Ex vivo lung perfusion is a leading-edge technique designed to make more lungs suitable for transplant, making it possible for more patients to receive a lifesaving lung transplant.
Learn more about this technique from Dr. Mark Roeser, a UVA specialist in lung transplants.
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Making More Lungs Safe for Transplant
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Mark Roeser, MD
Dr. Mark Roeser is a board-certified surgeon whose specialties include lung transplantation.Learn more about Dr. Mark Roeser
Learn more about UVA Children’s Hospital
Transcription:
Making More Lungs Safe for Transplant
Melanie Cole (Host): Ex Vivo lung perfusion is a leading edge technique designed to make lungs more suitable for transplant making it possible for more patients to receive a life-saving lung transplant. My guest today is Dr. Mark Roesser. He is a congenital heart and transplant surgeon at UVA Health System. Welcome to the show, Dr. Roesser. Briefly explain a little bit about what EVLP is to the listeners.
Dr. Mark Roesser (Guest): EVLP was designed – it came out of a lot of basic science research. It kind of hit its head in the 90’s and early 2000’s. The problem is there is a shortage of lung donors out there, especially quality lung donors. Whenever a patient is a donor they are declared brain dead. Whenever that happens to your body, it releases a lot of chemicals. Those chemicals can cause swelling in certain areas – one of those areas is the lungs. So, as they are laying there in bed, they are unable to cough because they’re brain dead. Their lungs slowly don’t do as well. So, it’s harder to get lungs from donors than it is other organs, such as livers or kidneys. What EVLP does is that it lets us take those lungs out of donors that may be questionable. It may not be the perfect lung to put into somebody. It puts it in a wait station which is a circuit with a ventilator and they perfuse and lets us see if these are actually going to be good lungs for somebody or are they, in fact, not good lungs for somebody. Instead of taking the risk of putting them into a living patient and then seeing what the results are, it is a wait station to see if these will be adequate lungs for donation.
Melanie: Is there any controversial issue with this type of procedure? Do the families of the donors question what you’re doing to get these lungs at that time?
Dr. Roesser: Everybody is informed that these will be Ex Vivo lungs and they sign off. Whenever we call them in we say, “We’re going to give you an Ex Vivo lung or we’re not” and if they refuse, even though they have written consent, if they refuse on that call in, we don’t penalize them at all. We say, “That’s not a problem.” Then we go to the next person on the list. That person won’t lose their spot in line or anything like that. It’s not allocated that way. It is allocated for the best person for that set of lungs – who’s the sickest. These lungs don’t necessarily come from high risk donors. Some people are very sick and they say, “I’ll take donor lungs from a high risk donor.” It may be somebody who has some needle marks. We test for HIV, we test for Hepatitis C but those tests aren’t 100% accurate. If you’re a healthy person, you may turn down those lungs. If you’re a sick person or you’re a person who doesn’t really care about those risks you’ll say, “Yes, I’ll take those high risk lungs.” Ex Vivo doesn’t really fall into the infection category. It falls into where the donors or the lungs weren’t doing very well. Once we take them out and we put them on the Ex Vivo circuit, we will not use those lungs if they don’t meet the standard criteria that we’d use for lungs that came straight from a donor. Even though we take lungs that are sub-par, we make sure that they are going to be adequate before we actually use them. If they are not adequate, then we don’t use them. What it does is help mitigate the risk that we would rather try to avoid.
Melanie: How has this changed the world of lung transplantation?
Dr. Roesser: It’s going to open up the donor pool quite a bit. At our center, we actually have a National Institutes of Health grant where we are actually going to give chemicals to modify these lungs. The great thing about the Ex Vivo circuit is it has no blood or blood products in it. We’re not exposing these lungs to any additional antibodies or blood-borne infections. We are just taking them out of a donor where they are in a bunch of cytokines chemicals that are making them sicker. We’re taking them out of that situation, putting them on a ventilator and a circuit that kind of separates this fluid. What that fluid does – it’s a special solution called “Steen” – it helps to take all of the free water out of these lungs and kind of dry them out. It gives us a better idea of how these lungs are going to work. I think the future of it is we’re going to be manipulating these lungs to actually make them healthier before we put them into somebody. I think that’s really going to explode lung transplantation.
Melanie: Can it reverse some previous lung injury that you might find in some of these higher risk donors?
Dr. Roesser: Exactly. That’s exactly what it will help do. Initially, this was designed to see if they were good lungs but we found out that the circuit will actually help. If you have a pulmonary edema or any extra fluid in your lung, this circuit will actually help to get that out. Let’s say there is a lot of snot or mucus and stuff. I can actually go in there and suck all that snot and stuff out and really get a good feel for how the lung is going to perform whenever I put it into a human.
Melanie: Wouldn’t that be amazing if you could do that inside a human body and reverse some of those injuries? I just wonder, do you see that is something that might be coming in the future that we might be able to do something like this for working lungs?
Dr. Roesser: Our lab is actually working on that. We have some pigs and we are injecting the pigs with this compound that makes their lungs get sick. Kind of like if you had a very bad pneumonia and you got sepsis. This compound kind of does that. What we’re trying to do is see if we can reverse those outside of the pig’s body. If those experiments work, then we’re going to go and start doing them inside while the pig – we’ll open up the pig and we’ll actually put cameras in the pig. We’ll put them on by-pass and we’ll isolate the lung and see if it will work that way. If we can show it on animal models, then my hope is that, in the future, we can use small catheters and wires in your groin. Let’s say you or your loved one or is very sick, we could actually go in and help the lungs out while they are in your own body. It wouldn’t be for a person who needed a lung transplant but it may be to prevent somebody who is very sick from needing additional procedures or it might help to rehab their lungs faster than it would otherwise.
Melanie: That is amazing, Dr. Roesser. Now, tell us about the risks for the surgery for the recipient. You said that if they are at end-stage kind of situation, they are not going to be as worried about what you’re giving them as long as you’re giving them something. But, besides rejection, are there other risks that people are concerned about?
Dr. Roesser: They actually did a national trial here. It was written up in the New England Journal of Medicine and got FDA approval or approval. There were equivalent outcomes between someone who had lungs that were placed on this machine and given to them and lungs that were just given to them. Our data shows there is no change at all in their risk of this lung. The good thing is, if you take these lungs that may not be the greatest lungs and you put them on the circuit and they look great, then you feel confident to putting them into somebody. If they don’t look great, then you just throw them away or do your research on them. All you really lose with that is money and time but you aren’t really affecting any humans or the quality of life which is really why us surgeons are very happy and excited about it. Lung transplantation, per se, may not extend your life. The average life expectancy after lung transplant is only 5.4 years. What we are really trying to do is to give people very good quality of life for the remaining time they have left. If you give them a lung that’s not very good, that quality of life is not going to improve. We’re very risk adverse. We only take very good lungs to give to people. What this will do is increase the donor pool of very good lungs to give to people.
Melanie: That’s what’s so amazing is the donor pool seems to be one of the hardest parts for any kind of transplant. Tell us a little about UVA and your team there at UVA Heath System.
Dr. Roesser: Our team consists of two pulmonologists and three surgeons. We also have four nurse practitioners and then, we also have a very predominant lab that does a lot of research. What we’re doing is using our research in the lab and helping to translate that over into our clinical activities. One of our researches is in adenosine compound. What these compounds do is, they kind of help reverse injury in the tissue. Our grant is to put this compound inside the recipients and inside lungs and see if that will help reverse any damage due to the fact that they are in a brain dead donor, due to the fact that you’re taking an organ out of somebody and putting it into somebody else. In the lab, we’ve shown that this is very helpful and now we’re ready to move into clinical trials on it.
Melanie: Wow. What an amazing job that you have. We applaud all of the great work that you are doing, Dr. Roesser. Thank you so much for being with us today. You’re listening to UVA Health Systems Radio and for more information you can go to UVAHealth.com. That’s UVAHealth.com. This is Melanie Cole. Thanks so much for listening.
Making More Lungs Safe for Transplant
Melanie Cole (Host): Ex Vivo lung perfusion is a leading edge technique designed to make lungs more suitable for transplant making it possible for more patients to receive a life-saving lung transplant. My guest today is Dr. Mark Roesser. He is a congenital heart and transplant surgeon at UVA Health System. Welcome to the show, Dr. Roesser. Briefly explain a little bit about what EVLP is to the listeners.
Dr. Mark Roesser (Guest): EVLP was designed – it came out of a lot of basic science research. It kind of hit its head in the 90’s and early 2000’s. The problem is there is a shortage of lung donors out there, especially quality lung donors. Whenever a patient is a donor they are declared brain dead. Whenever that happens to your body, it releases a lot of chemicals. Those chemicals can cause swelling in certain areas – one of those areas is the lungs. So, as they are laying there in bed, they are unable to cough because they’re brain dead. Their lungs slowly don’t do as well. So, it’s harder to get lungs from donors than it is other organs, such as livers or kidneys. What EVLP does is that it lets us take those lungs out of donors that may be questionable. It may not be the perfect lung to put into somebody. It puts it in a wait station which is a circuit with a ventilator and they perfuse and lets us see if these are actually going to be good lungs for somebody or are they, in fact, not good lungs for somebody. Instead of taking the risk of putting them into a living patient and then seeing what the results are, it is a wait station to see if these will be adequate lungs for donation.
Melanie: Is there any controversial issue with this type of procedure? Do the families of the donors question what you’re doing to get these lungs at that time?
Dr. Roesser: Everybody is informed that these will be Ex Vivo lungs and they sign off. Whenever we call them in we say, “We’re going to give you an Ex Vivo lung or we’re not” and if they refuse, even though they have written consent, if they refuse on that call in, we don’t penalize them at all. We say, “That’s not a problem.” Then we go to the next person on the list. That person won’t lose their spot in line or anything like that. It’s not allocated that way. It is allocated for the best person for that set of lungs – who’s the sickest. These lungs don’t necessarily come from high risk donors. Some people are very sick and they say, “I’ll take donor lungs from a high risk donor.” It may be somebody who has some needle marks. We test for HIV, we test for Hepatitis C but those tests aren’t 100% accurate. If you’re a healthy person, you may turn down those lungs. If you’re a sick person or you’re a person who doesn’t really care about those risks you’ll say, “Yes, I’ll take those high risk lungs.” Ex Vivo doesn’t really fall into the infection category. It falls into where the donors or the lungs weren’t doing very well. Once we take them out and we put them on the Ex Vivo circuit, we will not use those lungs if they don’t meet the standard criteria that we’d use for lungs that came straight from a donor. Even though we take lungs that are sub-par, we make sure that they are going to be adequate before we actually use them. If they are not adequate, then we don’t use them. What it does is help mitigate the risk that we would rather try to avoid.
Melanie: How has this changed the world of lung transplantation?
Dr. Roesser: It’s going to open up the donor pool quite a bit. At our center, we actually have a National Institutes of Health grant where we are actually going to give chemicals to modify these lungs. The great thing about the Ex Vivo circuit is it has no blood or blood products in it. We’re not exposing these lungs to any additional antibodies or blood-borne infections. We are just taking them out of a donor where they are in a bunch of cytokines chemicals that are making them sicker. We’re taking them out of that situation, putting them on a ventilator and a circuit that kind of separates this fluid. What that fluid does – it’s a special solution called “Steen” – it helps to take all of the free water out of these lungs and kind of dry them out. It gives us a better idea of how these lungs are going to work. I think the future of it is we’re going to be manipulating these lungs to actually make them healthier before we put them into somebody. I think that’s really going to explode lung transplantation.
Melanie: Can it reverse some previous lung injury that you might find in some of these higher risk donors?
Dr. Roesser: Exactly. That’s exactly what it will help do. Initially, this was designed to see if they were good lungs but we found out that the circuit will actually help. If you have a pulmonary edema or any extra fluid in your lung, this circuit will actually help to get that out. Let’s say there is a lot of snot or mucus and stuff. I can actually go in there and suck all that snot and stuff out and really get a good feel for how the lung is going to perform whenever I put it into a human.
Melanie: Wouldn’t that be amazing if you could do that inside a human body and reverse some of those injuries? I just wonder, do you see that is something that might be coming in the future that we might be able to do something like this for working lungs?
Dr. Roesser: Our lab is actually working on that. We have some pigs and we are injecting the pigs with this compound that makes their lungs get sick. Kind of like if you had a very bad pneumonia and you got sepsis. This compound kind of does that. What we’re trying to do is see if we can reverse those outside of the pig’s body. If those experiments work, then we’re going to go and start doing them inside while the pig – we’ll open up the pig and we’ll actually put cameras in the pig. We’ll put them on by-pass and we’ll isolate the lung and see if it will work that way. If we can show it on animal models, then my hope is that, in the future, we can use small catheters and wires in your groin. Let’s say you or your loved one or is very sick, we could actually go in and help the lungs out while they are in your own body. It wouldn’t be for a person who needed a lung transplant but it may be to prevent somebody who is very sick from needing additional procedures or it might help to rehab their lungs faster than it would otherwise.
Melanie: That is amazing, Dr. Roesser. Now, tell us about the risks for the surgery for the recipient. You said that if they are at end-stage kind of situation, they are not going to be as worried about what you’re giving them as long as you’re giving them something. But, besides rejection, are there other risks that people are concerned about?
Dr. Roesser: They actually did a national trial here. It was written up in the New England Journal of Medicine and got FDA approval or approval. There were equivalent outcomes between someone who had lungs that were placed on this machine and given to them and lungs that were just given to them. Our data shows there is no change at all in their risk of this lung. The good thing is, if you take these lungs that may not be the greatest lungs and you put them on the circuit and they look great, then you feel confident to putting them into somebody. If they don’t look great, then you just throw them away or do your research on them. All you really lose with that is money and time but you aren’t really affecting any humans or the quality of life which is really why us surgeons are very happy and excited about it. Lung transplantation, per se, may not extend your life. The average life expectancy after lung transplant is only 5.4 years. What we are really trying to do is to give people very good quality of life for the remaining time they have left. If you give them a lung that’s not very good, that quality of life is not going to improve. We’re very risk adverse. We only take very good lungs to give to people. What this will do is increase the donor pool of very good lungs to give to people.
Melanie: That’s what’s so amazing is the donor pool seems to be one of the hardest parts for any kind of transplant. Tell us a little about UVA and your team there at UVA Heath System.
Dr. Roesser: Our team consists of two pulmonologists and three surgeons. We also have four nurse practitioners and then, we also have a very predominant lab that does a lot of research. What we’re doing is using our research in the lab and helping to translate that over into our clinical activities. One of our researches is in adenosine compound. What these compounds do is, they kind of help reverse injury in the tissue. Our grant is to put this compound inside the recipients and inside lungs and see if that will help reverse any damage due to the fact that they are in a brain dead donor, due to the fact that you’re taking an organ out of somebody and putting it into somebody else. In the lab, we’ve shown that this is very helpful and now we’re ready to move into clinical trials on it.
Melanie: Wow. What an amazing job that you have. We applaud all of the great work that you are doing, Dr. Roesser. Thank you so much for being with us today. You’re listening to UVA Health Systems Radio and for more information you can go to UVAHealth.com. That’s UVAHealth.com. This is Melanie Cole. Thanks so much for listening.