surgeon cannulated the pulmonary artery and the lungs were infused with Perfadex lungs (disposability of organ preservation) until cleaning the pulmonary circuit, as a ruled extraction, performing Valsal maneuvers.
At the same time, NECMO continued to function and the liver surgeon performed a midline laparotomy to assess viability and confirm adequate liver perfusion.
Preventively, two tapered catheters and one liter of 0.9% saline were infused to increase the ECMO circuit before clamping the inferior vena cava.
When the thoracic surgeon informed that he was going to ligate the inferior vena cava at the mouth of the right atrium, both surgeons jointly mobilized the distal end of the ECMO centimeters underneath the right atrium.
Once the venous cannula was repositioned and the inferior vena cava was clamped, ECMO flows slightly decreased requiring administration of two other hemoconcentrates and 500 ml 0.9% saline.
At this stage, the thorax and abdomen were already separated with previous ligation of the aorta and the vena cava, and the pulmonary scheduled extraction was performed while continuing with NECMO.
Once the lungs and NECMO were removed 16 minutes more (total time of NECMO 84 minutes), an abdominal perfusion was started with Celsior (extrahepatic preservation of the abdominal organs) finally the EC was maintained.
Serial determinations of acid-base balance and ionic profile, hepatic and renal biochemistry were performed every 20 minutes throughout the process.
PaO2: arterial oxygen pressure (mmHg); PaCO2: arterial carbon dioxide pressure (mmHg); HCO3-: bicarbonate (mmol/L); Lactation: lactate (mg/dL); Glucose/HCV: bilirubin (mg/dL);
All recipients of grafts developed favorably after transplantation.
The lung receiver received a bipulmonary transplant with good evolution during his month of admission to the ICU and subsequent stay in the hospital ward.
