Lung donation after circulatory death

Donation after circulatory death (DCD) defines organs procurement after death determined using circulatory criteria, as opposed to a declaration based on neurological criteria. Nowadays, DCD donors represent a valuable resource to contrast lung donor shortage and waiting list mortality, while also avoiding the potential lung damages generated by brain death. On the other hand, lungs from DCD donors are exposed to a variable warm ischemia time and related potential detrimental effects. The extensive experimental investigation proved the feasibility of this practice, and the subsequent clinical experiences around the world showed good outcomes. In this paper, we review the pre -clinical and clinical experiences in the DCD field, focusing on ischemia time and the biological peculiarities of the lung tissue in animal models. We illustrate the clinical paths of the DCD donor categories as described in the Maastricht classification, and the different preservation techniques and procurement protocols, with particular regard to the ethical and legal differences around the world. We analyse the characteristics of both the controlled and uncontrolled setting, highlighting the advantages and disadvantages of each donation setting. We then proceed to review the clinical outcomes as well as the complications after lung transplantation from DCD donors as reported in literature. Lastly, we outline the role of machine perfusion for the function assessment and reconditioning of grafts procured in this scenario.