Beyond the Barriers of Ex Vivo Lung Perfusion Through an Emblematic Case: A New Way Forward to Expand the Donor Pool

: Background: Lung transplantation is the most effective treatment for end-stage respiratory diseases, but its application is limited by the shortage of organs. Ex vivo lung perfusion (EVLP) has emerged as a promising technique to evaluate and recondition donor lungs previously deemed unsuitable for transplantation. However, limitations such as lung contusions, air leaks, and perfusate extravasation, especially in portable EVLP systems, hinder the procedure. Despite prolonged perfusions that can result in blood pooling at the lung bases due to fixed lung positioning and diminished oncotic pressure, in some cases, extending perfusion time beyond the typical 5-6 h could benefit extended-criteria lungs, addressing factors such as edema or logistical complications. Methods: We present an innovative protocol involving prolonged EVLP, pronation of the graft, and the addition of anti-edematous drugs to the perfusate. Results: This novel approach, previously tested in animal models, enhances lung reconditioning and expands the donor pool. Conclusions: Our findings suggest that this strategy overcomes key limitations of standard EVLP, offering a valuable solution for improving the availability of transplantable lungs.