Ex Vivo Lung Perfusion: Expanding the Donor Pool and the APP’s Role in Lung Transplantation
By Margaret Fregoso and Simone Beattie
Introduction
Despite remarkable advances in lung transplantation, the availability of suitable donor organs remains the greatest barrier to providing this life-saving therapy to patients with end-stage lung disease. Although the number of patients awaiting lung transplantation continues to grow, many potentially transplantable donor lungs are declined because of concerns regarding injury, questionable function, or uncertainty about post-transplant performance. Many of these lungs have potentially reversible abnormalities, yet traditional donor assessment often requires transplant teams to make an accept-or-decline decision based on a single evaluation at the donor hospital.
Ex Vivo Lung Perfusion (EVLP) has emerged as one of the most significant innovations in lung transplantation over the past two decades. By allowing donor lungs to be perfused, ventilated, and carefully evaluated outside the body, EVLP enables transplant teams to reassess organs that may have previously been considered unsuitable. Clinical studies have demonstrated that appropriately selected EVLP-assessed lungs achieve short- and long-term outcomes comparable to those of lungs accepted using standard donor criteria.
For Advanced Practice Providers (APPs), EVLP represents more than a technological advance—it is reshaping clinical practice across the transplant continuum. APPs are integral members of multidisciplinary transplant teams, participating in candidate evaluation, perioperative management, critical care, patient education, and long-term follow-up. As EVLP becomes increasingly integrated into clinical practice, familiarity with its principles, benefits, and limitations is essential for APPs caring for patients with advanced lung disease.
To better understand how EVLP is changing lung transplantation, we spoke with thoracic transplant surgeon Dr. Bacchetta, whose interest in EVLP began with his background in engineering and love for cardiopulmonary physiology. When discussing the evolution of EVLP, Dr. Bacchetta noted that early logistical concerns have been addressed: “Since the advent of the 10-degree storage, the logistical concerns have pretty much gone away.” Advances in preservation have helped facilitate the use of EVLP in clinical practice.
What Is Ex Vivo Lung Perfusion?
Ex vivo lung perfusion (EVLP) is a preservation and assessment technique that allows donor lungs to be maintained in a normothermic, physiologic environment outside the body. During EVLP, the lungs are ventilated while a specialized perfusion solution circulates through the pulmonary vasculature, allowing clinicians to evaluate organ function in real time. EVLP is most commonly used to evaluate donor lungs with potentially reversible abnormalities, including borderline oxygenation, pulmonary edema, airway secretions, or lungs recovered following donation after circulatory death (DCD), where additional physiologic assessment may increase confidence in organ quality.
Rather than relying solely on donor characteristics or a single assessment at the donor hospital, EVLP allows transplant teams to observe lung function over several hours. This additional evaluation period transforms what was once an immediate accept-or-decline decision into a more informed clinical assessment.
Importantly, EVLP is not intended to “rescue” every declined organ; rather, it functions as a physiologic assessment platform that helps distinguish lungs with reversible injury from those unlikely to recover. As Dr. Bacchetta explained, EVLP provides a dynamic environment in which clinicians can continuously monitor donor lung physiology rather than relying on a single snapshot of organ quality. A tour of the EVLP facility further demonstrated that this assessment period also provides an opportunity for targeted interventions when appropriate, including bronchoscopic clearance of secretions, recruitment maneuvers to reverse atelectasis, administration of antibiotics for suspected infection, and, in selected cases, thrombolytic therapy to reduce pulmonary clot burden. For many donor lungs with potentially reversible injury, EVLP provides the additional physiologic information needed to demonstrate adequate function and determine whether transplantation can be performed safely.
The APP Perspective: A Critical Role Throughout the Transplant Journey
As lung transplant programs continue to incorporate EVLP into clinical practice, APPs play an increasingly important role throughout the transplant process.
Before transplantation, APPs contribute to candidate selection, interpretation of donor information, coordination among procurement and transplant teams, patient education, and communication with recipients awaiting organ offers. As donor information evolves during EVLP assessment, APPs frequently serve as liaisons among donor procurement teams, EVLP specialists, transplant surgeons, and recipient care teams, facilitating multidisciplinary decision-making and coordinating communication regarding operative timing. Their understanding of EVLP allows them to explain why a donor organ may require additional evaluation and help patients and families navigate evolving timelines.
Dr. Bacchetta shared the integral role of APPs within his lung transplant program, emphasizing their clinical expertise: “We have extraordinarily, highly skilled APPs. They know how to take care of patients. They know how to evaluate physiology.” He also highlighted their contribution to donor assessment, noting that APPs have helped “expand the way we look at donors, [including] marginal donors.” Beyond clinical care, APPs are deeply involved in transplant research. “Our APP group at Vanderbilt is heavily involved in research, and they’re heavily involved in lung transplant research,” he explained. “They are integral to our critical care research.” For Dr. Bacchetta, the role of APPs in lung transplantation, is already established: “This isn’t a question to me of, you know, is there a role for APPs? Our APPs are already involved. They’re already doing it.”
Following transplantation, APPs are central to the recognition and management of early graft function. Patients receiving EVLP-assessed lungs require careful postoperative monitoring, including evaluation of oxygenation, ventilator parameters, hemodynamics, immunosuppression, and early complications such as primary graft dysfunction. Familiarity with EVLP also helps APPs interpret early postoperative findings. For example, transient pulmonary edema following EVLP may improve rapidly during the first postoperative day and should be distinguished from evolving primary graft dysfunction. Differentiating expected postoperative recovery from evolving graft dysfunction requires close collaboration with surgeons, intensivists, pulmonologists, and the multidisciplinary transplant team.
Beyond direct patient care, APPs frequently lead quality improvement initiatives, protocol implementation, patient education, and clinical research. As EVLP programs expand, APPs will continue to play an essential role in translating emerging evidence into everyday clinical practice.
Looking Ahead
The future of EVLP extends well beyond organ assessment. While EVLP has become a mature platform for evaluating donor lung quality, emerging research is exploring its potential for organ repair and targeted therapeutic intervention before transplantation.
Current investigations include delivery of antimicrobial therapies, anti-inflammatory agents, stem cell–based therapies, gene-editing technologies, and other precision treatments during ex vivo perfusion. These advances have the potential not only to increase donor organ utilization but also to improve long-term transplant outcomes.
As these innovations move from research into clinical practice, APPs will remain at the forefront of implementation, helping develop clinical protocols, coordinate multidisciplinary care, educate patients, and contribute to research that continues to redefine the future of lung transplantation.
