Uncontrolled donation after circulatory death lung transplantation program: Clinical outcomes and perspectives for implementation

Lung transplantation (LT) remains limited by the scarcity of suitable donor organs. Uncontrolled donation after circulatory death (uDCD) is a promising yet underutilized source due to logistical barriers. This study presents a prospective, single-center experience with uDCD LT. From 2014 to 2025, all uDCD lung referrals at our center in Milan were prospectively assessed. Lungs were preserved via open-lung ventilation without in situ cooling, followed by ex vivo lung perfusion (EVLP) evaluation. Clinical outcomes were analyzed, and regional donor potential was explored using 2023 cardiac arrest data from Lombardy. Among 72 referred donors, 30 met eligibility criteria, 25 proceeded to recovery, and 18 were transplanted after EVLP (72% post-EVLP utilization rate). The 30-day and 1-year survival rates were 94.4% (95% confidence interval [CI] 83.9%-100.0%) and 83.3% (95% CI 57.5%-99.8%), respectively. Primary graft dysfunction grade 3 within 72 hours occurred in 16.7% (95% CI 6.4%-34.8%), while chronic lung allograft dysfunction developed in 27.8% (95% CI 13.2%-50.3%). Median warm ischemia time was 240 minutes. Regional analysis identified 119 uDCD-eligible cases in 2023, 20 activations, with 5 transplants performed, and major untapped potential. uDCD LT is feasible and effective. Our simplified normothermic strategy is operationally scalable and yields outcomes comparable to those historically reported from conventional LT. Broader implementation, supported by regional coordination, could substantially expand the lung donor pool.