J Card Surg. 2020;35:191–194. wileyonlinelibrary.com/journal/jocs © 2019 Wiley Periodicals, Inc. | 191 DOI: 10.1111/jocs.14273 NEW TECHNOLOGIES DCD and DBD lung transplantation optimized by ex vivo perfusion: What to do when the pump fails April A. Grant MD 1,2 | Shivang Bhakta BS 2 | Nicholas Brozzi 2,5 | Andrew Talon BS 2 | Alan Klima CCP 3 | Alejandro Duenas CCP 3 | David Galbut 4 | Matthias Loebe MD, PhD 2,5 | Ali Ghodsizad MD, PhD 2,5 1 Division of Trauma and Surgical Critical Care, Department of Surgery, University of Miami School of Medicine, Miami, Florida 2 Heart and Lung Transplant and Mechanical Circulatory Support, Miami Transplant Institute, Miami, Florida 3 Comprehensive Care Services, Inc, Livonia, Michigan 4 Division of Cardiothoracic Surgery, Department of Surgery, Jackson Hospital System, Miami, Florida 5 Division Heart and Lung Transplant and Mechanical Circulatory Support, Department of Surgery, University of Miami School of Medicine, Miami, Florida Correspondence Ali Ghodsizad, MD, PhD, FACC, FETCS, Assistant Professor of Surgery, University of Miami, Leonard M Miller School of Medicine, 1801 NW 9th Ave, 6th Floor, Miami, FL 33136. Email: axg1433@miami.edu Abstract Background: Ex vivo perfusion is a safe and feasible method of assessing and using high‐risk donor organs. Aim: We describe a case of successfully ex vivo treated and transplanted human lung allografts. Methods: Donor human lungs were assessed using ex vivo, our trouble shooting protocol allowed safe recovery. Results: We successfully implanted our ex vivo treated organs. KEYWORDS ex vivo perfusion, lung transplant, troubleshooting, XVIVO 1 | INTRODUCTION Ex vivo perfusion is a safe and feasible method of assessing and using high‐risk donor thoracic organs before transplantation and has been shown to lead to good long‐term survival, graft function, and improvement in of quality of life that is at least comparable with conventionally selected organs. 1-3 The number of lung transplants done worldwide has steadily increased. Unfortunately, the number of patients on the waiting list still exceeds the number of available donor lungs and many patients do not survive to lung transplantation. 4 At our institution, we place high‐risk lungs from brain death donors on the ex vivo lung perfusion (EVLP) circuit for 4 to 6 hours. The donor lungs are transported from the procurement site according to the center’s standard protocol. Then, the lungs are flushed thoroughly with Perfadex or Perfadex Plus (XVIVO Perfusion Inc, Englewood, CO) and placed on the EVLP platform for immediate or delayed normothermic perfusion. After warming the lungs to 32°C, the EVLP team uses a lung‐ protective mechanical ventilation protocol based upon the lung response. The oxygenation, pulmonary vascular resistance, dynamic compliance, and peak inspiratory pressure are evaluated hourly. Mechanically, the XVIVO Perfusion device (XVIVO Perfusion Inc) consists of a single circuit. The circuit is comprised of five components 1 : a reservoir where Steen solution (XVIVO Perfusion Inc) is collected; it is initially filled with the perfusate to prime the circuit, 2 a Cardiohelp (Maquet Cardiovascular LLC, Wayne, NJ), the lung chamber recovery pump, which provides the flow for the circuit, 3 a Quadrox D oxygenator (Maquet Cardiovascular LLC), 4 a leukodepletion filter, which is connected through an inline sensory and into the right atrium, and lastly 5 a Steen exchange pump. The Cardiohelp is eventually used to challenge the lung by reducing oxygen and introducing CO 2 to the solution via the pulmonary artery cannula. Any volume that escapes from the cannula sutured to the vessels is drained from the bottom of the lung