Ex-vivo organ perfusion by the recipient

Abstract

The present invention relates to methods, systems, and devices for extracorporeal support of an organ, tissue, or bioengineered graft. In some embodiments, the methods or systems comprise cross-circulation perfusion via cross-circulation to an extracorporeal membrane oxygenation (ECMO) circuit in connection with a subject.

Description

[0001] Attorney Docket No. 206030-03 lO-OOWO

[0002] TITLE OF THE INVENTION

[0003] Ex- Vivo Organ Perfusion by the Recipient

[0004] CROSS-REFERENCE TO RELATED APPLICATIONS

[0005] This application claims priority to U.S. Provisional Application No. 63 / 726,786, filed December 02, 2024, all of which applications are incorporated herein by reference in their entireties.

[0006] BACKGROUND OF THE INVENTION

[0007] More than 60% of consented donor thoracic organs are not transplanted due to quality concerns. Ex-vivo Organ Perfusion (EVOP) has been shown to improve the quality of donor organs prior to transplantation. The EVOP platform utilizes brain dead donor blood or banked blood or crystalloid solutions to circulate through the donor organ. However, EVOP has multiple limitations including a closed-circuit with limited homeostatic potentials (due to lack of kidney / liver to remove the accumulated toxins and availability of neurohormonal / other factors).

[0008] Thus, there is a need in the art for improved ex-vivo organ perfusion systems and methods. This invention addresses these continued unmet needs.

[0009] SUMMARY OF THE INVENTION

[0010] In some embodiments, the invention provides a system for maintaining an extracorporeal organ, comprising: an extracorporeal chamber having an extracorporeal organ positioned therein; an ex-vivo organ perfusion (EVOP) circuit fluidly connected to the extracorporeal organ within the extracorporeal chamber, the EVOP circuit comprising an EVOP pump, a first EVOP conduit and a second EVOP conduit, wherein the first EVOP conduit defines a flowpath from the EVOP pump into the extracorporeal organ and the second EVOP conduit defines a flowpath from the extracorporeal organ to the EVOP pump; an extracorporeal membrane oxygenation (ECMO) circuit fluidly connected to a host organism, the ECMO circuit comprising an ECMO pump, an oxygenator, a first ECMO conduit and a second ECMO conduit, wherein the first ECMO conduit defines a flowpath from the ECMO pump into the host organism and the second Attorney Docket No. 206030-0310-00WO

[0011] ECMO conduit defines a flowpath from the host organism to the ECMO pump; a first cross circuit conduit fluidly connecting the second ECMO conduit to the first EVOP conduit and defining a first cross circuit flowpath from the ECMO circuit to the EVOP circuit; and a second cross circuit conduit fluidly connecting the first EVOP conduit to the second ECMO conduit and defining a second cross circuit flowpath from the EVOP circuit to the ECMO circuit; wherein the system is configured to perfuse the extracorporeal organ with blood from the host organism.

[0012] In some embodiments, the first cross circuit conduit comprises a first reservoir. In some embodiments, the second cross circuit conduit comprises a second reservoir.

[0013] In some embodiments, the first cross circuit conduit comprises a first valve between the ECMO circuit and the first reservoir, and a second valve between the first reservoir and the EVOP circuit.

[0014] In some embodiments, the second cross circuit conduit comprises a third valve between the EVOP circuit and the second reservoir, and a fourth valve between the second reservoir and the ECMO circuit.

[0015] In some embodiments, the system further comprises a control unit, wherein the control unit is configured to operate at least one of the first, second, third and fourth valves.

[0016] In some embodiments, the system further comprises at least one sensor configured to measure fluid pressure, fluid volume, flow rate, pump speed, oxygen saturation, or blood viscosity.

[0017] In some embodiments, the control unit is configured to operate at least one of the first, second, third and fourth valves based on information obtained from the at least one sensor.

[0018] In some embodiments, the extracorporeal organ is a lung.

[0019] In some embodiments, the extracorporeal chamber further comprises one or more of the following features including time-controlled humidifier and misting spray onto the organ, integrated scale for monitoring and recording organ weight, real-time macroscopic video recording of the organ with remote monitoring capability, access ports with sterile air filter for biopsies and / or imaging, access for Attorney Docket No. 206030-0310-00WO sterile manual interventions in chamber, and sterilizable and single-use disposable components.

[0020] In some embodiments, the ECMO circuit maintains a physiologic level of oxygen in the blood perfusing the extracorporeal organ and the host organism.

[0021] In some embodiments, the invention provides a method for extracorporeal support of an organ, the method comprising a) connecting the vasculature of an extracorporeal organ to an ex vivo organ perfusion (EVOP) circuit; b) housing the extracorporeal organ in a sterile organ chamber; c) connecting the vasculature of a host organism to an extracorporeal membrane oxygenation (ECMO) circuit; d) connecting the EVOP circuit via cross-circulation to the ECMO circuit; e) perfusing blood from the host through the extracorporeal organ via the cross-circulation ECMO circuit; f) assessing the extracorporeal organ over time; and g) determining whether the extracorporeal organ can be transplanted into the subject.

[0022] In some embodiments, the blood from the ECMO circuit and EVOP circuit is drained in at least one reservoir to maintain steady state volume.

[0023] In some embodiments, the at least one reservoir collects and releases 250 cc of blood.

[0024] In some embodiments, at least one valve regulates the volume of blood entering and exiting the at least one reservoir.

[0025] In some embodiments, step e) comprises i) draining blood from the ECMO circuit into Reservoir 1; ii) releasing the blood in Reservoir 1 into the EVOP circuit; iii) draining blood from the EVOP circuit into Reservoir 2; and iv) releasing the blood in Reservoir 2 into the ECMO circuit.

[0026] In some embodiments, step e) is repeated every 5 minutes for at least 4 hours.

[0027] In some embodiments, the method further comprises treating the extracorporeal organ by providing at least one of an energy substrate, a circulating repair factor, metabolic clearance, or therapeutic intervention, including medication, drug nanoparticles, gene therapy, stem cell therapy decellularization cell replacement or inflammatory modulation. Attorney Docket No. 206030-0310-00WO

[0028] In some embodiments, the method further comprises disconnecting the extracorporeal organ from the cross-circulation ECMO circuit and transplanting the extracorporeal organ into the host organism.

[0029] In some embodiments, the extracorporeal organ maintains a temperature within a range of from 30° C to 40° C.

[0030] In some embodiments, the method is for treating an extracorporeal organ that has been subjected to maintenance at 4° C for a period of time, the method comprising: maintaining the extracorporeal organ within a temperature range of from 30° C to 40° C after connecting the extracorporeal organ to the cross-circulation ECMO circuit.

[0031] In some embodiments, the extracorporeal organ exhibits acute injury prior to treatment; or wherein the organ exhibits a reversible pathologic condition prior to treatment.

[0032] In some embodiments, the host organism is a human subject.

[0033] In some embodiments, the human subject is immunosuppressed.

[0034] In some embodiments, the extracorporeal organ is a lung.

[0035] BRIEF DESCRIPTION OF THE DRAWINGS

[0036] The following detailed description of embodiments of the invention will be better understood when read in conjunction with the appended drawings. It should be understood that the invention is not limited to the precise arrangements and instrumentalities of the embodiments shown in the drawings.

[0037] Figure 1 depicts an exemplary system for performing extracorporeal support of an organ. Recipient is given immunosuppressive medications prior to initiating ex-vivo lung perfusion via the recipient’s venoarterial extracorporeal membrane oxygenation (VA- ECMO) circuit. Blood flows from the venous limb of the recipient’s VA-ECMO circuit to the donor lung via the donor pulmonary arteries (PA). A pump is used help to push the deoxygenated blood from the recipient’s VA-ECMO circuit to the donor lungs. The donor lungs are housed in a sterile dome called the XVIVO® platform. The donor lungs are connected to a ventilator, which moves breathable air into the lungs and removes carbon dioxide, helping to optimize the lungs prior to transplant. The blood from the recipient circulates through the donor lungs and drained back to the venous limb of the Attorney Docket No. 206030-0310-00WO recipient’s VA-ECMO circuit via the donor’s pulmonary veins (PV) Another pump is used to push the blood from the VA-ECMO circuit back to the recipient. An oxygenator is used as per standard VA-ECMO protocol to oxygenate the blood prior to circulating back into the recipient. Oxygenated blood circulates through the recipient’s kidneys and liver, both of which helps to filter toxic metabolites that may have accumulated in the blood from the donor lungs. Following this, the blood is once again drained back into the venous limb of the recipient’s VA-ECMO circuit, completing the circuit.

[0038] Figure 2 depicts an exemplary system for the XPS device. The recipient is maintained on Novalung ECMO per routine. The EVLP circuit is primed with 2 Units of O Blood Packed Red Blood cells, colloid solution, steroids, antibiotics, and heparin (at Anti-Xa concentration range of 0.3-0.7 lU / mL). The donor lungs are connected to XPS lung Cannula set and placed inside the XPS by XVIVO Organ Chamber. At time 0, the Medtronic Bio-Console 560 starts the perfusion of the marginal donor lungs, per the XPS protocol. At time 5 minutes, Valve 1 is removed and 250 cc of blood from the ECMO circuit is drained into Reservoir 1. Valvel is closed. Valve 2 is then released to add this 250 cc to the EVLP Circuit. Simultaneously, Valve 3 is opened to allow drainage of 250 cc from the EVLP circuit into Reservoir 2. This process ensures a steady state volume in the EVLP circuit. Valves 2 and 3 are closed and valve 4 is then released to drain 250 cc from reservoir 2 into the ECMO Circuit. Steps 5-8 are be repeated every 5 minutes. This process ensures that the EVLP circuit volume is fully exchanged with the ECMO circuit about every hour. At hour 4, the decision is made regarding the suitability of the donor lungs for transplantation, per XPS protocol.

[0039] Figure 3 depicts an exemplary computing environment in accordance with some of the embodiments.

[0040] Figure 4 depicts an exemplary method for using a cross-circulation perfusion ECMO circuit and applications for use.

[0041] DETAILED DESCRIPTION

[0042] Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. As used herein, each of the following terms has the meaning Attorney Docket No. 206030-0310-00WO associated with it in this section. The articles “a” and “an” are used herein to refer to one or to more than one (i.e., to at least one) of the grammatical object of the article. By way of example, “an element” means one element or more than one element. “About” as used herein when referring to a measurable value such as an amount, a temporal duration, and the like, is meant to encompass variations of ±20%, ±10%, ±5%, ±1%, or ±0.1% from the specified value, as such variations are appropriate to perform the disclosed methods.

[0043] As used herein, the term “host organism” refers to any organism with a circulatory system with oxygen-carrying capacity, including, but not limited to, a human being, a pig, a rat, a mouse, a dog, a car, a goat, a sheep, a horse, a monkey, an ape, a rabbit, a cow, etc. that acts as the support system for an extracorporeal organ. For example, a host organism can be a different species than the extracorporeal organ it is supporting. As used herein, a “recipient” is an individual to whom an organ, tissue or cells from another individual (donor), commonly of the same species, has been transferred. As used herein, the term “patient,” “subject,” “individual,” and the like are used interchangeably herein, and refer to any animal, or cells thereof, whether in vitro or in situ, amenable to the methods described herein. In certain non-limiting embodiments, the patient, subject or individual is a mammal, non-limiting examples of which include a primate, dog, cat, goat, horse, pig, mouse, rat, rabbit, and the like, that is in need of bone formation. In some embodiments of the present invention, the subject is a human being. In such embodiments, the subject is often referred to as an “individual” or a “patient.” The terms “individual” and “patient” do not denote any particular age.

[0044] As used herein, the term “extracorporeal organ” refers to an organ situated outside the body of an organism (e.g., an organ provided by an organ donor, a lab grown organ, or an organ detached (voluntarily or involuntarily) from the host organism). An extracorporeal organ can include, but is not limited to, an internal organ (i.e., heart, liver, lungs, kidney, pancreas, small intestine, gut, etc.), an external organ (i.e., skin), tissue, a bioengineered graft, or a limb (i.e., arm, leg, hand, foot, etc.). As used herein “extracorporeal” refers to something situated or occurring outside of the body of an organism. As used herein, the term “immunosuppressed” refers to the state of being immunosuppressed (e.g., having a reduced ability to fight infections and diseases) which can lead to physiological instability. Attorney Docket No. 206030-0310-00WO

[0045] Throughout this disclosure, various aspects of the invention can be presented in a range format. It should be understood that the description in range format is merely for convenience and brevity and should not be construed as an inflexible limitation on the scope of the invention. Accordingly, the description of a range should be considered to have specifically disclosed all the possible sub-ranges as well as individual numerical values within that range. For example, description of a range such as from 1 to 6 should be considered to have specifically disclosed sub-ranges such as from 1 to 3, from 1 to 4, from 1 to 5, from 2 to 4, from 2 to 6, from 3 to 6 etc., as well as individual numbers within that range, for example, 1, 2, 2.7, 3, 4, 5, 5.3, and 6. This applies regardless of the breadth of the range.

[0046] Organ transplantation has become an effective therapy for many patients with end stage organ diseases. There is a nationwide shortage of donor lungs for patients waiting for a lung transplant. Many patients wait for months or years and may die while waiting for a suitable donor lung. In 2023, there were more than 16,000 consented brain-dead donors. Only 20-40% of these donors were lung donors, because the donor lungs were considered “marginal” in the remaining 60-80%. Marginal donor lungs are those that fail to meet ideal donor criteria by only a small margin, based on guidelines proposed by the International Society of Heart and Lung Transplantation. Such lungs may fail to meet one or two of the numerous criteria required for optimal donor lungs. Over the past decade, several techniques have been designed to expand the donor lung pool. Ex-vivo lung perfusion (EVLP) is a new technique / platform to resuscitate the marginal donor lungs and possibly utilize them. EVLP utilizes a crystalloid solution or banked blood to resuscitate the marginal donor lungs. However, it is a closed circuit that allows the marginal donor lungs to continue to accumulate toxic metabolites and may lead to deterioration of the marginal donor lungs as there are no kidneys or liver attached to an EVLP circuit for removal of toxic metabolites or addition of vital nutrients.

[0047] To address these foundational shortcomings of EVLP, the systems and methods presented herein provide potential lung transplant recipients on extracorporeal membrane oxygenation (ECMO) to serve as their own “bioreactor” and “repair” marginal donor Attorney Docket No. 206030-0310-00WO lungs using EVLP. This highly unique approach enables, for the first time, a recipient’s own blood / circulation to be the ideal system to resuscitate the marginal donor lungs.

[0048] The present invention provides numerous advantages to the potential lung transplant recipients. For example it provides significantly improved access to a larger pool of donor lungs. Further, it uniquely provides the capability to repair and / or test the marginal donor lungs without the risk of undergoing surgery and post-transplant complications.

[0049] Accordingly, the present invention relates to methods, systems, and devices for ex-vivo organ perfusion by the recipient. In some embodiments, the invention provides methods and systems for extracorporeal support of an organ, tissue, or bioengineered graft comprising cross-circulation perfusion via cross-circulation to an ECMO circuit in connection with an immunosuppressed subject. The invention provides methods for ex- vivo organ perfusion with the recipient’s own perfusate via a cross-circulation perfusion extracorporeal membrane oxygenation circuit. Conventional methods utilize brain dead donor blood or banked blood to circulate through the donor organ. These conventional methods are restricted to a closed-circuit system with limited homeostatic potential. For instance, these closed-circuit systems are associated with the accumulation of toxins and lack availability of neurohormonal factors. In contrast, the present invention relates to a cross-circulation perfusion ECMO circuit which uses the recipient’s own blood for ex- vivo organ perfusion. Benefits of using the recipient's own blood include circulating repair factors, metabolic clearance, and allowing for extended immunological and graft performance assessment. The present invention therefore provides opportunities for testing the compatibility of the extracorporeal donor organ without risk of undergoing surgery and post-transplant complication.

[0050] Effective physiologic preservation of an ex-vivo or extracorporeal organ would provide important benefits compared to conventional approaches. For instance, physiologic ex-vivo preservation would permit more careful monitoring, functional testing, assessment, and therapy of the harvested organ. This would in turn allow earlier detection and potential repair of defects in the harvested organ, further reducing the likelihood of post-transplant organ failure. The ability to perform and assess simple repairs on the organ would also allow many organs with minor defects to be saved and Attorney Docket No. 206030-0310-00WO thus provide a larger pool of donor organs. This may be critically important when harvesting lungs because lungs are easily compromised even before harvesting within the donor's body.

[0051] The present invention includes methods and systems of attaching an extracorporeal organ via cross-circulation to an ECMO circuit attached to an immunosuppressed subject. In some embodiments, the cross-circulation perfusion ECMO circuit is an ex -vivo organ perfusion EVOP circuit fluidly connected to an ECMO circuit, wherein the EVOP is fluidly connected to an extracorporeal organ, and wherein the ECMO circuit is fluidly connected to a subject. In some embodiments, the immunosuppressed subject is an organ recipient. In some embodiments, the crosscirculation perfusion ECMO circuit provides opportunities for the recovery, regeneration, and maintenance of suboptimal donor organs (lung, liver, kidney, pancreas, injured limb, etc.) for transplantation.

[0052] In some embodiments, the invention includes systems for maintaining an extracorporeal organ. In some embodiments, the system can comprise an extracorporeal chamber having an extracorporeal organ positioned therein. In some embodiments, the system can comprise an ex-vivo organ perfusion (EVOP) circuit fluidly connected to the extracorporeal organ within the extracorporeal chamber. In some embodiments, the EVOP circuit comprises an EVOP pump, a first EVOP conduit and a second EVOP conduit, wherein the first EVOP conduit defines a flowpath from the EVOP pump into the extracorporeal organ and the second EVOP conduit defines a flowpath from the extracorporeal organ to the EVOP pump. In some embodiments, the system can comprise an extracorporeal membrane oxygenation (ECMO) circuit fluidly connected to a host organism. In some embodiments, the ECMO circuit comprises an ECMO pump, an oxygenator, a first ECMO conduit and a second ECMO conduit, wherein the first ECMO conduit defines a flowpath from the ECMO pump into the host organism and the second ECMO conduit defines a flowpath from the host organism to the ECMO pump. In some embodiments, the system can comprise a first cross circuit conduit fluidly connecting the second ECMO conduit to the first EVOP conduit and defining a first cross circuit flowpath from the ECMO circuit to the EVOP circuit. In some embodiments, the system can comprise a second cross circuit conduit fluidly connecting the first EVOP conduit to Attorney Docket No. 206030-0310-00WO the second ECMO conduit and defining a second cross circuit flowpath from the EVOP circuit to the ECMO circuit. In some embodiments, the system is configured to perfuse the extracorporeal organ with blood from the host organism.

[0053] In some embodiments, cross-circulation support of extracorporeal organs including heart, lung, liver, pancreas, kidney, small intestine, bioengineered grafts and xenogeneic organ grafts are provided. In some embodiments, the cross-circulation perfusion ECMO circuit between an organ recipient and an extracorporeal organ include rescue of donor organs deemed unacceptable for transplantation, salvage of traumatized limbs, or support of bioengineered or xenogeneic organ grafts. Both conventional EVOP and cross-circulation perfusion ECMO allow for administration of energy substrates, maintenance of barrier integrity, organ function assessment and oedema clearance. However, cross-circulation perfusion ECMO circuits further provide the ability to use the recipient’s own blood for ex-vivo organ perfusion. Benefits of using the recipient's own blood include circulating repair factors, metabolic clearance, and allowing for extended immunological and graft performance assessment.

[0054] In some embodiments, the system comprises an organ chamber, an EVOP circuit, an ECMO circuit, a cart / stand, and / or a safety clamp. In some embodiments, these components may be separate components, or in other embodiments, the components may be aggregated into a single device or apparatus. For example, components of the organ chamber, perfusion circuit, cart / stand and / or the safety clamp that do not come in direct contact with the subject or recipient, the extracorporeal organ or blood or plasma may be combined. Such components may include heaters, coolers, temperature regulators, pumps, ventilators, sensors, water recirculation conduits, monitoring equipment, control equipment, electronics, processors, video displays, imaging devices, scales, clamps, valves and / or the like that provide the “infrastructure” of the systems contemplated herein.

[0055] In some embodiments, the system comprises an extracorporeal chamber to contain and support the organ, tissue or bioengineered graft; and an extracorporeal crosscirculation perfusion ECMO circuit to connect the organ, tissue or bioengineered graft with a host organism wherein the circuit comprises auto-regulation of blood flow based Attorney Docket No. 206030-0310-00WO on the trans-organ blood pressure difference between arterial and venous pressure. In some embodiments, the extracorporeal organ chamber comprises a ventilated organ specific negative molded soft bladder. In some embodiments, the extracorporeal organ chamber contains a tissue, graft, or an organ, such as, but not limited to, lung, heart-lung, liver, kidney, gut, and limb. In some embodiments, the extracorporeal organ chamber comprises a temperature-controlled interior maintained with recirculating temperature- controlled water in a range from about 4° C to about 40° C; and an articulated base for organ orientation variability. Additional embodiments of the extracorporeal chamber which may be helpful include, but are not limited to, a time-controlled humidifier, an integrated scale for monitoring and recording organ weight, real-time macroscopic video recording of the organ with remote monitoring capability, access ports with sterile air filter for biopsies and / or imaging, access for sterile manual interventions in chamber, and sterilizable and single-use disposable components.

[0056] In some embodiments, the EVOP circuit comprises fluid conduits, such as, but not limited to, tubing and / or cannulae providing fluid connectivity from the vascular system of a host or recipient to the extracorporeal organ vasculature and from the extracorporeal organ back to the host or recipient. The conduits are configured so that fluid, such as whole blood and / or plasma, can form a continuous loop or circuit to support the extracorporeal organ by supplying fluid flow containing oxygen and nutrients to the organ from the host and returning waste and / or metabolites from the extracorporeal organ to the host for clearance.

[0057] In some embodiments, the ECMO circuit comprises a blood pump, gas exchange device, cannulae, and / or tubing connectors. In some embodiments, the invention also provides a patient safety clamp for a risk assessment, comprising at least one sensor to monitor a condition, including at least one of air bubbles, bleeding, blood pressure, heart rate or other host vital signs. For example, the safety clamp can monitor the venous oxygen saturation and lactate levels of the recipient connected to the EVOP circuit. In some embodiments, the safety clamp automatically clamps the recipient’s cannula to prevent air bubbles, bleeding, or significant physiologic changes in recipient’s condition. The “automatic clamping” or flow control (reduction, occlusion) is managed through a feedback circuit on pressure and flow monitors. In some embodiments, the invention also Attorney Docket No. 206030-0310-00WO provides a machine learning system that can analyze the multivariate data generated during EVOP including, but not limited to, compliance, vascular resistance, gas exchange, biochemical markers, imaging data, or interventional logs such as drug dosing and ventilator settings. This multivariate analysis can be used to predict lung viability and guide interventions in real time.

[0058] In some embodiments, the present invention described and embodied herein relates to the use of the systems described herein, and any embodiments thereof, to maintain an extracorporeal organ, tissue, or bioengineered graft by perfusing blood from a host or subject (recipient) through the extracorporeal organ, tissue, or bioengineered graft via an EVOP attached to an ECMO circuit of the said patient (recipient) while modulating the blood flow to maintain desired trans-organ vascular gradients; and maintaining the extracorporeal organ, tissue, or bioengineered graft within a temperature range of from about 4° C to 40° C, such as but not limited to, about 4° C to 37° C, about 30° C to 40° C, or from about 35° C to 40° C. In some embodiments, the crosscirculation perfusion ECMO circuit comprises auto-regulation of blood flow based on the trans-organ blood pressure difference between arterial and venous pressure.

[0059] In some embodiments and as shown in Figure 1, the present invention provides a system for extracorporeal support of an organ, tissue, or bioengineered graft by EVOP. In some embodiments, the EVOP circuit is connected to an ECMO circuit. In some embodiments the ECMO circuit is connected to a host or subject, such as any human or other animal patient. Exemplary subjects include organ transplant recipients. In some embodiments, the system generally includes: 1) an organ chamber, 2) a ventilator connected to the chamber, 3) biological tissues such as marginal donor lungs having pulmonary arteries and veins positioned withing the organ chamber, 4) a cannulation system for cannulating the arteries and veins of the marginal donor lungs, 5) a blood pumping system, and 6) an ECMO system.

[0060] Accordingly, shown in Figure 1 is a representative exemplary system 100 configured to perform the methods and techniques described herein. System 100 may generally include: (a) a pump: Machine used to pressurize blood flow to push it through the oxygenator and ultimately back into the recipient, (b) PA: Donor pulmonary arteries Attorney Docket No. 206030-0310-00WO

[0061] (PA) carrying deoxygenated blood from the recipient to the donor lungs, (c) XVIVO® Platform: Sterile dome used to house donor lungs outside of the human body for optimization prior to transplantation, (d) ventilator: Machine used to move breathable air into the donor lungs and remove carbon dioxide, (e) PV: Donor pulmonary veins (PV) carrying partially oxygenated blood from the donor lungs back into the circuit, (f) Oxygenator: Machine used to oxygenate blood and remove carbon dioxide prior to circulating blood back into recipient, and (g) VA-ECMO circuit: venoarterial extracorporeal membrane oxygenation circuit (VA-ECMO) connected to a potential lung transplant recipient, functioning as a temporary heart-lung machine to support the recipient’s cardiac and pulmonary functions prior to transplant.

[0062] In another example, shown in Figure 2 is a representative exemplary system 200 configured to perform the methods and techniques described herein. System 300 may generally include: (a) Recipient patient, (b) Novalung ECMO Circuit, (c) Valve 1, (d) Reservoir 1, (e) Valve 2, (f) Medtronic Bio-Console 560 Blood Pumping System, (g) Valve 3, (h) Reservoir 2, (i) Valve 4, (j) XPS by XVIVO® Lung Cannula with built-in pressure line, (k) Marginal donor lung pulmonary arteries cannulated with XPS by XVIVO® Lung Cannula, (1) Marginal donor lungs, (m) XPS by XVIVO® Organ Chamber housing the marginal donor lungs, (n) XPS by XVIVO® Ventilator moving breathable air into the marginal lungs, (o) Marginal donor lung pulmonary veins cannulated with XPS by XVIVO® Lung Cannula, and (p) XPS by XVIVO® Lung Cannula with built-in pressure line.

[0063] In some embodiments, the system can comprise an extracorporeal chamber having an extracorporeal organ positioned therein. In some embodiments, the system can comprise an EVOP circuit fluidly connected to the extracorporeal organ within the extracorporeal chamber. In some embodiments, the EVOP circuit comprises an EVOP pump, a first EVOP conduit and a second EVOP conduit. In some embodiments, the first EVOP conduit defines a flowpath from the EVOP pump into the extracorporeal organ and the second EVOP conduit defines a flowpath from the extracorporeal organ to the EVOP pump. In some embodiments, the system can comprise an extracorporeal membrane oxygenation (ECMO) circuit fluidly connected to a host organism. In some embodiments, the ECMO circuit comprises an ECMO pump, an oxygenator, a first Attorney Docket No. 206030-0310-00WO

[0064] ECMO conduit and a second ECMO conduit. Tn some embodiments, the first ECMO conduit defines a flowpath from the ECMO pump into the host organism and the second ECMO conduit defines a flowpath from the host organism to the ECMO pump. In some embodiments, a first cross circuit conduit fluidly connecting the second ECMO conduit to the first EVOP conduit and defining a first cross circuit flowpath from the ECMO circuit to the EVOP circuit. In some embodiments, a second cross circuit conduit fluidly connecting the first EVOP conduit to the second ECMO conduit and defining a second cross circuit flowpath from the EVOP circuit to the ECMO circuit. In some embodiments, the first cross circuit conduit comprises a first reservoir. In some embodiments, the second cross circuit conduit comprises a second reservoir. In some embodiments, the first cross circuit conduit comprises a first valve between the ECMO circuit and the first reservoir, and a second valve between the first reservoir and the EVOP circuit. In some embodiments, the second cross circuit conduit comprises a third valve between the EVOP circuit and the second reservoir, and a fourth valve between the second reservoir and the ECMO circuit.

[0065] In some aspects of the present invention, software executing the instructions provided herein may be stored on a non-transitoiy computer-readable medium, wherein the software performs some or all of the steps of the present invention when executed on a processor.

[0066] Aspects of the invention relate to algorithms executed in computer software. Though certain embodiments may be described as written in particular programming languages, or executed on particular operating systems or computing platforms, it is understood that the system and method of the present invention is not limited to any particular computing language, platform, or combination thereof. Software executing the algorithms described herein may be written in any programming language known in the art, compiled or interpreted, including but not limited to C, C++, C#, Objective-C, Java, JavaScript, MATLAB, Python, PHP, Perl, Ruby, or Visual Basic. It is further understood that elements of the present invention may be executed on any acceptable computing platform, including but not limited to a server, a cloud instance, a workstation, a thin Attorney Docket No. 206030-0310-00WO client, a mobile device, an embedded microcontroller, a television, or any other suitable computing device known in the art.

[0067] Parts of this invention are described as software running on a computing device. Though software described herein may be disclosed as operating on one particular computing device (e.g. a dedicated server or a workstation), it is understood in the art that software is intrinsically portable and that most software running on a dedicated server may also be run, for the purposes of the present invention, on any of a wide range of devices including desktop or mobile devices, laptops, tablets, smartphones, watches, wearable electronics or other wireless digital / cellular phones, televisions, cloud instances, embedded microcontrollers, thin client devices, or any other suitable computing device known in the art.

[0068] Similarly, parts of this invention are described as communicating over a variety of wireless or wired computer networks. For the purposes of this invention, the words “network”, “networked”, and “networking” are understood to encompass wired Ethernet, fiber optic connections, wireless connections including any of the various 802.11 standards, cellular WAN infrastructures such as 3G, 4G / LTE, or 5G networks, Bluetooth®, Bluetooth® Low Energy (BLE) or Zigbee® communication links, or any other method by which one electronic device is capable of communicating with another. In some embodiments, elements of the networked portion of the invention may be implemented over a Virtual Private Network (VPN).

[0069] Figure 3 and the following discussion are intended to provide a brief, general description of a suitable computing environment in which the invention may be implemented. While the invention is described above in the general context of program modules that execute in conjunction with an application program that runs on an operating system on a computer, those skilled in the art will recognize that the invention may also be implemented in combination with other program modules.

[0070] Generally, program modules include routines, programs, components, data structures, and other types of structures that perform particular tasks or implement particular abstract data types. Moreover, those skilled in the art will appreciate that the invention may be practiced with other computer system configurations, including handheld devices, multiprocessor systems, microprocessor-based or programmable consumer Attorney Docket No. 206030-0310-00WO electronics, minicomputers, mainframe computers, and the like. The invention may also be practiced in distributed computing environments where tasks are performed by remote processing devices that are linked through a communications network. In a distributed computing environment, program modules may be located in both local and remote memory storage devices.

[0071] Figure 3 depicts an illustrative computer architecture for a computer 300 for practicing the various embodiments of the invention. The computer architecture shown in Figure 3 illustrates a conventional personal computer, including a central processing unit 350 (“CPU”), a system memory 305, including a random access memory 310 (“RAM”) and a read-only memory (“ROM”) 315, and a system bus 335 that couples the system memory 305 to the CPU 350. A basic input / output system containing the basic routines that help to transfer information between elements within the computer, such as during startup, is stored in the ROM 315. The computer 300 further includes a storage device 320 for storing an operating system 325, application / program 330, and data.

[0072] The storage device 320 is connected to the CPU 350 through a storage controller (not shown) connected to the bus 335. The storage device 320 and its associated computer-readable media provide non-volatile storage for the computer 300. Although the description of computer-readable media contained herein refers to a storage device, such as a hard disk or CD-ROM drive, it should be appreciated by those skilled in the art that computer-readable media can be any available media that can be accessed by the computer 300.

[0073] By way of example, and not to be limiting, computer-readable media may comprise computer storage media. Computer storage media includes volatile and nonvolatile, removable and non-removable media implemented in any method or technology for storage of information such as computer-readable instructions, data structures, program modules or other data. Computer storage media includes, but is not limited to, RAM, ROM, EPROM, EEPROM, flash memory or other solid state memory technology, CD-ROM, DVD, or other optical storage, magnetic cassettes, magnetic tape, magnetic disk storage or other magnetic storage devices, or any other medium which can be used to store the desired information and which can be accessed by the computer. Attorney Docket No. 206030-0310-00WO

[0074] According to various embodiments of the invention, the computer 300 may operate in a networked environment using logical connections to remote computers through a network 340, such as TCP / IP network such as the Internet or an intranet. The computer 300 may connect to the network 340 through a network interface unit 345 connected to the bus 335. It should be appreciated that the network interface unit 345 may also be utilized to connect to other types of networks and remote computer systems.

[0075] The computer 300 may also include an input / output controller 355 for receiving and processing input from a number of input / output devices 360, including a keyboard, a mouse, a touchscreen, a camera, a microphone, a controller, a joystick, or other type of input device. Similarly, the input / output controller 355 may provide output to a display screen, a printer, a speaker, or other type of output device. The computer 300 can connect to the input / output device 360 via a wired connection including, but not limited to, fiber optic, Ethernet, or copper wire or wireless means including, but not limited to, Wi-Fi, Bluetooth, Near-Field Communication (NFC), infrared, or other suitable wired or wireless connections.

[0076] As mentioned briefly above, a number of program modules and data files may be stored in the storage device 320 and / or RAM 310 of the computer 300, including an operating system 325 suitable for controlling the operation of a networked computer. The storage device 320 and RAM 310 may also store one or more applications / programs 330. In particular, the storage device 320 and RAM 310 may store an application / program 330 for providing a variety of functionalities to a user. For instance, the application / program 330 may comprise many types of programs such as a word processing application, a spreadsheet application, a desktop publishing application, a database application, a gaming application, internet browsing application, electronic mail application, messaging application, and the like. According to an embodiment of the present invention, the application / program 330 comprises a multiple functionality software application for providing word processing functionality, slide presentation functionality, spreadsheet functionality, database functionality and the like.

[0077] The computer 300 in some embodiments can include a variety of sensors 365 for monitoring the environment surrounding and the environment internal to the computer 300. These sensors 365 can include a Global Positioning System (GPS) sensor, a Attorney Docket No. 206030-0310-00WO photosensitive sensor, a gyroscope, a magnetometer, thermometer, a proximity sensor, an accelerometer, a microphone, biometric sensor, barometer, humidity sensor, radiation sensor, or any other suitable sensor.

[0078] In some embodiments, the system comprises a software and electrical control system that together form a closed-loop feedback system configured to dynamically regulate the volume and pressure of a fluid within the system. In some embodiments, the closed-loop feedback system receives and processes output signals from one or more sensors associated with the fluid conduits, reservoirs, and fluidic circuits. Based on these sensor readings, the software executes control algorithms that adjust one or more operational parameters, such as valve positions, pump speed, or actuator displacement, thereby altering the fluid volume and pressure in real time. In this manner, the system maintains desired fluidic conditions and compensates for changes or disturbances in flow characteristics, ensuring stable and responsive fluid control throughout operation.

[0079] In some embodiments, the system comprises an electrical control subsystem configured to regulate the operation of one or more valves, clamps, or other flow-control components that direct the movement of a fluid into a reservoir, fluid conduit, or fluid circuit. In some embodiments, the electrical system includes one or more actuators, sensors, and a controller operatively connected to the valves. The controller may be programmed to selectively open or close the valves in response to user input, sensor feedback, or predefined operating parameters. In this manner, the electrical system provides precise control of the timing, rate, and volume of fluid flow into a reservoir, fluid conduit, or fluid circuit, ensuring reliable and repeatable operation of the system.

[0080] Shown in Figure 2 is a representative exemplary system 200 configured to perform the methods and techniques described herein. In some embodiments, the closed- loop feedback system is configured to regulate a first valve and a second valve (c and e in Figure 2) that controls the volume and pressure of fluid within a first reservoir (d in Figure 2), wherein the first reservoir is fluidly connected to an ECMO circuit and an EVOP circuit. In some embodiments, the closed-loop feedback system monitors one or more parameters (e.g., pressure, flow rate, or fluid level) within the first reservoir and the associated circuits, and dynamically adjusts the valve to maintain desired fluidic Attorney Docket No. 206030-0310-00WO conditions. Tn some embodiments, the closed-loop feedback system is further configured to regulate a third valve and a fourth valve (g and i in Figure 2) controlling the volume and pressure of fluid within a second reservoir (h in Figure 2), wherein the second reservoir is fluidly connected to the EVOP circuit and the ECMO circuit. The system may independently or simultaneously adjust the flow conditions in the first reservoir and the second reservoir to achieve coordinated control of fluid distribution and pressure balance across the interconnected circuits.

[0081] In some embodiments, the system is configured to withdraw fluid from a subject at a controlled negative pressure of about -20 to -100 mmHg. In some embodiments, the system is configured to withdraw fluid from a subject at a controlled negative pressure of about -40 mmHg. In some embodiments, the system is configured to maintain a controlled negative pressure of about -20 to -100 mmHg in the venous drainage conduit attached to the subject, wherein the venous drainage conduit is fluidity connected to an EVOP circuit attached to an extracorporeal organ, tissue, or bioengineered graft. In some embodiments, the system is configured to withdraw fluid from an extracorporeal organ, tissue, or bioengineered graft at a controlled negative pressure of about -1 to -10 mmHg. In some embodiments, the system is configured to withdraw fluid from an extracorporeal organ, tissue, or bioengineered graft at a controlled negative pressure of about -5 mmHg. In some embodiments, the ratio of negative pressure of the fluid conduit leaving the subject relative to the fluid conduit leaving the extracorporeal organ, tissue, or bioengineered graft is about 8: 1. The applied negative pressure may be generated and regulated by a pump or vacuum subsystem under control of the closed-loop feedback system described herein. The pressure level of about -20 to -100 mmHg is selected to facilitate consistent blood flow from the subject without causing vascular collapse, hemolysis, or undue shear stress. In some embodiments, the system monitors the fluid pressure in real time and dynamically adjusts suction parameters to maintain the desired negative pressure range during blood collection or circulation through the ECMO and EVOP circuit.

[0082] In some embodiments, the system is configured to deliver fluid to a subject at a controlled positive pressure of about +150 to +400 mmHg. In some embodiments, the system is configured to deliver fluid to a subject at a controlled positive pressure of about Attorney Docket No. 206030-0310-00WO

[0083] +200 mmHg. In some embodiments, the system is configured to maintain a controlled positive pressure of about +150 to +400 mmHg in the arterial outflow conduit attached to the subject, wherein the arterial outflow conduit is fluidity connected to an EVOP circuit attached to an extracorporeal organ, tissue, or bioengineered graft. In some embodiments, the system is configured to deliver fluid to an extracorporeal organ, tissue, or bioengineered graft at a controlled positive pressure of about +5 to +40 mmHg. In some embodiments, the system is configured to deliver fluid to an extracorporeal organ, tissue, or bioengineered graft at a controlled positive pressure of about +20 mmHg. In some embodiments, the ratio of positive pressure of the fluid conduit returning fluid to the subject relative to the fluid conduit returning fluid to the extracorporeal organ, tissue, or bioengineered graft is about 10: 1. The applied positive pressure may be generated and regulated by a pump subsystem under control of the closed-loop feedback system described herein. In some embodiments, the system monitors the fluid pressure in real time and dynamically adjusts suction parameters to maintain the desired positive pressure range during blood collection or circulation through the ECMO and EVOP circuit.

[0084] In some embodiments, the system is configured to control the transfer of fluid volume between an ECMO circuit and an EVOP circuit through one or more regulating elements, such as valves, clamps, or similar flow-restricting devices, in combination with one or more reservoirs configured to temporarily receive, store, or return fluid volume.

[0085] In some embodiments, the ECMO circuit includes a flexible conduit or tubing segment connected to a first reservoir, while the EVOP circuit includes a corresponding conduit connected to a second reservoir. A transfer conduit provides a fluid communication path between the two circuits. One or more valves are positioned along the transfer conduit to regulate, restrict, or permit the flow of fluid between the circuits. By adjusting the state of the valves, the rate or volume of transfer can be dynamically controlled according to system requirements.

[0086] In some embodiments, the reservoirs act as compensating or buffer volumes. For example, when a valve on the ECMO circuit is released, a portion of the working fluid may flow into the EVOP circuit until equilibrium is reached, at which point the valve is closed to fix the transferred volume. The reservoirs may be rigid or compliant, depending on the desired pressure-volume characteristics. In certain versions, elastic or deformable Attorney Docket No. 206030-0310-00WO reservoirs (e.g., bladders or bellows) provide a self-regulating effect that moderates pressure transients during transfer events.

[0087] In some embodiments, the valves are actuated manually, pneumatically, electrically, or hydraulically. Automated control of the transfer may be achieved through sensors monitoring pressure, volume, or flow rate within each circuit, and a control unit configured to open or close the valves in response to predefined thresholds.

[0088] In some embodiments, the volume transfer mechanism enables balancing, calibration, or replenishment between closed-loop systems, such as in biomedical, hydraulic, or microfluidic applications. For example, in a dual-circuit configuration, the invention may maintain equalized pressure by periodically allowing controlled fluid communication through a calibrated valve, with excess volume absorbed by one or more reservoirs acting as compliance chambers.

[0089] In some embodiments, the system is configured to permit the controlled transfer of about 100 to 500 cubic centimeters (cc) of fluid from the ECMO circuit to the EVOP circuit. The magnitude of the transferred volume may be fixed or adjustable, depending on the configuration of the regulating devices and the dimensions of the associated reservoirs. In some embodiments, the system is configured to permit the controlled transfer of about 250 cc of fluid from the ECMO circuit to the EVOP circuit.

[0090] In some embodiments, the cross-circulation perfusion ECMO circuit also enables a variety of therapeutic interventions, including medication, drug nanoparticles, gene therapy, stem cell therapy, decellularization cell replacement and inflammatory modulation, in donor organs unacceptable for transplantation, which could significantly expand donor organ pools by allowing recovery of organs and tissues that were previously unacceptable for transplantation. For example, this technology allows the maintenance of human lungs outside the body which provides a viable platform for genetic and phenotypic modification of the organ to improve compatibility matching. Delivery of bioactive or therapeutic agents to the extracorporeal lung can be by intratracheal delivery of CFSE, microbeads, and stem cells (including mesenchymal stem cells) for example. Native cells can be harvested, deepithelialized and recellularized for decellularization cell replacement therapy. Transpleural imaging can be used to examine Attorney Docket No. 206030-0310-00WO the extracorporeal lung and / or guide delivery of agents to specific portions of the lung. In another example, the therapeutic agents can include CRISPR / Cas-Based Gene correction technology. In another example, the therapeutic agents can include extracellular vesicles. Extracellular vesicles include all nanometer-scale lipid vesicles that are secreted by cells including, but not limited to, exosomes, microvesicles, and apoptotic bodies.

[0091] In some embodiments, the cross-circulation perfusion ECMO circuit enables repair strategies such as anti-inflammatory and anti-oxidative therapy. Exemplary repair strategies include, but are not limited to, administration of corticosteroids, antioxidants such as N-acetylcysteine, or antimicrobials. In some embodiments, the repair strategies include the use of mesenchymal stromal cells (MSCs) or endothelial progenitor cells to reduce inflammation, enhance repair, and restore endothelial integrity. In some embodiments, the repair strategies include gene therapy techniques to increase or upregulate cytoprotective or anti-apoptotic proteins.

[0092] In some embodiments, the cross-circulation perfusion ECMO circuit enables fluid and edema management such as oncotic support with albumin or dextran in perfusate to draw out interstitial fluid or the use of diuretics or P-agonists to enhance alveolar fluid clearance.

[0093] In some embodiments, the cross-circulation perfusion ECMO circuit enables surfactant replacement and ventilation strategies to restore surface tension properties and optimize alveolar stability.

[0094] In some embodiments, the cross-circulation perfusion ECMO circuit enables decellularization to remove damaged or immunogenic cells. In some embodiments, the cross-circulation perfusion ECMO circuit enables recellularization with recipient-derived or stem cells to regenerate or repair functional tissue.

[0095] In some embodiments, the cross-circulation perfusion ECMO circuit further comprises a continuous renal replacement therapy (CRRT) module such as a hemofilter or dialysis membrane for ultrafiltration of small solutes and excess fluids.

[0096] In some embodiments, the cross-circulation perfusion ECMO circuit further comprises a plasma exchange or adsorption module for removal of circulating inflammatory mediators, endotoxins, or donor-derived cytokines. Attorney Docket No. 206030-0310-00WO

[0097] In some embodiments and as shown in Figure 4, the present invention provides methods for ex-vivo organ perfusion via cross-circulation to an ECMO circuit. In some embodiments, the method comprises connecting the extracorporeal organ via crosscirculation to an ECMO circuit of a subject, housing the extracorporeal organ in a sterile organ chamber or dome for ventilation, assessing the extracorporeal organ over time, and determining whether the extracorporeal organ can be transplanted into the subject.

[0098] As shown in Figure 4, method 400 may include the steps of; a) Connecting the vasculature of a host organism (i.e. the subject patient) to an ECMO circuit; b) Housing an extracorporeal organ in a sterile organ chamber or dome for ventilation; c) Connecting the extracorporeal organ via cross-circulation to the ECOM circuit; d) Perfusing blood from the host through the extracorporeal organ via the cross-circulation ECMO circuit; e) Assessing the extracorporeal organ over time; and f) Determining whether the extracorporeal organ can be transplanted into the subject.

[0099] In some embodiments, the extracorporeal organ is attached via cross-circulation to an ECMO circuit of a subject. In some embodiments, the extracorporeal organ is attached directly to the host vasculature. In some embodiments, the extracorporeal organ is in direct connection with the host vasculature and an oxygenator. In some embodiments, the extracorporeal membrane oxygenation circuit comprises a pump, wherein the pump communicates blood from a patient to an oxygenator, to the attached extracorporeal organ, and thence back to the patient, comprising: (a) a venous subsystem comprising a medium diameter venous line configured to accept blood from the patient, wherein the venous subsystem is configured to communicate the blood to the pump; (b) a medium diameter arterial line configured to accept blood from the oxygenator and communicate the blood to the attached extracorporeal organ and thence back to the patient; (c) one or more shunts connected in a series, where each shunt comprises a medium diameter input connected to a medium diameter output, where the medium diameter output is configured to connect to a medium diameter input of a successive shunt; a small diameter outlet between the medium diameter input and the medium diameter output; and a stopcock connected to the small diameter output such that flow out of the small diameter outlet can be controlled by the stopcock; wherein a first of such shunts is connected to accept blood from the arterial line and wherein a last of such Attorney Docket No. 206030-0310-00WO shunts is connected communicate blood to the venous subsystem. In some embodiments, the extracorporeal organ is attached via cross-circulation to an ECMO circuit of an immunosuppressed subject. In some embodiments, the immunosuppressed subject is a transplant candidate awaiting lung transplantation.

[0100] In some embodiments, a transplant recipient has a venous line inserted and their blood is then directly connected to the ex-vivo donor organ via a pump for ex-vivo organ perfusion.

[0101] In some embodiments, the extracorporeal organ is housed in a sterile and ventilated organ chamber or dome. In some embodiments, the extracorporeal organ is assessed over time after perfusion. In some embodiments, the extracorporeal organ is assessed for maintenance of organ function, tissue architecture, and cellular / microscopic integrity of an extracorporeal organ. In some embodiments, the extracorporeal organ is assessed in about 30 minutes, about 1 hour, about 2 hours, about 3 hours, about 4 hours, about 8 hours, about 12 hours, about 24 hours, or about 36 hours after perfusion.

[0102] In some embodiments, following assessment of the extracorporeal organ a decision may be made whether the recipient in which the extracorporeal organ is attached to via the cross-circulation perfusion ECMO circuit meets transplant criteria.

[0103] In some embodiments, the present invention provides methods for recovery, regeneration, and maintenance of viable and functional donor organs and tissues over times sufficient for therapeutic intervention, including but not limited to, conditioning prior to transplant, gene transfer to correct disease, cell removal / delivery. Additional research applications include but are not limited to studies in xenotransplantation, theragnostic, organ physiology, drug therapy and stem cell therapy.

[0104] In some embodiments, the present invention provides methods for the recovery of injured human donor organs specifically using the recipient’s own perfusate and systems as a “bioreactor”. In some embodiments, having the recipient serve as their own “bioreactor” provides significantly expanded ability to recover a greater number of injured donor organs. Furthermore, the present invention can be combined with other methods such as, but not limited to, standard methods used in gene therapy, immunomodulation, organ physiology, xenotransplantation, pharmacologic agents, and other organ modification and repair strategies. Attorney Docket No. 206030-0310-00WO

[0105] In some embodiment, the present invention provides methods to clear / filter / modify the effluent form the ex-vivo organ.

[0106] In some embodiment, the present invention provides methods to add / enhance the blood that is flowing into the ex-vivo organ.

[0107] EXPERIMENTAL EXAMPLES

[0108] The invention is further described in detail by reference to the following experimental examples. These examples are provided for purposes of illustration only, and are not intended to be limiting unless otherwise specified. Thus, the invention should in no way be construed as being limited to the following examples, but rather, should be construed to encompass any and all variations which become evident as a result of the teaching provided herein.

[0109] Without further description, it is believed that one of ordinary skill in the art can, using the preceding description and the following illustrative examples, make and utilize the present invention and practice the claimed methods. The following working examples therefore are not to be construed as limiting in any way the remainder of the disclosure. e 1 : Safetv and Feasibility Study of Ex-Vivo Perfusion

[0110] Blood

[0111] There is a shortage of donor lungs nationwide.! Many patients wait for months or years and may die while waiting for a suitable donor lung (Valapour et al., 2023, Lung. Am J Transplant. 23(2 Suppl 1):S379-S442). In 2023, there were more than 16,000 consented brain-dead donors. Only 20-40% of these donors were lung donors, because the donor lungs were considered “marginal” in the remaining 60-80% (optn.transplant.hrsa.gov / data / view-data-reports / national-data). Marginal donor lungs are those that fail to meet ideal donor criteria (Orens et al., 2003, J Heart Lung Transplant. 22(11): 1183-200).

[0112] Over the past decade, several techniques have been designed to expand the donor pool. Ex-vivo lung perfusion (EVLP) is a new technique / platform to resuscitate the marginal donor lungs and possibly utilize them (Machucaet al., 2014, J Thorac Dis.

[0113] 6(8): 1054-62; Warnecke et al., 2018, Lancet Respir Med. 6(5):357-367; Iske et al., 2021, Attorney Docket No. 206030-0310-00WO

[0114] Am J Transplant. 21 (12):3831-3839). EVLP utilizes crystalloid solution or banked blood to resuscitate the donor lungs. Multiple studies have shown the safety and efficacy of EVLP in resuscitating marginal donor lung and their subsequent transplantation, with favorable short and medium term outcomes (Machucaet al., 2014, J Thorac Dis.

[0115] 6(8): 1054-62; Warnecke et al., 2018, Lancet Respir Med. 6(5):357-367; Iske et al., 2021, Am J Transplant. 21(12):3831-3839; Cypel et al., 2011, N Engl J Med. 364(15): 1431-40; Loor et al., 2019, Lancet Respir Med. 7(11):975-984). However, it is a closed circuit that allows the donor lungs to continue to accumulate toxic metabolites and may lead to deterioration of the donor lungs as there are no kidneys or liver attached to an EVLP circuit for removal of toxic metabolites or addition of vital nutrients.

[0116] Several studies have also examined xenogeneic cross-circulation, successfully recovering acutely injured human lungs by cross-circulation of whole blood from Yorkshire Swine (Hozain et al., 2020, Nat Med. 26(7): 1102-1113; Hozain et al., 2020, J Thorac Cardiovasc Surg. 159(4): 1640- 1653.el 8; Guenthart et al., 2019, Nat Commun. 10(1): 1985). These encouraging findings have shown potential in the use of crosscirculation as a supplement to EVLP to recover marginal donor lungs that would otherwise be deemed unusable for transplantation (Hozain et al., 2020, Nat Med. 26(7): 1102- 1113 ; Hozain et al., 2020, J Thorac Cardiovasc Surg. 159(4): 1640-1653.el 8; Guenthart et al., 2019, Nat Commun. 10(1): 1985). However, this methodology still presents shortcomings, including the exposure to swine antigens with the donor allograft as well as insufficiency of the swine “bioreactor” to adequately recover the donor lungs.

[0117] There are no prior reports of resuscitating marginal donor lungs using recipient blood in the ECMO or EVLP circuit.

[0118] To address these foundational shortcomings of EVLP, this study demonstrates that transplant candidates on extracorporeal membrane oxygenation (ECMO) can serve as their own “bioreactor” and “repair” marginal donor lungs using EVLP and that a recipient’s blood / circulation may be an ideal system to resuscitate the marginal donor lungs. Attorney Docket No. 206030-0310-00WO

[0119] This proof-of-concept study evaluates 5 subjects in the TCU who are on ECMO in the ICU, awaiting lung transplantation. “Marginal donor lungs” are attached to the ECMO circuit of the immunosuppressed patient waiting for double lung transplantation. The donor lungs are housed in a sterile dome and ventilated, using the FDA approved XPS™ device by XVIVO® 7. Assessment of the donor lungs are made at 4 hours after reperfusion and a decision is made to transplant the donor lungs or not.

[0120] The potential advantages to the lung transplant recipient include 1) access to a larger pool of donor lungs, 2) to repair / test the “marginal donor lungs” without the risk of undergoing surgery and post-transplant complications. The potential risks to the subject patient are 1) need for immunosuppression during EVLP, and 2) the risks of an EVLP circuit.

[0121] XPS Device

[0122] The XVIVO® Perfusion System (XPS™) with the STEEN Solution™ Perfusate (a crystalloid solution) is indicated for the flushing and temporary continuous normothermic machine perfusion of initially unacceptable excised donor lungs during which time the ex vivo function of the lungs can be reassessed for transplantation.

[0123] This study proposes to use the XPS™ off label by replacing the STEEN Solution™ (a crystalloid solution) with recipient blood from the recipient ECMO circuit to perfuse the donor lungs.

[0124] XPS™ is an integrated Ex vivo Lung Perfusion system that includes all components. The XPS™ system utilizes a centrifugal pump (MAQUET CardioHelp), the heater / cooler system and an ICU-ventilator (Hamilton) (Guenthart et al., 2019, Nat Commun. 10(1): 1985).

[0125] The XPS™ is used for temporary continuous normothermic machine perfusion of marginal donor lungs during which time the ex vivo function of the lungs can be reassessed for transplantation.

[0126] The donor lungs are transported using the current standard protocols, in a cooler box from the procurement site. The donor lungs are flushed thoroughly in PERFADEX® solution and then placed on the EVLP platform. The recipient ECMO circuit may be adjusted to direct blood to the EVLP circuit, using the current XPS™ criteria for flow Attorney Docket No. 206030-0310-00WO and pressure and temperature (Sanchez, et al ., 2020, The Journal of Heart and Lung Transplantation, Volume 39, Issue 4, Supplement, Page SI 10). After warming up, the donor lungs may be ventilated according to the XPS™ protocol (Sanchez, et al., 2020, The Journal of Heart and Lung Transplantation, Volume 39, Issue 4, Supplement, Page SI 10). Arterial and venous blood gas samples and donor lungs ventilation parameters may be tested according to the study protocol. A chest radiograph may also be obtained at 1 and 3 hours of perfusion, before a final decision of utilization of the donor lungs may be made.

[0127] Study Design

[0128] As contemplated herein, studies may be performed in subjects who are on FDA cleared Novalung® System for ECMO (due to their previous cardiac or pulmonary instability), awaiting lung transplantation. These potential lung transplant recipients may be treated with standard immunosuppressive medications (500mg of IV methylprednisolone and 1000 mg of PO mycophenolate mofetil). Marginal donor lungs may be instrumented using XPS™ device by XVIVO®8components (Lung Cannula Set). Medtronic Bio-Console 560 Blood Pumping System9may pump blood from the venous limb of the Novalung® System for ECMO circuit of the potential lung transplant recipient into the marginal lungs. The marginal donor lungs may be housed in the FDA approved XPS™ device by XVIVO® Organ chamber and ventilated by the XPS™ device by XVIVO® Ventilator. The blood from the pulmonary vein of the marginal lungs may drain back into the venous limb of potential lung transplant recipient’s Novalung® System for ECMO circuit. Assessment of the marginal donor lungs may be made at 4 hours after reperfusion and a decision may be made to transplant the marginal donor lungs or not. System set up for these studies is generally shown and described herein as System 100 of Figure 1.

[0129] The marginal donor lungs may be transported to the recipient hospital using the current standard protocols (PERFADEX® solution), in a cooler box from the procurement site. The marginal donor lungs may then be cannulated using the XPS™ device by XVIVO® Lung Cannula Kit, and housed in XPS™ device by XVIVO* Organ Chamber. The recipient ECMO circuit may be modified to direct recipient blood to the EVLP Attorney Docket No. 206030-0310-00WO circuit The FDA approved XPS™ criteria for flow, pressure and temperature may be followed. After warming up, the marginal donor lungs may be ventilated by XPS™ device by XVIVO® Ventilator according to the FDA approval for XPS™. Arterial and venous blood gas samples and marginal donor lungs ventilation parameters may be tested according to the FDA approval for XPS™. A chest radiograph may also be obtained at 1 and 3 hours of perfusion, before a final decision of utilization of the marginal donor lungs may be made by the Investigator.

[0130] The study team physician may decide if the marginal donor lung is suitable for lung transplantation. If transplantable, the donor lungs may be removed from the XPS, stored in PERFADEX® solution (according to the FDA approval for XPS™) until the recipient is prepared for transplantation surgery. If not transplantable, the donor lungs may be disconnected from EVLP and recipient ECMO circuit. The subject may return to the ICU.

[0131] The Novalung® System for ECMO is indicated for long-term (>6 hours) respiratory / cardiopulmonary support that provides assisted extracorporeal circulation and physiologic gas exchange (oxygenation and CO2 removal) of the patient's blood in adults with acute respiratory failure or acute cardiopulmonary failure, where other available treatment options have failed, and continued clinical deterioration is expected or the risk of death is imminent. These may include a failure to wean from cardiopulmonary bypass following cardiac surgery in adult patients or ECMO-assisted cardiopulmonary resuscitation in adults. The Novalung® System for ECMO is an integrated ECMO platform designed to oxygenate blood and remove CO2. The Novalung® System for ECMO includes the x.ellence® oxygenator with heparin and albumin coating to enhance hemocompatibility. Heparin coating is designed to provide hemocompatibility for longterm applications. The Novalung® System for ECMO includes a DPE pump which requires minimal prime volume and has precise control at low and high flows. The system also includes pressure sensors, bubble traps, and a backup drive. The closed circuit Novalung® System for ECMO may be converted to an open circuit by splicing the venous limb of the ECMO circuit to direct blood to and from the marginal donor lungs.

[0132] Medtronic Bio-Console 560 Blood Pumping System is approved to pump blood through the extracorporeal bypass circuit for extracorporeal support for periods up to six Attorney Docket No. 206030-0310-00WO hours. The Medtronic Bio-Console 560 Blood Pumping System consists of Medtronic Bio-console 560 Hardware console, Medtronic model 540T Pump Motor, Medtronic Bio Console 560 Flow Probe Hardware, Medtronic Affinity CP40 disposable blood pump, and Medtronic Sterile Medical Tubing in pre-cut lengths. The Medtronic Bio-Console 560 Blood Pumping System may be inserted into the venous limb of the Novalung® System for ECMO circuit. The Medtronic Bio-Console 560 Blood Pumping System may pump venous blood into the marginal donor lungs, as approved for use by FDA.

[0133] The commercially available XPS™ device by XVIVO® components that have been FDA approved for EVLP may be used with use of STEEN Solution™ (a crystalloid solution) and the Novalung® System for ECMO by Fresenius Medical Care that has been FDA cleared for ECMO. These studies may use the XPS™ device components and the Novalung® System for ECMO off-label by replacing the use of STEEN Solution™ with lung transplant recipient blood from their Novalung® System for ECMO circuit to perfuse the marginal donor lungs. The recipient ECMO venous circuit may be spliced such that recipient blood is pumped by the Medtronic Bio-Console 560 Blood Pumping System into the marginal donor lungs. The marginal donor lung pulmonary venous blood may be drained into the recipient venous ECMO circuit and may be returned to the recipient.

[0134] Accordingly, and using the systems and methods described herein, the following may be performed. First, the recipient may be given standard of care immunosuppressive medications (500mg of IV methylprednisolone and 1000 mg of PO mycophenolate mofetil) prior to initiating EVLP. Next, blood from the venous limb of Novalung® System for ECMO circuit may be pumped by the Medtronic Bio-Console 560 Blood Pumping System into the marginal donor lungs. Next, the marginal donor lungs pulmonary arteries may be cannulated with XPS by XVIVO® Lung Cannula. The XPS by XVIVO® Lung Cannula has a built-in pressure line that monitors the pressure and allows samples to be drawn. The marginal donor lungs may be housed in the XPS by XVIVO® Organ Chamber, and the marginal donor lungs may be ventilated using the XPS by XVIVO® ventilator which moves breathable air into the lungs. Next, the marginal donor lungs pulmonary veins may be cannulated with XPS by XVIVO® Lung Cannula. The Attorney Docket No. 206030-0310-00WO

[0135] XPS by XVIVO® Lung Cannula has a built-in pressure line that monitors the pressure and allows samples to be drawn. The blood from the marginal donor lungs pulmonary veins may drain back into the venous limb of the Novalung “ System for ECMO circuit. The recipient Novalung® System for ECMO may then circulate blood into the arterial system of the recipient, as per device specifications. Lastly, the oxygenated blood may circulate through the recipient’s kidneys and liver, both of which may help to filter toxic metabolites that may have accumulated in the blood from the marginal donor lungs. Following this, the blood may be once again drained back into the venous limb of the recipient’s ECMO circuit, completing the circuit.

[0136] To determine efficacy clinical endpoints were measured. The primary endpoint is safety of lung transplant recipient who is on ECMO to repair the marginal donor lung using the XPS™ device by XVIVO® as measured by incidence of adverse events. Secondary endpoints include utilization of marginal donor lungs, freedom from primary graft dysfunction (PGD) III at 72 hours post lung transplantation, and survival at 30 days of post lung transplantation. Other clinical endpoints that were measured include PGD III at 24, 48, and 72 hours as measured by arterial blood gas blood test and chest x-ray, duration of mechanical ventilation time post lung transplantation as measured by time on ventilator, survival at 6-months post lung transplantation as measured by mortality, index hospital length of stay post lung transplantation as measured by length of hospital stay, and 3 -month and 6-month pulmonary function tests. Other clinical evaluations tested include all standard of care (SOC) recipient vital signs, oxygen saturation, and ECMO flow q 30 minutes while on EVLP. Donor lung physiologic parameters (hemodynamic and ventilatory parameters, and blood gases) may be assessed every hour during EVLP. An x-ray may be performed at 1 and 3 hours during EVLP. The donor lungs may be considered acceptable if the delta PO2 (e.g., oxygenation left atrium - oxygenation pulmonary artery) is greater than 350 mmHg at 2 different time intervals AND the static compliance remains stable (defined as < 15% deterioration from baseline).

[0137] 2: XPS Clinical Protocol

[0138] Pre-transplant EVLP (up to 4 hours + / - 2 hours) Attorney Docket No. 206030-0310-00WO

[0139] 1 . Tn the OR, the recipient is dosed with immunosuppression medications in preparation for their lung transplant procedure: 500mg of IV methylprednisolone and 1000 mg of PO my cophenolate mofetil, prior to connecting the ECMO circuit to the XPS™ device by XVIVO™ (SOC).

[0140] 2. Record recipient vital signs, ventilatory settings, hemodynamics, and laboratory data including microbiological data, and radiographic studies (SOC) at baseline.

[0141] 3. Connect the donor lungs pulmonary artery to the XPS™ pulmonary artery cannula (SOC).

[0142] 4. Connect the donor lungs pulmonary veins to the XPS™ pulmonary venous cannula (SOC).

[0143] 5. Connect the donor lung trachea to the XPS™ ventilator (SOC).

[0144] 6. Connect the XPS™ pulmonary artery and venous cannula to the recipient’s ECMO venous circuit (research).

[0145] 7. Recipient blood is perfusing the donor lungs, using the XPS™ criteria for flow and pressure and temperature for 4 hours. After warming up, the donor lungs are ventilated according to the XPS™ protocol (Sanchez, et al., 2020, The Journal of Heart and Lung Transplantation, Volume 39, Issue 4, Supplement, Page SI 10).

[0146] 8. Record recipient vital signs, ventilatory settings, hemodynamics, and laboratory data q 30 minutes while on EVLP (SOC)

[0147] 9. Record donor lung physiologic parameters (hemodynamic and ventilatory parameters, and blood gases) every hour during EVLP (SOC).

[0148] 10. Obtain an x-ray at 1 and 3 hours during EVLP (SOC).

[0149] 11. Study team physician decides if marginal donor lung is suitable for lung transplantation: a. If transplantable, the donor lungs remain on XPS until recipient is ready for transplantation (research). b. If not transplantable, the donor lungs are disconnected from EVLP and recipient ECMO circuit (research). The subject returns to the ICU and is monitored by the study team for 24 hours. No additional testing is performed, and the subject is withdrawn from the study and placed on the standard lung transplant wait list.

[0150] Lung Transplant (12 hours + / - 2 hours) Attorney Docket No. 206030-0310-00WO

[0151] 1 . Perform lung transplant procedure according to standard of care (SOC).

[0152] 2. Record vital signs, ventilatory settings, hemodynamics, laboratory data including microbiological data, and radiographic studies (SOC).

[0153] 3. Continue immunosuppression medications as needed (SOC).

[0154] 4. Adverse events (AE) and serious adverse events assessment (SAE) (research).

[0155] Post-transplant (24 hours + / - 6 hours)

[0156] 1. Record complete physical exam information from EHR (SOC).

[0157] 2. Perform an abbreviated physical exam by a qualified member of the study team (research).

[0158] 3. Record vital signs, ventilatory settings, hemodynamics, laboratory data including microbiological data, and radiographic studies (SOC).

[0159] 4. Record arterial blood gas test to measure PGD III (SOC).

[0160] 5. Record chest x-ray to measure PGD III (SOC).

[0161] 6. Record survival data (research).

[0162] 7. Continue immunosuppression medications as needed (SOC).

[0163] 8. Adverse events (AE) and serious adverse events assessment (SAE) (research).

[0164] Post-transplant (48 hours + / - 6 hours)

[0165] 1. Record complete physical exam information from EHR (SOC).

[0166] 2. Perform an abbreviated physical exam by a qualified member of the study team (research).

[0167] 3. Record vital signs, ventilatory settings, hemodynamics, laboratory data including microbiological data, and radiographic studies (SOC).

[0168] 4. Record arterial blood gas test to measure PGD III (SOC).

[0169] 5. Record chest x-ray to measure PGD III (SOC).

[0170] 6. Record survival data (research).

[0171] 7. Continue immunosuppression medications as needed (SOC).

[0172] 8. Adverse events (AE) and serious adverse events assessment (SAE) (research).

[0173] Post-transplant (72 hours + / - 6 hours) Attorney Docket No. 206030-0310-00WO

[0174] 1 . Record complete physical exam information from EHR (SOC).

[0175] 2. Perform an abbreviated physical exam by a qualified member of the study team (research).

[0176] 3. Record vital signs, ventilatory settings, hemodynamics, laboratory data including microbiological data, and radiographic studies (SOC).

[0177] 4. Record arterial blood gas test to measure PGD III (SOC).

[0178] 5. Record chest x-ray to measure PGD III (SOC).

[0179] 6. Record survival data (research).

[0180] 7. Continue immunosuppression medications as needed (SOC).

[0181] 8. Adverse events (AE) and serious adverse events assessment (SAE) (research).

[0182] Discharge Day (14 days - 7 days + 90 days)

[0183] 1. Record complete physical exam information from EHR (SOC).

[0184] 2. Perform an abbreviated physical exam by a qualified member of the study team (research).

[0185] 3. Record vital signs, ventilatory settings, hemodynamics, laboratory data including microbiological data, and radiographic studies (SOC).

[0186] 4. Record duration of mechanical ventilation.

[0187] 5. Record index hospital length of stay (research).

[0188] 6. Record survival data (research).

[0189] 7. Continue immunosuppression medications as needed (SOC).

[0190] 8. Adverse events (AE) and serious adverse events assessment (SAE) (research).

[0191] Follow-up (1 month + / - 2 weeks)

[0192] 1. Record complete physical exam and vital signs from EHR (SOC).

[0193] 2. Record chest x-ray and PFT findings if available from EHR (SOC).

[0194] 3. Record survival data (research).

[0195] 4. Continue immunosuppression medications as needed (SOC).

[0196] 5. Adverse events (AE) and serious adverse events assessment (SAE) (research).

[0197] Follow-up (3 months + / - 2 weeks) Attorney Docket No. 206030-0310-00WO

[0198] 1 . Record complete physical exam and vital signs from EHR (SOC).

[0199] 2. Record chest x-ray and PFT findings if available from EHR (SOC).

[0200] 3. Record survival data (research).

[0201] 4. Continue immunosuppression medications as needed (SOC).

[0202] 5. Adverse events (AE) and serious adverse events assessment (SAE) (research).

[0203] Follow-up (6 months + / - 1 month)

[0204] 1. Record complete physical exam and vital signs from EHR (SOC).

[0205] 2. Perform an abbreviated physical exam by a qualified member of the study team (research).

[0206] 3. Record chest x-ray and PFT findings if available from EHR (SOC).

[0207] 4. Record survival data (research).

[0208] 5. Continue immunosuppression medications as needed (SOC).

[0209] 6. Adverse events (AE) and serious adverse events assessment (SAE) (research).

[0210] The disclosures of each and every patent, patent application, and publication cited herein are hereby incorporated herein by reference in their entirety. While this invention has been disclosed with reference to specific embodiments, it is apparent that other embodiments and variations of this invention may be devised by others skilled in the art without departing from the true spirit and scope of the invention. The appended claims are intended to be construed to include all such embodiments and equivalent variations.

Claims

Attorney Docket No. 206030-0310-00WOCLAIMSWhat is claimed is:

1. A system for maintaining an extracorporeal organ, comprising: an extracorporeal chamber having an extracorporeal organ positioned therein; an ex-vivo organ perfusion (EVOP) circuit fluidly connected to the extracorporeal organ within the extracorporeal chamber, the EVOP circuit comprising an EVOP pump, a first EVOP conduit and a second EVOP conduit, wherein the first EVOP conduit defines a flowpath from the EVOP pump into the extracorporeal organ and the second EVOP conduit defines a flowpath from the extracorporeal organ to the EVOP pump; an extracorporeal membrane oxygenation (ECMO) circuit fluidly connected to a host organism, the ECMO circuit comprising an ECMO pump, an oxygenator, a first ECMO conduit and a second ECMO conduit, wherein the first ECMO conduit defines a flowpath from the ECMO pump into the host organism and the second ECMO conduit defines a flowpath from the host organism to the ECMO pump; a first cross circuit conduit fluidly connecting the second ECMO conduit to the first EVOP conduit and defining a first cross circuit flowpath from the ECMO circuit to the EVOP circuit; and a second cross circuit conduit fluidly connecting the first EVOP conduit to the second ECMO conduit and defining a second cross circuit flowpath from the EVOP circuit to the ECMO circuit; wherein the system is configured to perfuse the extracorporeal organ with blood from the host organism.

2. The system of claim 1, wherein the first cross circuit conduit comprises a first reservoir.

3. The system of claim 2, wherein the second cross circuit conduit comprises a second reservoir.Attorney Docket No. 206030-0310-00WO4. The system of claim 3, wherein the first cross circuit conduit comprises a first valve between the ECMO circuit and the first reservoir, and a second valve between the first reservoir and the EVOP circuit.

5. The system of claim 4, wherein the second cross circuit conduit comprises a third valve between the EVOP circuit and the second reservoir, and a fourth valve between the second reservoir and the ECMO circuit.

6. The system of claim 5, further comprising a control unit, wherein the control unit is configured to operate at least one of the first, second, third and fourth valves.

7. The system of claim 6, further comprising at least one sensor configured to measure fluid pressure, fluid volume, flow rate, pump speed, oxygen saturation, or blood viscosity.

8. The system of claim 7, wherein the control unit is configured to operate at least one of the first, second, third and fourth valves based on information obtained from the at least one sensor.

9. The system of claim 1, wherein the extracorporeal organ is a lung.

10. The system of claim 1, wherein the extracorporeal chamber further comprises one or more of the following features including time-controlled humidifier and misting spray onto the organ, integrated scale for monitoring and recording organ weight, real-time macroscopic video recording of the organ with remote monitoring capability, access ports with sterile air filter for biopsies and / or imaging, access for sterile manual interventions in chamber, and sterilizable and single-use disposable components.

11. The system of claim 1, wherein the ECMO circuit maintains a physiologic level of oxygen in the blood perfusing the extracorporeal organ and the host organism.Attorney Docket No. 206030-0310-00WO12. A method for extracorporeal support of an organ, the method comprising a) connecting the vasculature of an extracorporeal organ to an ex vivo organ perfusion (EVOP) circuit; b) housing the extracorporeal organ in a sterile organ chamber; c) connecting the vasculature of a host organism to an extracorporeal membrane oxygenation (ECMO) circuit; d) connecting the EVOP circuit via cross-circulation to the ECMO circuit; e) perfusing blood from the host through the extracorporeal organ via the crosscirculation ECMO circuit; f) assessing the extracorporeal organ over time; and g) determining whether the extracorporeal organ can be transplanted into the subject.

13. The method of claim 12, wherein blood from the ECMO circuit and EVOP circuit is drained in at least one reservoir to maintain steady state volume.

14. The method of claim 13, wherein the at least one reservoir collects and releases 250 cc of blood.

15. The method of claim 12, wherein at least one valve regulates the volume of blood entering and exiting the at least one reservoir.

16. The method of claim 12, wherein step e) comprises i) draining blood from the ECMO circuit into Reservoir 1; ii) releasing the blood in Reservoir 1 into the EVOP circuit; iii) draining blood from the EVOP circuit into Reservoir 2; and iv) releasing the blood in Reservoir 2 into the ECMO circuit.

17. The method of claim 12, wherein step e) is repeated every 5 minutes for at least 4 hours.Attorney Docket No. 206030-0310-00WO18. The method of claim 12, further comprising treating the extracorporeal organ by providing at least one of an energy substrate, a circulating repair factor, metabolic clearance, or therapeutic intervention, including medication, drug nanoparticles, gene therapy, stem cell therapy decellularization cell replacement or inflammatory modulation.

19. The method of claim 12, further comprising disconnecting the extracorporeal organ from the cross-circulation ECMO circuit and transplanting the extracorporeal organ into the host organism.

20. The method of claim 12, wherein the extracorporeal organ maintains a temperature within a range of from 30° C to 40° C.

21. The method of claim 12 for treating an extracorporeal organ that has been subjected to maintenance at 4° C for a period of time, the method comprising: maintaining the extracorporeal organ within a temperature range of from 30° C to 40° C after connecting the extracorporeal organ to the cross-circulation ECMO circuit.

22. The method of claim 12, wherein the extracorporeal organ exhibits acute injury prior to treatment; or wherein the organ exhibits a reversible pathologic condition prior to treatment.

23. The method of claim 12, wherein the host organism is a human subject.

24. The method of claim 23, wherein the human subject is immunosuppressed.

25. The method of claim 12, wherein the extracorporeal organ is a lung.

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