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Evolving challenges in thoracic transplantation.

DOI:10.1097/MOT.0000000000000533 reliable life-saving alternative for patients with end-stage heart and lung diseases. The short and medium-term outcomes of heart and lung transplantation have steadily improved in the past few decades. The improvements can be attributed to advances in several areas: improved organ procurement and preservation, safer implant procedures, improved perioperative care and better immunosuppressive regimens with less side effects. The long-term survival of thoracic transplant patients remains a challenge, especially among lung transplant recipients. The improved short and medium-term outcomes in thoracic transplantation have resulted in new challenges for the scientific community. We have, in the past few decades, successfully pushed the boundaries of organ utilization, recipient selection and peri-transplant care. Many transplant centres are now dealing with clinical questions and challenges that were not conceivable 2 decades ago: how far can we push the boundaries of marginal donor organs (age, quality, ischaemia time, donation after circulatory death donor hearts and so on), how and where ex-vivo organ perfusion fits in contemporary thoracic organ transplantation (can we reliably remove the issue of ‘cold ischemia time’ in organ procurement?), should we offer organ transplantation to highly sensitized patients and under what protocol? Why is there an uptick in primary graft dysfunction (PGD) in heart transplantation among many heart transplant centres? These are some representative questions that contemporary heart and lung transplant programmes face on a regular basis. Unfortunately, there is paucity of Level 1 data to help guide clinicians in these or similar scenarios. The purpose of this edition of Current Opinion in Organ Transplantation is to highlight some controversial issues and present the opinion of some of the thought leaders in these areas. Although the technique for heart and lung procurement has undergone minimal changes in the past 2 decades, the science and art of organ procurement has evolved greatly. Dr Copeland et al. (pp. 281–285) emphasize the role of the procurement team in assessing the donor organ, and discuss the optimal management of the donor organ at