Ex vivo lung perfusion in donation after circulatory death lung transplantation: A systematic review and meta-analysis.

Lung transplantation is the definitive therapy for end-stage lung disease, but donor shortages contribute to high waiting list mortality. Donation after circulatory death (DCD) expands the donor pool, and ex vivo lung perfusion (EVLP) enables graft assessment and optimization. However, its impact in this setting remains uncertain. This meta-analysis aimed to evaluate whether EVLP in DCD lungs affects graft function and short-term outcomes compared with direct transplantation. Three databases were searched. The main outcome was grade 3 primary graft dysfunction (PGD). Additional outcomes included intensive care unit (ICU) and hospital length of stay (LOS), both analyzed quantitatively. Outcomes assessed qualitatively comprised short-term survival, pneumonia, and acute rejection. Random-effects models were applied to quantitative analyses. Five observational studies (654 patients) were included. The incidence of grade 3 PGD was comparable between EVLP and non-EVLP groups (RR 1.29; 95%CI 0.97 to 1.71; p = 0.08; I² = 12.63%). Similarly, ICU LOS (p = 0.12) and hospital LOS (p = 0.83) were also comparable. Qualitative assessment showed no apparent differences in short- and mid-term survival or in the frequency of pneumonia and acute rejection between groups. EVLP in DCD lung transplantation was not associated with significant differences in grade 3 PGD, ICU or hospital LOS, or short- to mid-term outcomes compared with direct transplantation. Given its time and resource demands, EVLP may not be necessary for all DCD grafts; however, it remains particularly valuable for evaluating uncertain-quality lungs, where its selective use can help ensure graft safety.