201
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Direct Heart Procurement After Donation After Circulatory Death With Ex Situ Reperfusion. Ann Thorac Surg 2018; 106:e211-e214. [DOI: 10.1016/j.athoracsur.2018.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 04/02/2018] [Accepted: 04/09/2018] [Indexed: 01/05/2023]
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202
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National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ 2018; 27:1123-1208. [DOI: 10.1016/j.hlc.2018.06.1042] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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203
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Marsia S, Khan A, Khan M, Ahmed S, Hayat J, Minhas AMK, Mirza S, Asmi N, Constantin J. Heart transplantation after the circulatory death; The ethical dilemma. Indian Heart J 2018; 70 Suppl 3:S442-S445. [PMID: 30595305 PMCID: PMC6309566 DOI: 10.1016/j.ihj.2018.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 01/09/2023] Open
Abstract
Donors after brain death (DBD) have been the major source of organ donation due to good perfusion of the organs. However, owing to the mismatch in demand and supply of the organ donors and recipients, donors after circulatory death (DCDDs) has increased recently all over the world. Kidneys, liver, and lungs are being used for transplantation from DCDDs. Recently, heart transplantation from DCDDs has been started, which is under the firestorm of scrutiny by the ethicists. The ethical dilemma revolves around the question whether the donors are actually dead when they are declared dead by cardiocirculatory death criteria for organ procurement. The subsequent literature review addresses all the perspectives by differentiating between the donation methods known as DBDs and DCDDs, explaining the implications of the dead-donor rule on the organ donation pool, and categorizing the determinants of death leading to separation of the arguments under the two methods of donations.
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Affiliation(s)
- Shayan Marsia
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan.
| | - Ariba Khan
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Maryam Khan
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Saba Ahmed
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Javeria Hayat
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Samir Mirza
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Nisar Asmi
- Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, USA
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204
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Human heart transplantation from donation after circulatory-determined death donors using normothermic regional perfusion and cold storage. J Heart Lung Transplant 2018; 37:865-869. [DOI: 10.1016/j.healun.2018.03.017] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 03/23/2018] [Accepted: 03/28/2018] [Indexed: 12/19/2022] Open
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205
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Jain P, Prichard RA, Connellan MB, Dhital KK, Macdonald PS. Long distance heart transplantation: a tale of two cities. Intern Med J 2018; 47:1202-1205. [PMID: 28994259 DOI: 10.1111/imj.13568] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/19/2016] [Accepted: 01/11/2017] [Indexed: 11/27/2022]
Abstract
In this 'paired' case report, we describe two heart transplants performed 3 days apart at our centre. Both cases involved very prolonged transportation time of the donor heart. In one case, the donor heart was transported in an ice chest, while in the other case the organ was transported using a normothermic ex vivo perfusion (NEVP) system. The additional retrieval costs incurred by the use NEVP were more than offset by the reduction in subsequent inpatient costs.
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Affiliation(s)
- Pankaj Jain
- Heart Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Roslyn A Prichard
- Heart Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.,University of Technology, Sydney, New South Wales, Australia
| | - Mark B Connellan
- Heart Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Kumud K Dhital
- Heart Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | - Peter S Macdonald
- Heart Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
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206
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Steroids Limit Myocardial Edema During Ex Vivo Perfusion of Hearts Donated After Circulatory Death. Ann Thorac Surg 2018; 105:1763-1770. [DOI: 10.1016/j.athoracsur.2018.01.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 10/21/2017] [Accepted: 01/03/2018] [Indexed: 12/18/2022]
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207
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Affiliation(s)
- Stefan G Tullius
- From Harvard Medical School and Brigham and Women's Hospital, Boston (S.G.T.); and Johns Hopkins University School of Medicine and the Johns Hopkins Hospital, Baltimore (H.R.)
| | - Hamid Rabb
- From Harvard Medical School and Brigham and Women's Hospital, Boston (S.G.T.); and Johns Hopkins University School of Medicine and the Johns Hopkins Hospital, Baltimore (H.R.)
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208
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Farine E, Egle MU, Boone AC, Christensen S, Carrel TP, Tevaearai Stahel HT, Longnus SL. Development of a cardiac loading device to monitor cardiac function during ex vivo graft perfusion. PLoS One 2018; 13:e0195721. [PMID: 29702648 PMCID: PMC5922540 DOI: 10.1371/journal.pone.0195721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 03/28/2018] [Indexed: 11/18/2022] Open
Abstract
Background Ex vivo heart perfusion systems, allowing continuous perfusion of the coronary vasculature, have recently been introduced to limit ischemic time of donor hearts prior to transplantation. Hearts are, however, perfused in an unloaded manner (via the aorta) and therefore, cardiac contractile function cannot be reliably evaluated. Objectives We aim to develop a ventricular loading device that enables monitoring of myocardial function in an ex vivo perfusion system. In this initial study, was to develop a prototype for rat experimentation. Methods We designed a device consisting of a ventricular balloon and a reservoir balloon, connected through an electronic check valve, which opens and closes in coordination with changes in ventricular pressure. All balloons were produced in our laboratory and their properties, particularly pressure-volume relationships, were characterized. We developed a mock ventricle in vitro test system to evaluate the device, which was ultimately tested in ex vivo perfused rat hearts. Results Balloon production was consistent and balloon properties were maintained over time and with use on the device. Results from in vitro and ex vivo experiments show that the device functions appropriately; hemodynamic function can be measured and compares well to measurements made in an isolated, working (loaded) rat heart preparation. Conclusions Our cardiac loading device appears to reliably allow measurement of several left ventricular hemodynamic parameters and provides the opportunity to control ventricular load.
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Affiliation(s)
- Emilie Farine
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Manuel U. Egle
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Alice C. Boone
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Sandro Christensen
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Thierry P. Carrel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | | | - Sarah L. Longnus
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
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209
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Zhao Q, Huang S, Wang D, Zhang Z, Wu L, Yang L, Ma Y, Ji F, Tang Y, Wang L, Zhu Z, Zhu Y, Xiong W, Chen M, Han M, Zhou J, Hu A, Wang G, Jiao X, Zhu X, Ju W, Guo Z, He X. Does Ischemia Free Liver Procurement Under Normothermic Perfusion Benefit the Outcome of Liver Transplantation? Ann Transplant 2018. [PMID: 29674604 PMCID: PMC6248288 DOI: 10.12659/aot.909645] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background In contrast to conventional static cold preservation, normothermic machine perfusion (NMP) provides a beneficial alternative preservation of donor livers. However, the liver still suffered cold ischemic injury before attaching to the perfusion device. Material/Methods To prevent cold ischemic injury during procurement, we describe a novel procedure called ischemia-free liver procurement (IFLP) under NMP. Two liver grafts were procured from brain death donor under NMP and underwent 2-hour ex vivo NMP followed by 3 and 6 hours of static cold preservation. From procurement to post-transplantation course, evidence was collected to prove that IFLP is safe and benefits recipients. Results The post-transplantation course was uneventful, and the liver function tests and histological study revealed minimal hepatocyte and biliary epithelium injury during the preservation. Conclusions This preliminary experience demonstrates the clinical feasibility and safety of IFLP under NMP which offering opportunities to increase the number of donor livers and to improve the organ function.
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Affiliation(s)
- Qiang Zhao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Shanzhou Huang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Dongping Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Zhiheng Zhang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Linwei Wu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Lu Yang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Yi Ma
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Fei Ji
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Yunhua Tang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Linhe Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Zebin Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Yanling Zhu
- Department of Cardiopulmonary Bypass, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Wei Xiong
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Maogen Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Ming Han
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Jian Zhou
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Anbin Hu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Guodong Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Xingyuan Jiao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Xiaofeng Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Weiqiang Ju
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Zhiyong Guo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
| | - Xiaoshun He
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China (mainland).,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, China (mainland)
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210
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Abstract
This article summarizes recent knowledge and clinical advances in machine perfusion (MP) of thoracic organs. MP of thoracic organs has gained much attention during the last decade. Clinical studies are investigating the role of MP to preserve, resuscitate, and assess heart and lungs prior to transplantation. Currently, MP of the cardiac allograft is essential in all type DCD heart transplantation while MP of the pulmonary allograft is mandatory in uncontrolled DCD lung transplantation. MP of thoracic organs also offers an exciting platform to further investigate downregulation of the innate and adaptive immunity prior to reperfusion of the allograft in recipients. MP provides a promising technology that allows pre-transplant preservation, resuscitation, assessment, repair, and conditioning of cardiac and pulmonary allografts outside the body in a near physiologic state prior to planned transplantation. Results of ongoing clinical trials are awaited to estimate the true clinical value of this new technology in advancing the field of heart and lung transplantation by increasing the total number and the quality of available organs and by further improving recipient early and long-term outcome.
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Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, KU Leuven University, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium
| | - Steffen Rex
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
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211
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Rodrigue JR, Luskin R, Nelson H, Glazier A, Henderson GV, Delmonico FL. Measuring Critical Care Providers' Attitudes About Controlled Donation After Circulatory Death. Prog Transplant 2018; 28:142-150. [PMID: 29558878 DOI: 10.1177/1526924818765821] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Unfavorable attitudes and insufficient knowledge about donation after cardiac death among critical care providers can have important consequences for the appropriate identification of potential donors, consistent implementation of donation after cardiac death policies, and relative strength of support for this type of donation. The lack of reliable and valid assessment measures has hampered research to capture providers' attitudes. Design and Research Aims: Using stakeholder engagement and an iterative process, we developed a questionnaire to measure attitudes of donation after cardiac death in critical care providers (n = 112) and examined its psychometric properties. Exploratory factor analysis, internal consistency, and validity analyses were conducted to examine the measure. RESULTS A 34-item questionnaire consisting of 4 factors (Personal Comfort, Process Satisfaction, Family Comfort, and System Trust) provided the most parsimonious fit. Internal consistency was acceptable for each of the subscales and the total questionnaire (Cronbach α > .70). A strong association between more favorable attitudes overall and knowledge ( r = .43, P < .001) provides evidence of convergent validity. Multivariable regression analyses showed that white race ( P = .002) and more experience with donation after cardiac death ( P < .001) were significant predictors of more favorable attitudes. CONCLUSION Study findings support the utility, reliability, and validity of a questionnaire for measuring attitudes in critical care providers and for isolating targets for additional education on donation after cardiac death.
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Affiliation(s)
- James R Rodrigue
- 1 Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | | | | | | | - Galen V Henderson
- 2 Harvard Medical School, Boston, MA, USA.,3 New England Donor Services, Waltham, MA, USA.,4 Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Francis L Delmonico
- 2 Harvard Medical School, Boston, MA, USA.,3 New England Donor Services, Waltham, MA, USA.,5 Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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212
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He X, Guo Z, Zhao Q, Ju W, Wang D, Wu L, Yang L, Ji F, Tang Y, Zhang Z, Huang S, Wang L, Zhu Z, Liu K, Zhu Y, Gao Y, Xiong W, Han M, Liao B, Chen M, Ma Y, Zhu X, Huang W, Cai C, Guan X, Li XC, Huang J. The first case of ischemia-free organ transplantation in humans: A proof of concept. Am J Transplant 2018; 18:737-744. [PMID: 29127685 DOI: 10.1111/ajt.14583] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 10/10/2017] [Accepted: 11/02/2017] [Indexed: 01/25/2023]
Abstract
Ischemia and reperfusion injury (IRI) is an inevitable event in conventional organ transplant procedure and is associated with significant mortality and morbidity post-transplantation. We hypothesize that IRI is avoidable if the blood supply for the organ is not stopped, thus resulting in optimal transplant outcomes. Here we described the first case of a novel procedure called ischemia-free organ transplantation (IFOT) for patients with end-stage liver disease. The liver graft with severe macrovesicular steatosis was donated from a 25-year-old man. The recipient was a 51-year-old man with decompensated liver cirrhosis and hepatocellular carcinoma. The graft was procured, preserved, and implanted under continuous normothermic machine perfusion. The recipient did not suffer post-reperfusion syndrome or vasoplegia after revascularization of the allograft. The liver function test and histological study revealed minimal hepatocyte, biliary epithelium and vascular endothelium injury during preservation and post-transplantation. The inflammatory cytokine levels were much lower in IFOT than those in conventional procedure. Key pathways involved in IRI were not activated after allograft revascularization. No rejection, or vascular or biliary complications occurred. The patient was discharged on day 18 post-transplantation. This marks the first case of IFOT in humans, offering opportunities to optimize transplant outcomes and maximize donor organ utilization.
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Affiliation(s)
- Xiaoshun He
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Zhiyong Guo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Qiang Zhao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Weiqiang Ju
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Dongping Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Linwei Wu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Lu Yang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Fei Ji
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Yunhua Tang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Zhiheng Zhang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Shanzhou Huang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Linhe Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Zebin Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Kunpeng Liu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Yanling Zhu
- Department of Cardiopulmonary Bypass, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yifang Gao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Wei Xiong
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ming Han
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Bing Liao
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Department of Pathology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Maogen Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Yi Ma
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Xiaofeng Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Wenqi Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Changjie Cai
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiangdong Guan
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xian Chang Li
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China.,Immunobiology and Transplant Science Center Houston Methodist Research Institute, Houston, TX, USA
| | - Jiefu Huang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Peking Union Medical College Hospital, Beijing, China
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213
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White CW, Messer SJ, Large SR, Conway J, Kim DH, Kutsogiannis DJ, Nagendran J, Freed DH. Transplantation of Hearts Donated after Circulatory Death. Front Cardiovasc Med 2018; 5:8. [PMID: 29487855 PMCID: PMC5816942 DOI: 10.3389/fcvm.2018.00008] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 01/19/2018] [Indexed: 12/17/2022] Open
Abstract
Cardiac transplantation has become limited by a critical shortage of suitable organs from brain-dead donors. Reports describing the successful clinical transplantation of hearts donated after circulatory death (DCD) have recently emerged. Hearts from DCD donors suffer significant ischemic injury prior to organ procurement; therefore, the traditional approach to the transplantation of hearts from brain-dead donors is not applicable to the DCD context. Advances in our understanding of ischemic post-conditioning have facilitated the development of DCD heart resuscitation strategies that can be used to minimize ischemia-reperfusion injury at the time of organ procurement. The availability of a clinically approved ex situ heart perfusion device now allows DCD heart preservation in a normothermic beating state and minimizes exposure to incremental cold ischemia. This technology also facilitates assessments of organ viability to be undertaken prior to transplantation, thereby minimizing the risk of primary graft dysfunction. The application of a tailored approach to DCD heart transplantation that focuses on organ resuscitation at the time of procurement, ex situ preservation, and pre-transplant assessments of organ viability has facilitated the successful clinical application of DCD heart transplantation. The transplantation of hearts from DCD donors is now a clinical reality. Investigating ways to optimize the resuscitation, preservation, evaluation, and long-term outcomes is vital to ensure a broader application of DCD heart transplantation in the future.
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Affiliation(s)
| | - Simon J Messer
- Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Stephen R Large
- Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Daniel H Kim
- Cardiology, University of Alberta, Edmonton, AB, Canada
| | | | - Jayan Nagendran
- Cardiac Surgery, University of Alberta, Edmonton, AB, Canada
| | - Darren H Freed
- Cardiac Surgery, University of Alberta, Edmonton, AB, Canada.,Department of Physiology, University of Alberta, Edmonton, AB, Canada.,Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
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214
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215
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Schraufnagel DP, Steffen RJ, Vargo PR, Attia T, Elgharably H, Hasan SM, Bribriesco A, Wierup P. Devices for ex vivo heart and lung perfusion. Expert Rev Med Devices 2018; 15:183-191. [PMID: 29376452 DOI: 10.1080/17434440.2018.1430568] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The number of organs available for heart and lung transplantation is far short of the number that is needed to meet demand. Perfusion and ventilation of donor organs after procurement has led to exciting advances in the field of cardiothoracic transplantation. The clinical implications of this technology allows for techniques to evaluate the quality of an organ, active rehabilitation of organs after procurement and prior to implantation, and increased time between organ procurement and implantation. This ex-vivo perfusion technique has also been referred to in the lay press as the 'heart in a box' or 'lung in a box.' AREAS COVERED This review includes information from case reports, case series, and clinical trials on ex vivo heart and lung perfusion. The focus is on the devices, ventilation and perfusion techniques, outcomes, and application of the technology. EXPERT COMMENTARY Ex vivo perfusion of donor hearts and lungs prior to transplantation has proven to be a viable alternative to standard cold-preservation strategies. Its use has allowed for ongoing expansion of the donor pool. The biggest barriers to expansion of this technology are access, cost, and lack of evidence which clearly supports superior outcomes.
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Affiliation(s)
- Dean P Schraufnagel
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Robert J Steffen
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Patrick R Vargo
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Tamer Attia
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Haytham Elgharably
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Saad M Hasan
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Alejandro Bribriesco
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Per Wierup
- a Department of Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
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216
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Schlegel A, Muller X, Dutkowski P. Hypothermic Machine Preservation of the Liver: State of the Art. CURRENT TRANSPLANTATION REPORTS 2018; 5:93-102. [PMID: 29564206 PMCID: PMC5843682 DOI: 10.1007/s40472-018-0183-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW In this review, we highlight which livers may benefit from additional treatment before implantation and describe the concept of hypothermic machine liver perfusion. Furthermore, we explain why cold oxygenated perfusion concepts could potentially lead to a breakthrough in this challenging field of transplantation. Accordingly, we summarize recent clinical applications of different hypothermic perfusion approaches. RECENT FINDINGS The impact of end-ischemic, hypothermic liver perfusion in liver transplantation is currently assessed by two multicenter, randomized controlled trials. Recently, new applications of hypothermic perfusion showed promising results and recipients were protected from severe intrahepatic biliary complications, despite the use of very extended criteria grafts including donation after circulatory death livers. SUMMARY Hypothermic machine liver perfusion is beneficial for high-risk livers and protects recipients from most feared complications. Importantly, such easy approach is currently implemented in several European centers and new markers obtained from perfusate may improve the prediction of liver function in the future.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
- NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK
| | - Xavier Muller
- Department of Surgery & Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery & Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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217
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Stehlik J, Kobashigawa J, Hunt SA, Reichenspurner H, Kirklin JK. Honoring 50 Years of Clinical Heart Transplantation in
Circulation. Circulation 2018; 137:71-87. [DOI: 10.1161/circulationaha.117.029753] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Heart transplantation has become a standard therapy option for advanced heart failure. The translation of heart transplantation from innovative experiments to long-term clinical success has married prescient insights with discipline and organization in the domains of surgical techniques, organ preservation, immunosuppression, organ donation and transplantation logistics, infection control, and long-term graft surveillance. This review explores the key milestones of the past 50 years of heart transplantation and discusses current challenges and promising innovations on the clinical horizon.
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Affiliation(s)
- Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City (J.S.)
| | | | - Sharon A. Hunt
- Division of Cardiovascular Medicine, Stanford University, CA (S.A.H.)
| | | | - James K. Kirklin
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham (J.K.K.)
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218
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Page A, Messer S, Large SR. Heart transplantation from donation after circulatory determined death. Ann Cardiothorac Surg 2018; 7:75-81. [PMID: 29492385 DOI: 10.21037/acs.2018.01.08] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Fifty years since the first successful human heart transplant from a non-heart beating donor, this concept of heart transplantation from donation after circulatory determined death (DCD) promises to be one of the most exciting developments in heart transplantation. Heart transplantation has established itself as the best therapeutic option for patients with end-stage heart failure, with the opportunity to provide these patients with a near-normal quality of life. However, this treatment is severely limited by the availability of suitable donor hearts. In recent times, heart transplantation has been limited to using donor hearts from donors following brain stem death. The use of donor hearts from DCD had been thought to be associated with high risk and poor outcomes until recent developments in organ perfusion and retrieval techniques have shown that this valuable resource may provide an answer to the global shortage of suitable donor hearts. With established DCD heart transplant programmes reporting encouraging results, this technique has been shown to be comparable to the current gold standard of donation after brain death (DBD) heart transplantation.
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Affiliation(s)
- Aravinda Page
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, UK
| | - Simon Messer
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, UK
| | - Stephen R Large
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, UK
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219
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Farmer BE, Zhukov IO. Anesthesia for Heart and Lung Transplantation. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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220
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Abstract
The first human-to-human heart transplant was performed 50 years ago in 1967. Heart transplantation has now entered an era of tremendous growth and innovation. The future of heart transplantation is bright with the advent of newer immunosuppressive medications and strategies that may even result in tolerance. Much of this progress in heart transplant medicine is predicated on a better understanding of acute and chronic rejection pathways through basic science studies. The future will also include personalized medicine where genomics and molecular science will dictate customized treatment for optimal outcomes. The introduction of mechanical circulatory support (MCS) devices has changed the landscape for patients with severe heart failure to stabilize the most ill patient and make them better candidates for heart transplant. As ex vivo preservation takes hold, we may witness an expansion of the donor pool through the use of donation after cardiac death (DCD) donors. In addition, further geographical donor heart sharing through ex vivo preservation may further decrease waitlist mortality by enabling longer distance donor hearts to be allocated for the sickest waitlist patient. It is no doubt an exciting time to be involved in the field of heart transplantation. In this perspective, we will summarize the present state of heart transplantation and discuss various innovations that are being pursued.
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221
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Monteagudo Vela M, García Sáez D, Simon AR. Current approaches in retrieval and heart preservation. Ann Cardiothorac Surg 2018; 7:67-74. [PMID: 29492384 DOI: 10.21037/acs.2018.01.06] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Fifty years after the first successful heart transplantation, despite multiple advances in the treatment of advanced acute and chronic heart failure, there is still no equivalent to heart transplantation as a long-term treatment for end-stage heart failure. Transplantation is, however, limited by the scarcity and quality of heart allografts. Donors are nowadays significantly older, particularly in European countries, and traumatic head injury as the cause of death has been replaced by intracerebral hemorrhage or hypoxic brain damage in the majority of cases. In addition, many donors have undergone extensive resuscitation efforts. Recipient characteristics have progressively changed too within the last couple of decades; recipients are older, often with comorbidities and nearly half of them are bridged to transplant with a wide variety of mechanical circulatory support devices. These developments have resulted in heart transplant surgery becoming significantly more challenging with longer more complex surgery and increased ischemia times for organs that were previously considered to be borderline or non-transplantable in many cases. To address this, several options have been explored within the last years and as a result, novel strategies have been developed and tested in order to optimize graft preservation and potentially increase the donor pool. The two notable developments are the ability to procure hearts from donors after circulatory death and the advent of ex-vivo perfusion of hearts. This technology has made the transplantation of extended criteria organs, including those from circulatory determined death (DCD) donors possible, and allow for out of body time of more than 12 hours in heart transplantation. In this review, we set out the basis of the current practices in organ procurement, and the opportunities for the future as demands for organ transplantation continue to increase.
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Affiliation(s)
- Maria Monteagudo Vela
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
| | - Diana García Sáez
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
| | - Andre R Simon
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
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222
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Kim IC, Youn JC, Kobashigawa JA. The Past, Present and Future of Heart Transplantation. Korean Circ J 2018; 48:565-590. [PMID: 29968430 PMCID: PMC6031715 DOI: 10.4070/kcj.2018.0189] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 06/18/2018] [Indexed: 01/04/2023] Open
Abstract
Heart transplantation (HTx) has become standard treatment for selected patients with end-stage heart failure. Improvements in immunosuppressant, donor procurement, surgical techniques, and post-HTx care have resulted in a substantial decrease in acute allograft rejection, which had previously significantly limited survival of HTx recipients. However, limitations to long-term allograft survival exist, including rejection, infection, coronary allograft vasculopathy, and malignancy. Careful balance of immunosuppressive therapy and vigilant surveillance for complications can further improve long-term outcomes of HTx recipients.
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Affiliation(s)
- In Cheol Kim
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Jong Chan Youn
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea.
| | - Jon A Kobashigawa
- Division of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA.
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223
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Affiliation(s)
- Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02492, USA.
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224
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Hodgson R, Young AL, Attia MA, Lodge JPA. Impact of a National Controlled Donation After Circulatory Death (DCD) Program on Organ Donation in the United Kingdom: A 10-Year Study. Am J Transplant 2017; 17:3172-3182. [PMID: 28556608 DOI: 10.1111/ajt.14374] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 04/09/2017] [Accepted: 05/15/2017] [Indexed: 01/25/2023]
Abstract
Organ transplantation is the most successful treatment for some forms of organ failure, yet a lack of organs means many die on the waiting list. In the United Kingdom, the Organ Donation Taskforce was set up to identify barriers to organ donation and in 2008 released its first report (Organ Donation Taskforce Report; ODTR). This study assesses the success since the ODTR and examines the impact of the United Kingdom's controlled donation after circulatory death (DCD) program and the controversies surrounding it. There were 12 864 intended donation after brain death (DBD) or DCD donors from April 2004 to March 2014. When the 5 years preceding the ODTR was compared to the 5 years following, intended DCD donors increased 292% (1187 to 4652), and intended DBD donors increased 11% (3327 to 3698). Organs retrieved per intended DBD donor remained static (3.30 to 3.26), whereas there was a decrease in DCD (1.54 to 0.99) due to a large rise in donors who did not proceed to donation (325 to 2464). The majority of DCD donors who proceeded did so within 30 min from time of withdrawal. Our study suggests further work on converting eligible referrals to organ donation and exploring methods of converting DCD to DBD donors.
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Affiliation(s)
- R Hodgson
- University of Melbourne, Department of Surgery, Austin Health, Heidelberg, Victoria, Australia.,Department of Hepatobiliary and Transplant Surgery, St James's University Hospital, Leeds, West Yorkshire, UK
| | - A L Young
- Department of Hepatobiliary and Transplant Surgery, St James's University Hospital, Leeds, West Yorkshire, UK
| | - M A Attia
- Department of Hepatobiliary and Transplant Surgery, St James's University Hospital, Leeds, West Yorkshire, UK
| | - J P A Lodge
- Department of Hepatobiliary and Transplant Surgery, St James's University Hospital, Leeds, West Yorkshire, UK
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225
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Cardiac Transplantation. JACC-HEART FAILURE 2017; 5:857-868. [DOI: 10.1016/j.jchf.2017.08.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 08/18/2017] [Accepted: 08/29/2017] [Indexed: 01/28/2023]
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226
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Kleinmahon JA, Patel SS, Auerbach SR, Rossano J, Everitt MD. Hearts transplanted after circulatory death in children: Analysis of the International Society for Heart and Lung Transplantation registry. Pediatr Transplant 2017; 21. [PMID: 28940999 DOI: 10.1111/petr.13064] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2017] [Indexed: 11/25/2022]
Abstract
We aimed to describe worldwide DCD HT experience in children using the International Society for Heart and Lung Transplantation Registry. The Registry was queried for primary HT performed in children (2005-2014). Kaplan-Meier analysis was used to assess survival for recipients grouped by DCD or DBD hearts. Recipient characteristics were compared between DCD and DBD and between survivors and non-survivors of DCD HT. Among 3877 pediatric HT performed, 21 (0.5%) were DCD. DCD 1-year survival was 61% vs 91% DBD, P < .01. DCD recipients were more often supported by ECMO pre-HT (24% vs 6%, P < .001) and more often receiving inhaled nitric oxide (10% vs 0.6%, P < .001) compared to DBD. Older DCD recipients had significantly lower 1-year survival of 57% vs 93% for DBD, P < .01. Survival for infant DCD recipients was not statistically different to DBD recipients (survival 62% at 1 year and 62% at 5 years for DCD vs 85% at 1 year and 77% at 5 years for DBD, P = .15). Recipients of DCD HT who died were more often supported by ECMO pre-HT (56% non-survivors vs 0% survivors, P = .004) and receiving mechanical ventilation (44% vs 0%, P = .012). DCD HT is uncommon in children. DCD-independent factors in recipients may have contributed to worse survival as DCD recipients who died were more often supported by ECMO and mechanical ventilation. More research is needed to identify donor factors and recipient factors that contribute to mortality after DCD HT.
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Affiliation(s)
- Jake A Kleinmahon
- Division of Cardiology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Sonali S Patel
- Division of Cardiology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Scott R Auerbach
- Division of Cardiology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Joseph Rossano
- Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Melanie D Everitt
- Division of Cardiology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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227
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Krezdorn N, Tasigiorgos S, Wo L, Turk M, Lopdrup R, Kiwanuka H, Win TS, Bueno E, Pomahac B. Tissue conservation for transplantation. Innov Surg Sci 2017; 2:171-187. [PMID: 31579751 PMCID: PMC6754021 DOI: 10.1515/iss-2017-0010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 06/27/2017] [Indexed: 02/07/2023] Open
Abstract
Pathophysiological changes that occur during ischemia and subsequent reperfusion cause damage to tissues procured for transplantation and also affect long-term allograft function and survival. The proper preservation of organs before transplantation is a must to limit these injuries as much as possible. For decades, static cold storage has been the gold standard for organ preservation, with mechanical perfusion developing as a promising alternative only recently. The current literature points to the need of developing dedicated preservation protocols for every organ, which in combination with other interventions such as ischemic preconditioning and therapeutic additives offer the possibility of improving organ preservation and extending it to multiple times its current duration. This review strives to present an overview of the current body of knowledge with regard to the preservation of organs and tissues destined for transplantation.
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Affiliation(s)
- Nicco Krezdorn
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover Medical School, Hannover, Germany
| | - Sotirios Tasigiorgos
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Luccie Wo
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Marvee Turk
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachel Lopdrup
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Harriet Kiwanuka
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Thet-Su Win
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ericka Bueno
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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228
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Messer S, Page A, Axell R, Berman M, Hernández-Sánchez J, Colah S, Parizkova B, Valchanov K, Dunning J, Pavlushkov E, Balasubramanian SK, Parameshwar J, Omar YA, Goddard M, Pettit S, Lewis C, Kydd A, Jenkins D, Watson CJ, Sudarshan C, Catarino P, Findlay M, Ali A, Tsui S, Large SR. Outcome after heart transplantation from donation after circulatory-determined death donors. J Heart Lung Transplant 2017; 36:1311-1318. [DOI: 10.1016/j.healun.2017.10.021] [Citation(s) in RCA: 162] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 10/20/2017] [Accepted: 10/21/2017] [Indexed: 11/26/2022] Open
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229
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Abstract
PURPOSE OF REVIEW Despite continued expansion in the use of extended-criteria donor hearts following donation after brain death, there remains an unacceptable discrepancy between the supply of suitable donor hearts and the demand from increasing recipient numbers on transplant wait lists. Until recently, the additional approach of utilizing organs following donation after circulatory death (DCD) had not been possible for clinical heart transplantation in the modern era. This review describes relevant advances in translational research and provides an update on the favourable adoption of this donation pathway for clinical heart transplantation. RECENT FINDINGS The use of an ex-situ transportable cardiac perfusion platform together with modified cardioplegia, supplemented with postconditioning agents, has allowed three centres to report successful transplantation of distantly procured human DCD hearts. This has been achieved by utilizing either a method of direct procurement and ex-situ perfusion on the device or through an initial in-situ reanimation with extracorporeal normothermic regional perfusion prior to ex-situ perfusion. SUMMARY DCD heart transplantation is feasible with excellent early outcomes. In the face of continued and significant donor organ shortage and inevitable wait list attrition, the rejection of suitable DCD hearts, in jurisdictions permitting this donation pathway, is increasingly difficult to justify.
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230
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Abstract
PURPOSE OF REVIEW Countries in Europe and in the USA are proclaiming their need for an objective allocation system that can cope with distribution of a scarce resource in a changing environment of an older donor and recipient population and of an increased number of patients on mechanical circulatory support, whose prospects are increasing. RECENT FINDINGS The current heart allocation systems in Eurotransplant, France and the USA are all urgency tier systems, where within the same tier a first-come, first-served principle is applied. Both Eurotransplant and France are developing new heart allocation schemes that hinge on a benefit principle, thereby combining the prospects of patients after transplantation with their expected clinical course while on the waiting list. In the USA, a different approach has been chosen for their new allocation scheme, as the medical urgency of the patient is the driving force behind the proposal. SUMMARY Policies to ensure a fair, efficient, and medically optimal matching of donor organs and recipients are continually evaluated and refined. The ethical cornerstone of each organ allocation policy in the described countries is the effort of balancing justice and utility.
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231
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Mehra MR. Challenges, diligence, and a breakthrough in donation after circulatory death in heart transplantation. J Heart Lung Transplant 2017; 36:1319-1321. [PMID: 29173395 DOI: 10.1016/j.healun.2017.10.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 10/21/2017] [Indexed: 11/25/2022] Open
Affiliation(s)
- Mandeep R Mehra
- Brigham Health Center for Advanced Heart Disease and Harvard Medical School, Boston, Massachusetts.
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232
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The Use of an Acellular Oxygen Carrier in a Human Liver Model of Normothermic Machine Perfusion. Transplantation 2017; 101:2746-2756. [PMID: 28520579 DOI: 10.1097/tp.0000000000001821] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Normothermic machine perfusion of the liver (NMP-L) is a novel technique that preserves liver grafts under near-physiological conditions while maintaining their normal metabolic activity. This process requires an adequate oxygen supply, typically delivered by packed red blood cells (RBC). We present the first experience using an acellular hemoglobin-based oxygen carrier (HBOC) Hemopure in a human model of NMP-L. METHODS Five discarded high-risk human livers were perfused with HBOC-based perfusion fluid and matched to 5 RBC-perfused livers. Perfusion parameters, oxygen extraction, metabolic activity, and histological features were compared during 6 hours of NMP-L. The cytotoxicity of Hemopure was also tested on human hepatic primary cell line cultures using an in vitro model of ischemia reperfusion injury. RESULTS The vascular flow parameters and the perfusate lactate clearance were similar in both groups. The HBOC-perfused livers extracted more oxygen than those perfused with RBCs (O2 extraction ratio 13.75 vs 9.43 % ×10 per gram of tissue, P = 0.001). In vitro exposure to Hemopure did not alter intracellular levels of reactive oxygen species, and there was no increase in apoptosis or necrosis observed in any of the tested cell lines. Histological findings were comparable between groups. There was no evidence of histological damage caused by Hemopure. CONCLUSIONS Hemopure can be used as an alternative oxygen carrier to packed red cells in NMP-L perfusion fluid.
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233
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Abstract
OBJECTIVES Create trustworthy, rigorous, national clinical practice guidelines for the practice of pediatric donation after circulatory determination of death in Canada. METHODS We followed a process of clinical practice guideline development based on World Health Organization and Canadian Medical Association methods. This included application of Grading of Recommendations Assessment, Development, and Evaluation methodology. Questions requiring recommendations were generated based on 1) 2006 Canadian donation after circulatory determination of death guidelines (not pediatric specific), 2) a multidisciplinary symposium of national and international pediatric donation after circulatory determination of death leaders, and 3) a scoping review of the pediatric donation after circulatory determination of death literature. Input from these sources drove drafting of actionable questions and Good Practice Statements, as defined by the Grading of Recommendations Assessment, Development, and Evaluation group. We performed additional literature reviews for all actionable questions. Evidence was assessed for quality using Grading of Recommendations Assessment, Development, and Evaluation and then formulated into evidence profiles that informed recommendations through the evidence-to-decision framework. Recommendations were revised through consensus among members of seven topic-specific working groups and finalized during meetings of working group leads and the planning committee. External review was provided by pediatric, critical care, and critical care nursing professional societies and patient partners. RESULTS We generated 63 Good Practice Statements and seven Grading of Recommendations Assessment, Development, and Evaluation recommendations covering 1) ethics, consent, and withdrawal of life-sustaining therapy, 2) eligibility, 3) withdrawal of life-sustaining therapy practices, 4) ante and postmortem interventions, 5) death determination, 6) neonatal pediatric donation after circulatory determination of death, 7) cardiac and innovative pediatric donation after circulatory determination of death, and 8) implementation. For brevity, 48 Good Practice Statement and truncated justification are included in this summary report. The remaining recommendations, detailed methodology, full Grading of Recommendations Assessment, Development, and Evaluation tables, and expanded justifications are available in the full text report. CONCLUSIONS This process showed that rigorous, transparent clinical practice guideline development is possible in the domain of pediatric deceased donation. Application of these recommendations will increase access to pediatric donation after circulatory determination of death across Canada and may serve as a model for future clinical practice guideline development in deceased donation.
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ISHLT Transplant Registry: Youthful Investment—The Path to Progress. J Heart Lung Transplant 2017; 36:1027-1036. [DOI: 10.1016/j.healun.2017.07.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 07/19/2017] [Indexed: 12/11/2022] Open
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Rao V, Dhanani S, MacLean J, Payne C, Paltser E, Humar A, Zaltzman J. Effect of organ donation after circulatory determination of death on number of organ transplants from donors with neurologic determination of death. CMAJ 2017; 189:E1206-E1211. [PMID: 28947546 DOI: 10.1503/cmaj.161043] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2017] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND To increase the available pool of organ donors, Ontario introduced donation after circulatory determination of death (DCD) in 2006. Other jurisdictions have reported a decrease in donations involving neurologic determination of death (NDD) after implementation of DCD, with a drop in organ yield and quality. In this study, we examined the effect of DCD on overall transplant activity in Ontario. METHODS We examined deceased donor and organ transplant activity during 3 distinct 4-year eras: pre-DCD (2002/03 to 2005/06), early DCD (2006/07 to 2009/10) and recent DCD (2010/11 to 2013/14). We compared these donor groups by categorical characteristics. RESULTS Donation increased by 57%, from 578 donors in the pre-DCD era to 905 donors in the recent DCD era, with a 21% proportion (190/905) of DCD donors in the recent DCD era. However, overall NDD donation also increased. The mean length of hospital stay before declaration for NDD was 2.7 days versus 6.0 days before withdrawal of life support and subsequent asystole in cases of DCD. The average organ yield was 3.73 with NDD donation versus 2.58 with DCD (p < 0.001). Apart from hearts, all organs from DCD donors were successfully transplanted. From the pre-DCD era to the recent DCD era, transplant activity in each era increased for all solid-organ recipients, including heart (from 158 to 216), kidney (from 821 to 1321), liver (from 477 to 657) and lung (from 160 to 305). INTERPRETATION Implementation of DCD in Ontario led to increased transplant activity for all solid-organ recipients. There was no evidence that the use of DCD was pre-empting potential NDD donation. In contrast to groups receiving other organs, heart transplant candidates have not yet benefited from DCD.
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Affiliation(s)
- Vivek Rao
- Division of Cardiovascular Surgery (Rao), Peter Munk Cardiac Centre, University of Toronto, Toronto, Ont.; Division of Critical Care (Dhanani), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ont.; Trillium Gift of Life Network (MacLean, Payne, Paltser); Multiorgan Transplant Unit (Rao, Humar), Toronto General Hospital, University of Toronto; Division of Nephrology (Zaltman), St. Michael's Hospital, University of Toronto, Toronto, Ont.
| | - Sonny Dhanani
- Division of Cardiovascular Surgery (Rao), Peter Munk Cardiac Centre, University of Toronto, Toronto, Ont.; Division of Critical Care (Dhanani), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ont.; Trillium Gift of Life Network (MacLean, Payne, Paltser); Multiorgan Transplant Unit (Rao, Humar), Toronto General Hospital, University of Toronto; Division of Nephrology (Zaltman), St. Michael's Hospital, University of Toronto, Toronto, Ont
| | - Janet MacLean
- Division of Cardiovascular Surgery (Rao), Peter Munk Cardiac Centre, University of Toronto, Toronto, Ont.; Division of Critical Care (Dhanani), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ont.; Trillium Gift of Life Network (MacLean, Payne, Paltser); Multiorgan Transplant Unit (Rao, Humar), Toronto General Hospital, University of Toronto; Division of Nephrology (Zaltman), St. Michael's Hospital, University of Toronto, Toronto, Ont
| | - Clare Payne
- Division of Cardiovascular Surgery (Rao), Peter Munk Cardiac Centre, University of Toronto, Toronto, Ont.; Division of Critical Care (Dhanani), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ont.; Trillium Gift of Life Network (MacLean, Payne, Paltser); Multiorgan Transplant Unit (Rao, Humar), Toronto General Hospital, University of Toronto; Division of Nephrology (Zaltman), St. Michael's Hospital, University of Toronto, Toronto, Ont
| | - Elizabeth Paltser
- Division of Cardiovascular Surgery (Rao), Peter Munk Cardiac Centre, University of Toronto, Toronto, Ont.; Division of Critical Care (Dhanani), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ont.; Trillium Gift of Life Network (MacLean, Payne, Paltser); Multiorgan Transplant Unit (Rao, Humar), Toronto General Hospital, University of Toronto; Division of Nephrology (Zaltman), St. Michael's Hospital, University of Toronto, Toronto, Ont
| | - Atul Humar
- Division of Cardiovascular Surgery (Rao), Peter Munk Cardiac Centre, University of Toronto, Toronto, Ont.; Division of Critical Care (Dhanani), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ont.; Trillium Gift of Life Network (MacLean, Payne, Paltser); Multiorgan Transplant Unit (Rao, Humar), Toronto General Hospital, University of Toronto; Division of Nephrology (Zaltman), St. Michael's Hospital, University of Toronto, Toronto, Ont
| | - Jeffrey Zaltzman
- Division of Cardiovascular Surgery (Rao), Peter Munk Cardiac Centre, University of Toronto, Toronto, Ont.; Division of Critical Care (Dhanani), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ont.; Trillium Gift of Life Network (MacLean, Payne, Paltser); Multiorgan Transplant Unit (Rao, Humar), Toronto General Hospital, University of Toronto; Division of Nephrology (Zaltman), St. Michael's Hospital, University of Toronto, Toronto, Ont
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Rakhra SS, Opdam HI, Gladkis L, Arcia B, Fink MA, Kanellis J, Macdonald PS, Snell GI, Pilcher DV. Untapped potential in Australian hospitals for organ donation after circulatory death. Med J Aust 2017; 208:276. [DOI: 10.5694/mja16.01405] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 11/03/2017] [Indexed: 11/17/2022]
Affiliation(s)
| | - Helen I Opdam
- Austin Health, Melbourne, VIC
- Australian Organ and Tissue Authority, Canberra, ACT
| | - Laura Gladkis
- Australian Organ and Tissue Authority, Canberra, ACT
| | - Byron Arcia
- Australian Organ and Tissue Authority, Canberra, ACT
| | - Michael A Fink
- Austin Health, Melbourne, VIC
- University of Melbourne, Melbourne, VIC
| | - John Kanellis
- Monash Health, Melbourne, VIC
- Centre for Inflammatory Diseases, Monash University, Melbourne, VIC
| | | | | | - David V Pilcher
- Alfred Health, Melbourne, VIC
- Monash University, Melbourne, VIC
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A Rodent Model of Cardiac Donation After Circulatory Death and Novel Biomarkers of Cardiac Viability During Ex Vivo Heart Perfusion. Transplantation 2017; 101:e231-e239. [PMID: 28505025 DOI: 10.1097/tp.0000000000001815] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Organ donation after circulatory death (DCD) is increasingly being used as a means of addressing the organ supply/demand mismatch in solid organ transplantation. There is reluctance to use DCD hearts, due to an inability to precisely identify hearts that have suffered irreversible injury. We investigated novel biomarkers and clinically relevant endpoints across a spectrum of warm ischemic times, before and during ex vivo heart perfusion (EVHP), to identify features associated with a nonviable cardiac phenotype. METHODS Donor rats sustained a hypoxic cardiac arrest, followed by variable acirculatory standoff periods (DCD groups). Left ventricular function, histochemical injury, and differences in left ventricular gene expression were studied before, and during, EVHP. RESULTS As warm ischemic time exposure increased in DCD groups, fewer hearts were functional during EVHP, and ventricular function was increasingly impaired. Histochemical assessment identified severely injured hearts during EVHP. A novel gene expression signature identified severely injured hearts during EVHP (upregulation of c-Jun, 3.19 (2.84-3.60); P = 0.0014; HMOX-1, 3.87 (2.72-5.50); P = 0.0037; and Hsp90, 7.66 (6.32-9.27); P < 0.0001 in DCD20), and may be useful in identifying high-risk hearts at the point of harvest (Hsp90). CONCLUSIONS We demonstrate that our preclinical model recapitulates the cardio-respiratory decompensation observed in humans, and that EVHP appears necessary to unmask distinguishing features of severely injured DCD hearts. Furthermore, we outline a clinically relevant multimodal approach to assessing candidate DCD hearts. Novel mRNA signatures correlated with elevations in cardiac Troponin-I in severely injured hearts during EVHP, and may also detect injury at the point of harvest.
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238
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Allen RD, Pleass HC. Improving organ donation rates and transplantation in Australia. Med J Aust 2017; 207:287-288. [PMID: 28954614 DOI: 10.5694/mja17.00590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 08/03/2017] [Indexed: 11/17/2022]
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Abstract
End-organ failure is associated with high mortality and morbidity, in addition to increased health care costs. Organ transplantation is the only definitive treatment that can improve survival and quality of life in such patients; however, due to the persistent mismatch between organ supply and demand, waiting lists continue to grow across the world. Careful intensive care management of the potential organ donor with goal-directed therapy has the potential to optimize organ function and improve donation yield.
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Dos Remedios CG, Lal SP, Li A, McNamara J, Keogh A, Macdonald PS, Cooke R, Ehler E, Knöll R, Marston SB, Stelzer J, Granzier H, Bezzina C, van Dijk S, De Man F, Stienen GJM, Odeberg J, Pontén F, Linke WA, Linke W, van der Velden J. The Sydney Heart Bank: improving translational research while eliminating or reducing the use of animal models of human heart disease. Biophys Rev 2017; 9:431-441. [PMID: 28808947 DOI: 10.1007/s12551-017-0305-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 07/31/2017] [Indexed: 01/09/2023] Open
Abstract
The Sydney Heart Bank (SHB) is one of the largest human heart tissue banks in existence. Its mission is to provide high-quality human heart tissue for research into the molecular basis of human heart failure by working collaboratively with experts in this field. We argue that, by comparing tissues from failing human hearts with age-matched non-failing healthy donor hearts, the results will be more relevant than research using animal models, particularly if their physiology is very different from humans. Tissue from heart surgery must generally be used soon after collection or it significantly deteriorates. Freezing is an option but it raises concerns that freezing causes substantial damage at the cellular and molecular level. The SHB contains failing samples from heart transplant patients and others who provided informed consent for the use of their tissue for research. All samples are cryopreserved in liquid nitrogen within 40 min of their removal from the patient, and in less than 5-10 min in the case of coronary arteries and left ventricle samples. To date, the SHB has collected tissue from about 450 failing hearts (>15,000 samples) from patients with a wide range of etiologies as well as increasing numbers of cardiomyectomy samples from patients with hypertrophic cardiomyopathy. The Bank also has hearts from over 120 healthy organ donors whose hearts, for a variety of reasons (mainly tissue-type incompatibility with waiting heart transplant recipients), could not be used for transplantation. Donor hearts were collected by the St Vincent's Hospital Heart and Lung transplantation team from local hospitals or within a 4-h jet flight from Sydney. They were flushed with chilled cardioplegic solution and transported to Sydney where they were quickly cryopreserved in small samples. Failing and/or donor samples have been used by more than 60 research teams around the world, and have resulted in more than 100 research papers. The tissues most commonly requested are from donor left ventricles, but right ventricles, atria, interventricular system, and coronary arteries vessels have also been reported. All tissues are stored for long-term use in liquid N or vapor (170-180 °C), and are shipped under nitrogen vapor to avoid degradation of sensitive molecules such as RNAs and giant proteins. We present evidence that the availability of these human heart samples has contributed to a reduction in the use of animal models of human heart failure.
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Affiliation(s)
- C G Dos Remedios
- Sydney Heart Bank, Discipline of Anatomy & Histology, University of Sydney, Sydney, Australia.
| | - S P Lal
- Sydney Heart Bank, Discipline of Anatomy & Histology, University of Sydney, Sydney, Australia
| | - A Li
- Sydney Heart Bank, Discipline of Anatomy & Histology, University of Sydney, Sydney, Australia.,Department of Molecular Physiology and Biophysics, University of Vermont, Burlington, VT, USA
| | - J McNamara
- Sydney Heart Bank, Discipline of Anatomy & Histology, University of Sydney, Sydney, Australia
| | - A Keogh
- Heart Transplant Unit, St Vincent's Hospital, Sydney, Australia
| | - P S Macdonald
- Heart Transplant Unit, St Vincent's Hospital, Sydney, Australia
| | - R Cooke
- Cardiovascular Research Institute, University of California San Francisco, California, USA
| | - E Ehler
- Cardiovascular Division, Randall Division of Cell and Molecular Biophysics, London, UK
| | - R Knöll
- Department of Medicine, Karolinska Institutet, Huddinge, Sweden
| | - S B Marston
- National Heart and Lung Institute, Imperial College London, London, UK
| | - J Stelzer
- Department of Physiology & Biophysics, Case Western Reserve University, Cleveland, OH, USA
| | - H Granzier
- Molecular Cardiovascular Research Program, University of Arizona, Tucson, USA
| | - C Bezzina
- Department of Experimental Cardiology, Heart Failure Research Center, Amsterdam, The Netherlands
| | - S van Dijk
- Department of Physiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - F De Man
- Department of Physiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - G J M Stienen
- Department of Physiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
| | - J Odeberg
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - F Pontén
- Science for Life Laboratory, KTH-Royal Institute of Technology, Stockholm, Sweden
| | | | - W Linke
- Ruhr University, Bochum, Germany
| | - J van der Velden
- Department of Physiology, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, The Netherlands
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Li Y, Zeng Q, Liu G, Du J, Gao B, Wang W, Zheng Z, Hu S, Ji B. Development and Evaluation of Heartbeat: A Machine Perfusion Heart Preservation System. Artif Organs 2017; 41:E240-E250. [PMID: 28800676 DOI: 10.1111/aor.12867] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 08/18/2016] [Accepted: 08/26/2016] [Indexed: 12/11/2022]
Abstract
Static cold storage is accompanied with a partial safe ischemic interval for donor hearts. In this current study, a machine perfusion system was built to provide a better preservation for the donor heart and assessment for myocardial function. Chinese mini-swine (weight 30-35 kg, n = 16) were randomly divided into HTK, Celsior, and Heartbeat groups. All donor hearts were respectively preserved for 8 hours under static cold storage or machine perfusion. The perfusion solution is aimed to maintain its homeostasis based on monitoring the Heartbeat group. The ultrastructure of myocardium suggests better myocardial protection in the Heartbeat group compared with HTK or Celsior-preserved hearts. The myocardial and coronary artery structural and functional integrity was evaluated by immunofluorescence and Western blots in the Heartbeat. In the Heartbeat group, donor hearts maintained a high adenosine triphosphate level. Bcl-2 and Beclin-1 protein demonstrates high expression in the Celsior group. The Heartbeat system can be used to preserve donor hearts, and it could guarantee the myocardial and endothelial function of hearts during machine perfusion. Translating Heartbeat into clinical practice, it is such as to impact on donor heart preservation for cardiac transplantation.
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Affiliation(s)
- Yongnan Li
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.,Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Qingdong Zeng
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Junzhe Du
- Department of Cardiac Surgery, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bingren Gao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Wei Wang
- Department of Cardiac Surgery, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhe Zheng
- Department of Cardiac Surgery, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shengshou Hu
- Department of Cardiac Surgery, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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von Dossow V, Costa J, D'Ovidio F, Marczin N. Worldwide trends in heart and lung transplantation: Guarding the most precious gift ever. Best Pract Res Clin Anaesthesiol 2017; 31:141-152. [PMID: 29110788 DOI: 10.1016/j.bpa.2017.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 08/03/2017] [Indexed: 01/17/2023]
Abstract
Transplantation is sadly a therapy to die for. The survival of a recipient with end-stage heart or lung disease requires the demise of a human being through brain death or cessation of circulation, with the noblest final act of offering one's organs to another. However, transplantation is constrained by severe hemodynamic, regulatory, inflammatory, and metabolic stresses in the donor, rendering the majority of offered organs unsuitable for transplantation. Coupled with our inability to acquire exact molecular and cellular information and missed opportunities for effectively modulating deteriorations of donors and allografts, anesthesia and critical care contributes to ongoing organ shortages. Progress is made with improving waiting lists by bridging patients for transplantation using mechanical support. However, this represents more complex recipients, higher risk transplant operations, and increased resource utilization. The advent of ex vivo perfusion allows implementing novel diagnostic and therapeutic strategies with real potential of reconditioning less ideal organs. This review advocates a paradigm change in critical care management of the potential donor for improving retrieval practices and for more intellectual involvement of our specialties in organ preservation, ex vivo evaluation and reconditioning, and the need for great advancement in our efficiency in converting unacceptable allografts to suitable donor organs.
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Affiliation(s)
- Vera von Dossow
- Department of Anesthesiology, Ludwig-Maximilians-University of Munich, Germany
| | - Joseph Costa
- Department of Surgery, Division of Cardiothoracic Surgery and Transplantation, Columbia University Medical Center, New York, NY, USA
| | - Frank D'Ovidio
- Department of Surgery, Division of Cardiothoracic Surgery and Transplantation, Columbia University Medical Center, New York, NY, USA
| | - Nandor Marczin
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Department of Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK; Centre of Anaesthesia and Intensive Care, Semmelweis University, Budapest, Hungary.
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Bossaert L, Perkins G, Askitopoulou H, Raffay V, Greif R, Haywood K, Mentzelopoulos S, Nolan J, Van de Voorde P, Xanthos T. Ethik der Reanimation und Entscheidungen am Lebensende. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0329-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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246
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Galeone A, Lebreton G, Leprince P. Old Europe carefully looks at a new heart: Cardiac arrest-resuscitated donors should not be turned down for heart transplant at first glance. J Thorac Cardiovasc Surg 2017; 154:540. [PMID: 28724239 DOI: 10.1016/j.jtcvs.2017.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/10/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Antonella Galeone
- Department of Thoracic and Cardiovascular Surgery, University Pierre et Marie Curie, Paris 6, Assistance Publique des Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Guillaume Lebreton
- Department of Thoracic and Cardiovascular Surgery, University Pierre et Marie Curie, Paris 6, Assistance Publique des Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Pascal Leprince
- Department of Thoracic and Cardiovascular Surgery, University Pierre et Marie Curie, Paris 6, Assistance Publique des Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
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Chambers DC, Yusen RD, Cherikh WS, Goldfarb SB, Kucheryavaya AY, Khusch K, Levvey BJ, Lund LH, Meiser B, Rossano JW, Stehlik J. The Registry of the International Society for Heart and Lung Transplantation: Thirty-fourth Adult Lung And Heart-Lung Transplantation Report-2017; Focus Theme: Allograft ischemic time. J Heart Lung Transplant 2017; 36:1047-1059. [PMID: 28784324 DOI: 10.1016/j.healun.2017.07.016] [Citation(s) in RCA: 414] [Impact Index Per Article: 59.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 07/16/2017] [Indexed: 01/06/2023] Open
Affiliation(s)
- Daniel C Chambers
- The International Society for Heart and Lung Transplantation Transplant Registry, Dallas, Texas
| | - Roger D Yusen
- The International Society for Heart and Lung Transplantation Transplant Registry, Dallas, Texas
| | - Wida S Cherikh
- The International Society for Heart and Lung Transplantation Transplant Registry, Dallas, Texas
| | - Samuel B Goldfarb
- The International Society for Heart and Lung Transplantation Transplant Registry, Dallas, Texas
| | - Anna Y Kucheryavaya
- The International Society for Heart and Lung Transplantation Transplant Registry, Dallas, Texas
| | - Kiran Khusch
- The International Society for Heart and Lung Transplantation Transplant Registry, Dallas, Texas
| | - Bronwyn J Levvey
- The International Society for Heart and Lung Transplantation Transplant Registry, Dallas, Texas
| | - Lars H Lund
- The International Society for Heart and Lung Transplantation Transplant Registry, Dallas, Texas
| | - Bruno Meiser
- The International Society for Heart and Lung Transplantation Transplant Registry, Dallas, Texas
| | - Joseph W Rossano
- The International Society for Heart and Lung Transplantation Transplant Registry, Dallas, Texas
| | - Josef Stehlik
- The International Society for Heart and Lung Transplantation Transplant Registry, Dallas, Texas.
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Saving lives despite 'failed' extracorporeal resuscitation. Resuscitation 2017; 118:A5-A6. [PMID: 28728895 DOI: 10.1016/j.resuscitation.2017.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 11/23/2022]
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Iyer A, Chew HC, Gao L, Villanueva J, Hicks M, Doyle A, Kumarasinghe G, Jabbour A, Jansz PC, Feneley MP, Harvey RP, Graham RM, Dhital KK, Macdonald PS. Pathophysiological Trends During Withdrawal of Life Support: Implications for Organ Donation After Circulatory Death. Transplantation 2017; 100:2621-2629. [PMID: 27861290 DOI: 10.1097/tp.0000000000001396] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Donation after circulatory death (DCD) provides an alternative pathway to deceased organ transplantation. Although clinical DCD lung, liver, and kidney transplantation are well established, transplantation of hearts retrieved from DCD donors has reached clinical translation only recently. Progress has been limited by concern regarding the viability of DCD hearts. The aim of this study was to document the pathophysiological changes that occur in the heart and circulation during withdrawal of life (WLS) support. METHODS In a porcine asphyxia model, we characterized the hemodynamic, volumetric, metabolic, biochemical, and endocrine changes after WLS for up to 40 minutes. Times to circulatory arrest and electrical asystole were recorded. RESULTS After WLS, there was rapid onset of profound hypoxemia resulting in acute pulmonary hypertension and right ventricular distension. Concurrently, progressive systemic hypotension occurred with a fall in left atrial pressure and little change in left ventricular volume. Mean times to circulatory arrest and electrical asystole were 8 ± 1 and 16 ± 2 minutes, respectively. Hemodynamic changes were accompanied by a rapid fall in pH, and rise in blood lactate, troponin-T, and potassium. Plasma noradrenaline and adrenaline levels rose rapidly with dramatic increases in coronary sinus levels indicative of myocardial release. CONCLUSIONS These findings provide insight into the nature and tempo of the damaging events that occur in the heart and in particular the right ventricle during WLS, and give an indication of the limited timeframe for the implementation of potential postmortem interventions that could be applied to improve organ viability.
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Affiliation(s)
- Arjun Iyer
- 1 The Victor Chang Cardiac Research Institute, Sydney, Australia. 2 Heart & Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, Australia. 3 Department of Cardiothoracic Surgery, St Vincent's Hospital, Darlinghurst, Australia. 4 Department of Clinical Pharmacology, St Vincent's Hospital, Darlinghurst, Australia. 5 Department of Physiology and Pharmacology, University of New South Wales, Randwick, Australia. 6 Department of Cardiology, St Vincent's Hospital, Darlinghurst, Australia. 7 St. Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Kensington, Australia. 8 School of Biotechnology and Biomolecular Science, Faculty of Science, University of New South Wales, Kensington, Australia
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Niederberger P, Farine E, Arnold M, Wyss RK, Sanz MN, Méndez-Carmona N, Gahl B, Fiedler GM, Carrel TP, Tevaearai Stahel HT, Longnus SL. High pre-ischemic fatty acid levels decrease cardiac recovery in an isolated rat heart model of donation after circulatory death. Metabolism 2017; 71:107-117. [PMID: 28521863 DOI: 10.1016/j.metabol.2017.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 01/07/2023]
Abstract
RATIONALE Donation after circulatory death (DCD) could improve cardiac graft availability. However, strategies to optimize cardiac graft recovery remain to be established in DCD; these hearts would be expected to be exposed to high levels of circulatory fat immediately prior to the inevitable period of ischemia prior to procurement. OBJECTIVE We investigated whether acute exposure to high fat prior to warm, global ischemia affects subsequent hemodynamic and metabolic recovery in an isolated rat heart model of DCD. METHODS AND RESULTS Hearts of male Wistar rats underwent 20min baseline perfusion with glucose (11mM) and either high fat (1.2mM palmitate; HF) or no fat (NF), 27min global ischemia (37°C), and 60min reperfusion with glucose only (n=7-8 per group). Hemodynamic recovery was 50% lower in HF vs. NF hearts (34±30% vs. 78±8% (60min reperfusion value of peak systolic pressure*heart rate as percentage of mean baseline); p<0.01). During early reperfusion, glycolysis (0.3±0.3 vs. 0.7±0.3μmol*min-1*g dry-1, p<0.05), glucose oxidation (0.1±0.03 vs. 0.4±0.2μmol*min-1*g dry-1, p<0.01) and pyruvate dehydrogenase activity (1.8±0.6 vs. 3.6±0.5U*g protein-1, p<0.01) were significantly reduced in HF vs. NF groups, respectively, while lactate release was significantly greater (1.8±0.9 vs. 0.6±0.2μmol*g wet-1*min-1; p<0.05). CONCLUSIONS Acute, pre-ischemic exposure to high fat significantly lowers post-ischemic cardiac recovery vs. no fat despite identical reperfusion conditions. These findings support the concept that oxidation of residual fatty acids is rapidly restored upon reperfusion and exacerbates ischemia-reperfusion (IR) injury. Strategies to optimize post-ischemic cardiac recovery should take pre-ischemic fat levels into consideration.
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Affiliation(s)
- Petra Niederberger
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Emilie Farine
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Maria Arnold
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Rahel K Wyss
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Maria N Sanz
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Natalia Méndez-Carmona
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Brigitta Gahl
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Georg M Fiedler
- Center of Laboratory Medicine, University Institute of Clinical Chemistry, University Hospital, Inselspital, Bern, Switzerland.
| | - Thierry P Carrel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Hendrik T Tevaearai Stahel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Sarah L Longnus
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
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