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Gregory V, Isath A, Lanier GM, Levine A, Pan S, Aggarwal-Gupta C, Elgar G, Shimamura J, Wolfe K, Gass A, Spielvogel D, Kai M, Ohira S. Single-center experience of extended brain-death donor heart preservation with the organ care system. Artif Organs 2024. [PMID: 39239771 DOI: 10.1111/aor.14855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 07/23/2024] [Accepted: 08/22/2024] [Indexed: 09/07/2024]
Abstract
BACKGROUND The Organ Care System (OCS) (Transmedics, Andover, MA) reduces cold ischemic time of donor hearts by producing a normothermic beating state during ex vivo perfusion, enabling extended ex situ intervals, which potentially increases donor pool. We aimed to compare outcomes in utilization of OCS and conventional cold storage technique. METHODS Consecutive heart transplants following brain death at our institution between May 2022 and July 2023 were analyzed. Recipients were divided into those receiving hearts preserved with OCS [N = 15] and those with conventional cold storage (Control, N = 27), with OCS utilization when anticipated ischemic time was more than 4 h. Pre-transplant characteristics and transplant outcomes were compared. RESULTS OCS utilization allowed a significant increase in distance traveled for heart retrieval (OCS, 624 ± 269 vs. Control, 153 ± 128 miles, p < 0.001), with longer mean total preservation times (6.2 ± 1.1 vs 2.6 ± 0.6 h, p < 0.001). All but one patient displayed a general decrease or plateau in lactate throughout perfusion time by OCS. Both groups experienced similar rates of severe primary graft dysfunction (OCS, 6.7% [N = 1] vs. Control, 11.1% [N = 3], p = 0.63), with 100% in-hospital survival in the OCS group compared to 96.3% in the Control group (p = 0.34). Kaplan-Meier survival analysis showed that estimated one-year survival were comparable (OCS, 93.3 ± 6.4% vs. Control, 88.9 ± 6.0%, p = 0.61). CONCLUSION With a mean preservation time of around 6 h and distance covered of over 600 miles, our results using OCS indicate a potential to safely increase the quantity and viability of accessible organs, thus broadening the donor pool without negatively affecting outcomes.
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Affiliation(s)
| | - Ameesh Isath
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Avi Levine
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Stephen Pan
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | | | - Guy Elgar
- New York Medical College, Valhalla, New York, USA
| | - Junichi Shimamura
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Kevin Wolfe
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Alan Gass
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Masashi Kai
- Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Suguru Ohira
- New York Medical College, Valhalla, New York, USA
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
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2
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Pradegan N, Di Pasquale L, Di Perna D, Gallo M, Lucertini G, Gemelli M, Beyerle T, Slaughter MS, Gerosa G. Ex vivo heart perfusion: an updated systematic review. Heart Fail Rev 2024; 29:1079-1096. [PMID: 39093495 DOI: 10.1007/s10741-024-10420-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2024] [Indexed: 08/04/2024]
Abstract
Due to the discrepancy between patients awaiting a heart transplant and the availability of donor hearts, strategies to expand the donor pool and improve the transplant's success are crucial. This review aims to summarize current knowledge on the ex vivo heart preservation (EVHP) experience as an alternative to standard cold static storage (CSS). EVHP techniques can improve the preservation of the donor's heart before transplantation and allow for pre-transplant organ evaluation.
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Affiliation(s)
- Nicola Pradegan
- Cardiac Surgery Unit, Cardio-thoraco-vascular and Public Health Department, Padova University Hospital, Padua, Italy
| | - Luigi Di Pasquale
- Division of Congenital Cardiovascular Surgery, Pediatric Heart Centre and Children's Research Centre, University Children's Hospital Zürich, Zurich, Switzerland
| | - Dario Di Perna
- Centre Hospitalier Annecy Genevois, Épagny-Metz-Tessy, France
| | - Michele Gallo
- Department of Cardiothoracic Surgery, University of Louisville, 201 Abraham Flexner Way, Suite 1200, Louisville, KY, 40202, USA.
| | - Giovanni Lucertini
- Cardiac Surgery Unit, Cardio-thoraco-vascular and Public Health Department, Padova University Hospital, Padua, Italy
| | - Marco Gemelli
- Cardiac Surgery Unit, Cardio-thoraco-vascular and Public Health Department, Padova University Hospital, Padua, Italy
| | - Thomas Beyerle
- Department of Cardiothoracic Surgery, University of Louisville, 201 Abraham Flexner Way, Suite 1200, Louisville, KY, 40202, USA
| | - Mark S Slaughter
- Department of Cardiothoracic Surgery, University of Louisville, 201 Abraham Flexner Way, Suite 1200, Louisville, KY, 40202, USA
| | - Gino Gerosa
- Cardiac Surgery Unit, Cardio-thoraco-vascular and Public Health Department, Padova University Hospital, Padua, Italy
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3
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Niroomand A, Nita GE, Lindstedt S. Machine Perfusion and Bioengineering Strategies in Transplantation-Beyond the Emerging Concepts. Transpl Int 2024; 37:13215. [PMID: 39267617 PMCID: PMC11390383 DOI: 10.3389/ti.2024.13215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 08/19/2024] [Indexed: 09/15/2024]
Abstract
Solid organ transplantation has progressed rapidly over the decades from the first experimental procedures to its role in the modern era as an established treatment for end-stage organ disease. Solid organ transplantation including liver, kidney, pancreas, heart, and lung transplantation, is the definitive option for many patients, but despite the advances that have been made, there are still significant challenges in meeting the demand for viable donor grafts. Furthermore, post-operatively, the recipient faces several hurdles, including poor early outcomes like primary graft dysfunction and acute and chronic forms of graft rejection. In an effort to address these issues, innovations in organ engineering and treatment have been developed. This review covers efforts made to expand the donor pool including bioengineering techniques and the use of ex vivo graft perfusion. It also covers modifications and treatments that have been trialed, in addition to research efforts in both abdominal organs and thoracic organs. Overall, this article discusses recent innovations in machine perfusion and organ bioengineering with the aim of improving and increasing the quality of donor organs.
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Affiliation(s)
- Anna Niroomand
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
| | - George Emilian Nita
- Department of Transplantation Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
- Division of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Sandra Lindstedt
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
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4
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Lee OJOJ, Bhatia I, Wan SHY, Fan KYY, Wong MKL, Au TWK, Ho CKL. Introduction of ex vivo perfusion of extended-criteria donor hearts in a single center in Asia. J Artif Organs 2024:10.1007/s10047-024-01447-x. [PMID: 38780672 DOI: 10.1007/s10047-024-01447-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/21/2024] [Indexed: 05/25/2024]
Abstract
The shortage of organs for heart transplantation has created a need to explore the use of extended-criteria organs. We report the preliminary use of normothermic TransMedics Organ Care System-an ex vivo approach to preserve extended-criteria brain-dead donor hearts. This System maintains a normal temperature, provides continuous perfusion and oxygenation, reduces ischemic time, and enables additional viability assessment options. In a retrospective single-centre study conducted from April 2020 to March 2023, four extended criteria brain-dead donor hearts were perfused and monitored using the Organ Care System. Suitability for transplantation was assessed based on stable or decreasing lactate levels, along with appropriate perfusion parameters. The Organ Care for use of the Organ Care System were coronary artery disease, left ventricular hypertrophy, high-dose inotrope use in the donor, a downtime exceeding 20 min, and a left ventricular ejection fraction of 40-50%. Three out of the four donor hearts were transplanted, while one was discarded due to rising lactate concentration. The three recipients had a higher surgical risk profile for heart transplant. All showed normal cardiac function and no primary graft dysfunction postoperatively. At 2-3 years post-transplant, all recipients have a ventricular function of > 60%, with only one showing evidence of mild rejection. The Organ Care System enables the successful transplantation of marginal donor organs in high-risk recipients, showcasing the feasibility of recruiting donors with extended criteria. This technique is safe and promising, expanding the donor pool and addressing the organ shortage in heart transplantation in Hong Kong.
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Affiliation(s)
- Oswald Joseph On Jing Lee
- Department of Cardiothoracic Surgery, New Clinical Building, Room 308, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, Hong Kong, China.
| | - Inderjeet Bhatia
- Department of Cardiothoracic Surgery, New Clinical Building, Room 308, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, Hong Kong, China.
| | - Sylvia Ho Yan Wan
- Department of Cardiothoracic Surgery, New Clinical Building, Room 308, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, Hong Kong, China
| | - Katherine Yue Yan Fan
- Cardiac Medicine Unit, 5/F Kwok Tak Seng Heart Center, Grantham Hospital, Wong Chuk Hang, Hong Kong SAR, Hong Kong, China
| | - Michael Ka Lam Wong
- Cardiac Medicine Unit, 5/F Kwok Tak Seng Heart Center, Grantham Hospital, Wong Chuk Hang, Hong Kong SAR, Hong Kong, China
| | - Timmy Wing Kuk Au
- Department of Cardiothoracic Surgery, New Clinical Building, Room 308, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, Hong Kong, China
| | - Cally Ka Lai Ho
- Department of Cardiothoracic Surgery, New Clinical Building, Room 308, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, Hong Kong, China
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5
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Kadowaki S, Parker M, Wang J, Mueller B, Steve Fan CP, Li J, Honjo O. A modified intraventricular balloon method for functional assessment of hearts from donation after circulatory death. JTCVS OPEN 2024; 18:104-117. [PMID: 38690439 PMCID: PMC11056455 DOI: 10.1016/j.xjon.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/22/2023] [Accepted: 01/04/2024] [Indexed: 05/02/2024]
Abstract
Objective Functional assessment of hearts during ex-vivo heart perfusion is not well-established. Conventional intraventricular balloon methods for large animals sacrifice the mitral valve. This study assessed the effectiveness of the modified intraventricular balloon method in comparison with other modalities used during working mode in juvenile pigs. Methods Following asphyxia circulatory arrest, hearts were ischemic for 15 minutes and then reperfused on an ex-vivo device for 2 hours before switching to working mode. Left ventricular pressure was continuously measured during reperfusion by a saline-filled balloon fixated in the left atrium. Spearman Correlation Coefficients with linear regression lines with confidence intervals were analyzed. Results Maximum dp/dt at 90 minutes of reperfusion and minimum dp/dt at 60 minutes of reperfusion showed a moderate positive correlation to that in working mode, respectively (Rs = 0.61, P = .04 and Rs = 0.60, P = .04). At 60 minutes of reperfusion, minimum dp/dt showed moderate positive correlation to tau (Rs = 0.52, P = .08). Myocardial oxygen consumption during reperfusion consistently decreased at least 30% compared to working mode (at 90 minutes as the highest during reperfusion, 3.3 ± 0.8; in working mode, 5.6 ± 1.4, mLO2/min/100 g, P < .001). Conclusions Functional parameters of contractility and relaxation measured during reperfusion by the modified balloon method showed significant correlations to respective parameters in working mode. This mitral valve sparing technique can be used to predict viability and ventricular function in the early phase of ex-vivo heart perfusion without loading the heart during working mode.
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Affiliation(s)
- Sachiko Kadowaki
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Marlee Parker
- Division of Perfusion Services, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jian Wang
- Division of Perfusion Services, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brigitte Mueller
- Ted Rogers Computational Program, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Ted Rogers Computational Program, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Jing Li
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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6
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M M, Attawar S, BN M, Tisekar O, Mohandas A. Ex vivo lung perfusion and the Organ Care System: a review. CLINICAL TRANSPLANTATION AND RESEARCH 2024; 38:23-36. [PMID: 38725180 PMCID: PMC11075812 DOI: 10.4285/ctr.23.0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/29/2024] [Accepted: 03/08/2024] [Indexed: 05/14/2024]
Abstract
With the increasing prevalence of heart failure and end-stage lung disease, there is a sustained interest in expanding the donor pool to alleviate the thoracic organ shortage crisis. Efforts to extend the standard donor criteria and to include donation after circulatory death have been made to increase the availability of suitable organs. Studies have demonstrated that outcomes with extended-criteria donors are comparable to those with standard-criteria donors. Another promising approach to augment the donor pool is the improvement of organ preservation techniques. Both ex vivo lung perfusion (EVLP) for the lungs and the Organ Care System (OCS, TransMedics) for the heart have shown encouraging results in preserving organs and extending ischemia time through the application of normothermic regional perfusion. EVLP has been effective in improving marginal or borderline lungs by preserving and reconditioning them. The use of OCS is associated with excellent short-term outcomes for cardiac allografts and has improved utilization rates of hearts from extended-criteria donors. While both EVLP and OCS have successfully transitioned from research to clinical practice, the costs associated with commercially available systems and consumables must be considered. The ex vivo perfusion platform, which includes both EVLP and OCS, holds the potential for diverse and innovative therapies, thereby transforming the landscape of thoracic organ transplantation.
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Affiliation(s)
- Menander M
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Sandeep Attawar
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Mahesh BN
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Owais Tisekar
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Anoop Mohandas
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
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7
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Lerman JB, Agarwal R, Patel CB, Keenan JE, Casalinova S, Milano CA, Schroder JN, DeVore AD. Donor Heart Recovery and Preservation Modalities in 2024. JACC. HEART FAILURE 2024; 12:427-437. [PMID: 38032571 DOI: 10.1016/j.jchf.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 10/06/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023]
Abstract
Historically, heart transplantation (HT) has relied on the use of traditional cold storage for donor heart preservation. This organ preservation modality has several limitations, including the risk for ischemic and cold-induced graft injuries that may contribute to primary graft dysfunction and poor post-HT outcomes. In recent years, several novel donor heart preservation modalities have entered clinical practice, including the SherpaPak Cardiac Transport System of controlled hypothermic preservation, and the Transmedics Organ Care System of ex vivo perfusion. Such technologies are altering the landscape of HT by expanding the geographic reach of procurement teams and enabling both donation after cardiac death and the use of expanded criteria donor hearts. This paper will review the emerging evidence on the association of these modalities with improved post-HT outcomes, and will also suggest best practices for selecting between donor heart preservation techniques.
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Affiliation(s)
- Joseph B Lerman
- Duke University Hospital, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Richa Agarwal
- Duke University Hospital, Durham, North Carolina, USA
| | | | | | | | | | | | - Adam D DeVore
- Duke University Hospital, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
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8
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Schroder JN, Patel CB, DeVore AD, Casalinova S, Koomalsingh KJ, Shah AS, Anyanwu AC, D'Alessandro DA, Mudy K, Sun B, Strueber M, Khaghani A, Shudo Y, Esmailian F, Liao K, Pagani FD, Silvestry S, Wang IW, Salerno CT, Absi TS, Madsen JC, Mancini D, Fiedler AG, Milano CA, Smith JW. Increasing Utilization of Extended Criteria Donor Hearts for Transplantation: The OCS Heart EXPAND Trial. JACC. HEART FAILURE 2024; 12:438-447. [PMID: 38276933 DOI: 10.1016/j.jchf.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 11/09/2023] [Accepted: 11/28/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Extended criteria donor (ECD) hearts available with donation after brain death (DBD) are underutilized for transplantation due to limitations of cold storage. OBJECTIVES This study evaluated use of an extracorporeal perfusion system on donor heart utilization and post-transplant outcomes in ECD DBD hearts. METHODS In this prospective, single-arm, multicenter study, adult heart transplant recipients received ECD hearts using an extracorporeal perfusion system if hearts met study criteria. The primary outcome was a composite of 30-day survival and absence of severe primary graft dysfunction (PGD). Secondary outcomes were donor heart utilization rate, 30-day survival, and incidence of severe PGD. The safety outcome was the mean number of heart graft-related serious adverse events within 30 days. Additional outcomes included survival through 2 years benchmarked to concurrent nonrandomized control subjects. RESULTS A total of 173 ECD DBD hearts were perfused; 150 (87%) were successfully transplanted; 23 (13%) did not meet study transplantation criteria. At 30 days, 92% of patients had survived and had no severe PGD. The 30-day survival was 97%, and the incidence of severe PGD was 6.7%. The mean number of heart graft-related serious adverse events within 30 days was 0.17 (95% CI: 0.11-0.23). Patient survival was 93%, 89%, and 86% at 6, 12, and 24 months, respectively, and was comparable with concurrent nonrandomized control subjects. CONCLUSIONS Use of an extracorporeal perfusion system resulted in successfully transplanting 87% of donor hearts with excellent patient survival to 2 years post-transplant and low rates of severe PGD. The ability to safely use ECD DBD hearts could substantially increase the number of heart transplants and expand access to patients in need. (International EXPAND Heart Pivotal Trial [EXPANDHeart]; NCT02323321; Heart EXPAND Continued Access Protocol; NCT03835754).
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Affiliation(s)
| | | | - Adam D DeVore
- Duke University Hospital, Durham, North Carolina, USA
| | | | | | - Ashish S Shah
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Karol Mudy
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Benjamin Sun
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | | | | | - Yasuhiro Shudo
- Stanford University Medical Center, Stanford, California, USA
| | | | | | | | | | - I-Wen Wang
- Memorial Healthcare System, Hollywood, Florida, USA
| | | | - Tarek S Absi
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joren C Madsen
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Donna Mancini
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy G Fiedler
- University of California-San Francisco, San Francisco, California, USA
| | | | - Jason W Smith
- University of California-San Francisco, San Francisco, California, USA
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9
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Quinn J, Kotru M, Bhatia M. Con: The Use of an Organ Care System for Heart Transplant Has Led to Similar Outcomes with Expanded Donor Pools. J Cardiothorac Vasc Anesth 2024; 38:573-575. [PMID: 37985287 DOI: 10.1053/j.jvca.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 11/22/2023]
Affiliation(s)
- Jacqueline Quinn
- Department of Anesthesiology, University of North Carolina School of Medicine, University of North Carolina Hospitals, Chapel Hill, NC.
| | | | - Meena Bhatia
- Department of Anesthesiology, University of North Carolina School of Medicine, University of North Carolina Hospitals, Chapel Hill, NC
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10
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López-Martínez S, Simón C, Santamaria X. Normothermic Machine Perfusion Systems: Where Do We Go From Here? Transplantation 2024; 108:22-44. [PMID: 37026713 DOI: 10.1097/tp.0000000000004573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Normothermic machine perfusion (NMP) aims to preserve organs ex vivo by simulating physiological conditions such as body temperature. Recent advancements in NMP system design have prompted the development of clinically effective devices for liver, heart, lung, and kidney transplantation that preserve organs for several hours/up to 1 d. In preclinical studies, adjustments to circuit structure, perfusate composition, and automatic supervision have extended perfusion times up to 1 wk of preservation. Emerging NMP platforms for ex vivo preservation of the pancreas, intestine, uterus, ovary, and vascularized composite allografts represent exciting prospects. Thus, NMP may become a valuable tool in transplantation and provide significant advantages to biomedical research. This review recaps recent NMP research, including discussions of devices in clinical trials, innovative preclinical systems for extended preservation, and platforms developed for other organs. We will also discuss NMP strategies using a global approach while focusing on technical specifications and preservation times.
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Affiliation(s)
- Sara López-Martínez
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Carlos Simón
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
- Department of Obstetrics and Gynecology, Universidad de Valencia, Valencia, Spain
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Xavier Santamaria
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
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11
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Nielsen WH, Gustafsson F, Olsen PS, Hansen PB, Rossing K, Lilleør NB, Møller-Sørensen PH, Møller CH. Short-term outcomes after heart transplantation using donor hearts preserved with ex vivo perfusion. SCAND CARDIOVASC J 2023; 57:2267804. [PMID: 37822186 DOI: 10.1080/14017431.2023.2267804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/01/2023] [Indexed: 10/13/2023]
Abstract
The standard Conventional Cold Storage (CCS) during heart transplantation procurement is associated with time-dependent ischemic injury to the graft, which is a significant independent risk factor for post-transplant early morbidity and mortality - especially when cold ischemic time exceeds four hours. Since 2018, Rigshospitalet (Copenhagen, Denmark) has been utilising ex vivo perfusion (Organ Care System, OCS) in selected cases. The objective of this study was to compare the short-term clinical outcomes of patients transplanted with OCS compared to CCS. Methods: This retrospective single-centre study was based on consecutive patients undergoing a heart transplant between January 2018 and April 2021. Patients were selected for the OCS group when the cold ischemic time was expected to exceed four hours. The primary outcome measure was six-month event-free survival. Results: In total, 48 patients were included in the study; nine were transplanted with an OCS heart. The two groups had no significant differences in baseline characteristics. Six-month event-free survival was 77.8% [95% CI: 54.9-100%] in the OCS group and 79.5% [95% CI: 67.8-93.2%] in the CCS group (p = 0.91). While the OCS group had a median out-of-body time that was 183 min longer (p < 0.0001), the cold ischemic time was reduced by 51 min (p = 0.007). Conclusion: In a Scandinavian setting, our data confirms that utilising OCS in heart procurement allows for a longer out-of-body time and a reduced cold ischemic time without negatively affecting safety or early post-transplant outcomes.
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Affiliation(s)
- William Herrik Nielsen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Skov Olsen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Bo Hansen
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kasper Rossing
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Nikolaj Bang Lilleør
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Hasse Møller-Sørensen
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Christian Holdflod Møller
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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12
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DiChiacchio L, Goodwin ML, Kagawa H, Griffiths E, Nickel IC, Stehlik J, Selzman CH. Heart Transplant and Donors After Circulatory Death: A Clinical-Preclinical Systematic Review. J Surg Res 2023; 292:222-233. [PMID: 37657140 DOI: 10.1016/j.jss.2023.07.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 09/03/2023]
Abstract
INTRODUCTION Heart transplantation is the treatment of choice for end-stage heart failure. There is a mismatch between the number of donor hearts available and the number of patients awaiting transplantation. Expanding the donor pool is critically important. The use of hearts donated following circulatory death is one approach to increasing the number of available donor hearts. MATERIALS AND METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines utilizing Pubmed/MEDLINE and Embase. Articles including adult human studies and preclinical animal studies of heart transplantation following donation after circulatory death were included. Studies of pediatric populations or including organs other than heart were excluded. RESULTS Clinical experience and preclinical studies are reviewed. Clinical experience with direct procurement, normothermic regional perfusion, and machine perfusion are included. Preclinical studies addressing organ function assessment and enhancement of performance of marginal organs through preischemic, procurement, preservation, and reperfusion maneuvers are included. Articles addressing the ethical considerations of thoracic transplantation following circulatory death are also reviewed. CONCLUSIONS Heart transplantation utilizing organs procured following circulatory death is a promising method to increase the donor pool and offer life-saving transplantation to patients on the waitlist living with end-stage heart failure. There is robust ongoing preclinical and clinical research to optimize this technique and improve organ yield. There are also ongoing ethical considerations that must be addressed by consensus before wide adoption of this approach.
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Affiliation(s)
- Laura DiChiacchio
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Matthew L Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Hiroshi Kagawa
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Eric Griffiths
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Ian C Nickel
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Josef Stehlik
- Division of Cardiology, University of Utah, Salt Lake City, Utah
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah.
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13
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Ughetto A, Roubille F, Molina A, Battistella P, Gaudard P, Demaria R, Guihaire J, Lacampagne A, Delmas C. Heart graft preservation technics and limits: an update and perspectives. Front Cardiovasc Med 2023; 10:1248606. [PMID: 38028479 PMCID: PMC10657826 DOI: 10.3389/fcvm.2023.1248606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Heart transplantation, the gold standard treatment for end-stage heart failure, is limited by heart graft shortage, justifying expansion of the donor pool. Currently, static cold storage (SCS) of hearts from donations after brainstem death remains the standard practice, but it is usually limited to 240 min. Prolonged cold ischemia and ischemia-reperfusion injury (IRI) have been recognized as major causes of post-transplant graft failure. Continuous ex situ perfusion is a new approach for donor organ management to expand the donor pool and/or increase the utilization rate. Continuous ex situ machine perfusion (MP) can satisfy the metabolic needs of the myocardium, minimizing irreversible ischemic cell damage and cell death. Several hypothermic or normothermic MP methods have been developed and studied, particularly in the preclinical setting, but whether MP is superior to SCS remains controversial. Other approaches seem to be interesting for extending the pool of heart graft donors, such as blocking the paths of apoptosis and necrosis, extracellular vesicle therapy, or donor heart-specific gene therapy. In this systematic review, we summarize the mechanisms involved in IRI during heart transplantation and existing targeting therapies. We also critically evaluate all available data on continuous ex situ perfusion devices for adult donor hearts, highlighting its therapeutic potential and current limitations and shortcomings.
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Affiliation(s)
- Aurore Ughetto
- Phymedexp INSERM, CNRS, University of Montpellier, CHRU Montpellier, Montpellier, France
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - François Roubille
- Phymedexp INSERM, CNRS, University of Montpellier, CHRU Montpellier, Montpellier, France
- Cardiology Department, CHU de Montpellier, University of Montpellier, Montpellier, France
| | - Adrien Molina
- Phymedexp INSERM, CNRS, University of Montpellier, CHRU Montpellier, Montpellier, France
- Cardio-thoracic and Vascular Surgery Department, CHU de Montpellier, University of Montpellier, Montpellier, France
| | - Pascal Battistella
- Cardio-thoracic and Vascular Surgery Department, CHU de Montpellier, University of Montpellier, Montpellier, France
| | - Philippe Gaudard
- Phymedexp INSERM, CNRS, University of Montpellier, CHRU Montpellier, Montpellier, France
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Roland Demaria
- Cardio-thoracic and Vascular Surgery Department, CHU de Montpellier, University of Montpellier, Montpellier, France
| | - Julien Guihaire
- Cardiac and Vascular Surgery, Marie Lanelongue Hospital, Paris Saclay University, Le Plessis Robinson, France
| | - Alain Lacampagne
- Phymedexp INSERM, CNRS, University of Montpellier, CHRU Montpellier, Montpellier, France
| | - Clément Delmas
- Phymedexp INSERM, CNRS, University of Montpellier, CHRU Montpellier, Montpellier, France
- Intensive Cardiac Care Unit, Cardiology Department, Rangueil University Hospital, Toulouse, France
- REICATRA, Institut Saint Jacques, CHU de Toulouse, Toulouse, France
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14
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Peled Y, Kittleson MM. Two negatives make a positive: Maximizing heart procurement in adult congenital heart disease. J Heart Lung Transplant 2023; 42:1489-1492. [PMID: 37579830 DOI: 10.1016/j.healun.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/03/2023] [Accepted: 08/05/2023] [Indexed: 08/16/2023] Open
Affiliation(s)
- Yael Peled
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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15
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Iske J, Schroeter A, Knoedler S, Nazari-Shafti TZ, Wert L, Roesel MJ, Hennig F, Niehaus A, Kuehn C, Ius F, Falk V, Schmelzle M, Ruhparwar A, Haverich A, Knosalla C, Tullius SG, Vondran FWR, Wiegmann B. Pushing the boundaries of innovation: the potential of ex vivo organ perfusion from an interdisciplinary point of view. Front Cardiovasc Med 2023; 10:1272945. [PMID: 37900569 PMCID: PMC10602690 DOI: 10.3389/fcvm.2023.1272945] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/22/2023] [Indexed: 10/31/2023] Open
Abstract
Ex vivo machine perfusion (EVMP) is an emerging technique for preserving explanted solid organs with primary application in allogeneic organ transplantation. EVMP has been established as an alternative to the standard of care static-cold preservation, allowing for prolonged preservation and real-time monitoring of organ quality while reducing/preventing ischemia-reperfusion injury. Moreover, it has paved the way to involve expanded criteria donors, e.g., after circulatory death, thus expanding the donor organ pool. Ongoing improvements in EVMP protocols, especially expanding the duration of preservation, paved the way for its broader application, in particular for reconditioning and modification of diseased organs and tumor and infection therapies and regenerative approaches. Moreover, implementing EVMP for in vivo-like preclinical studies improving disease modeling raises significant interest, while providing an ideal interface for bioengineering and genetic manipulation. These approaches can be applied not only in an allogeneic and xenogeneic transplant setting but also in an autologous setting, where patients can be on temporary organ support while the diseased organs are treated ex vivo, followed by reimplantation of the cured organ. This review provides a comprehensive overview of the differences and similarities in abdominal (kidney and liver) and thoracic (lung and heart) EVMP, focusing on the organ-specific components and preservation techniques, specifically on the composition of perfusion solutions and their supplements and perfusion temperatures and flow conditions. Novel treatment opportunities beyond organ transplantation and limitations of abdominal and thoracic EVMP are delineated to identify complementary interdisciplinary approaches for the application and development of this technique.
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Affiliation(s)
- Jasper Iske
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andreas Schroeter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Timo Z. Nazari-Shafti
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonard Wert
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maximilian J. Roesel
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Felix Hennig
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Adelheid Niehaus
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kuehn
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| | - Fabio Ius
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
| | - Volkmar Falk
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
- Department of Health Science and Technology, Translational Cardiovascular Technology, ETH Zurich, Zürich, Switzerland
| | - Moritz Schmelzle
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Arjang Ruhparwar
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| | - Axel Haverich
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
| | - Stefan G. Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Florian W. R. Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Bettina Wiegmann
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
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16
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Conway J, Hong Y, Pidborochynski T, Freed DH. The Impact of Ex Situ Heart Perfusion in Pediatric Transplantation: An Analysis of the OPTN Database. ASAIO J 2023; 69:962-966. [PMID: 37399273 DOI: 10.1097/mat.0000000000002007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023] Open
Abstract
Ex situ heart perfusion (ESHP) has increased the pool of donors in adults. However, this is not true in pediatrics due to lack of devices. Therefore, we sought to understand organ refusal in pediatrics and estimate donor heart usage with ESHP. Donor hearts offered to pediatrics were identified from the Organ Procurement and Transplantation Network Database (2000-2019). A linear regression model was built to predict average travel speed, and the extended maximum permitted distance with ESHP was calculated. This extended distance was compared with the policy for maximum travel distance. There were 33,708 donor offers (n = 10,807 hearts) to pediatric programs [24.1% (n = 2,604) transplanted]. Six percent of the offers (n = 1,832) (n = 771 hearts) were turned down due to distance, with 676 of the hearts never transplanted. Based on the modeling and using an ESHP time of 5.5 hours, 84% (n = 570/676) of hearts turned down due to distance could be utilized by pediatric programs. This proportion increased to 100% with 10 hours of support time. By addressing prolonged ischemic time due to distance, ESHP has the potential to increase the number of donors utilized in pediatric candidates. Although no device exists for pediatrics, this analysis lends support to the importance of developing this technology.
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Affiliation(s)
- Jennifer Conway
- From the Stollery Children's Hospital, Edmonton, Alberta, Canada
- Division of Pediatric Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Yongzhe Hong
- Division of Pediatric Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Tara Pidborochynski
- Division of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Darren H Freed
- Division of Pediatric Cardiology, University of Alberta, Edmonton, Alberta, Canada
- Division of Pediatric Cardiac Surgery, Stollery Children's Hospital, Edmonton, Alberta, Canada
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17
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Lechiancole A, Sponga S, Benedetti G, Semeraro A, Guzzi G, Daffarra C, Meneguzzi M, Nalli C, Piani D, Bressan M, Livi U, Vendramin I. Graft preservation in heart transplantation: current approaches. Front Cardiovasc Med 2023; 10:1253579. [PMID: 37636303 PMCID: PMC10450939 DOI: 10.3389/fcvm.2023.1253579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/01/2023] [Indexed: 08/29/2023] Open
Abstract
Heart transplantation (HTx) represents the current best surgical treatment for patients affected by end-stage heart failure. However, with the improvement of medical and interventional therapies, the population of HTx candidates is increasingly old and at high-risk for mortality and complications. Moreover, the use of "extended donor criteria" to deal with the shortage of donors could increase the risk of worse outcomes after HTx. In this setting, the strategy of donor organ preservation could significantly affect HTx results. The most widely used technique for donor organ preservation is static cold storage in ice. New techniques that are clinically being used for donor heart preservation include static controlled hypothermia and machine perfusion (MP) systems. Controlled hypothermia allows for a monitored cold storage between 4°C and 8°C. This simple technique seems to better preserve the donor heart when compared to ice, probably avoiding tissue injury due to sub-zero °C temperatures. MP platforms are divided in normothermic and hypothermic, and continuously perfuse the donor heart, reducing ischemic time, a well-known independent risk factor for mortality after HTx. Also, normothermic MP permits to evaluate marginal donor grafts, and could represent a safe and effective technique to expand the available donor pool. However, despite the increasing number of donor hearts preserved with these new approaches, whether these techniques could be considered superior to traditional CS still represents a matter of debate. The aim of this review is to summarize and critically assess the available clinical data on donor heart preservation strategies employed for HTx.
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Affiliation(s)
- Andrea Lechiancole
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, University Hospital of Udine, Udine, Italy
| | - Sandro Sponga
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, University Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Giovanni Benedetti
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, University Hospital of Udine, Udine, Italy
| | - Arianna Semeraro
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, University Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Giorgio Guzzi
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, University Hospital of Udine, Udine, Italy
| | - Cristian Daffarra
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, University Hospital of Udine, Udine, Italy
| | - Matteo Meneguzzi
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, University Hospital of Udine, Udine, Italy
| | - Chiara Nalli
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, University Hospital of Udine, Udine, Italy
| | - Daniela Piani
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, University Hospital of Udine, Udine, Italy
| | - Marilyn Bressan
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, University Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Ugolino Livi
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, University Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Igor Vendramin
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, University Hospital of Udine, Udine, Italy
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18
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Pizanis N, Dimitriou AM, Koch A, Luedike P, Papathanasiou M, Rassaf T, Ruhparwar A, Schmack B, Weymann A, Ferenz KB, Kamler M. Introduction of machine perfusion of donor hearts in a single center in Germany. IJC HEART & VASCULATURE 2023; 47:101233. [PMID: 37388420 PMCID: PMC10300355 DOI: 10.1016/j.ijcha.2023.101233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/04/2023] [Accepted: 06/06/2023] [Indexed: 07/01/2023]
Abstract
Introduction Organ shortage, subsequent use of extended donor criteria organs and high-risk recipients needing redo-surgery are increasing the complexity of heart transplantation. Donor organ machine perfusion (MP) is an emerging technology allowing reduction of ischemia time as well as standardized evaluation of the organ. The aim of this study was to review the introduction of MP and analyze the results of heart transplantation after MP in our center. Methods In a retrospective single-center study, data from a prospectively collected database were analysed. From July 2018 to August 2021, fourteen hearts were retrieved and perfused using the Organ Care System (OCS), 12 hearts were transplanted. Criteria to use the OCS were based on donor/recipient characteristics. Primary objective was 30-day survival, secondary objectives were major cardiac adverse events, graft function, rejection episodes as well as overall survival in the follow-up and assessment of MP technical reliability. Results All patients survived the procedure and the postoperative 30-day interval. No MP related complications were noted. Graft ejection fraction beyond 14 days was ≥ 50% in all cases. Endomyocardial biopsy showed excellent results with no or mild rejection. Two donor hearts were rejected after OCS perfusion and evaluation. Conclusion Ex vivo normothermic MP during organ procurement is a safe and promising technique to expand the donor pool. Reduction of cold ischemic time while providing additional donor heart assessment and reconditioning options increased the number of acceptable donor hearts. Additional clinical trials are necessary to develop guidelines regarding the application of MP.
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Affiliation(s)
- Nikolaus Pizanis
- University Hospital Essen, West German Heart and Vascular Center, Department of Thoracic and Cardiovascular Surgery, Essen, Germany
| | - Alexandros Merkourios Dimitriou
- University Hospital Essen, West German Heart and Vascular Center, Department of Thoracic and Cardiovascular Surgery, Essen, Germany
| | - Achim Koch
- University Hospital Essen, West German Heart and Vascular Center, Department of Thoracic and Cardiovascular Surgery, Essen, Germany
| | - Peter Luedike
- University Hospital Essen, West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine, Essen, Germany
| | - Maria Papathanasiou
- University Hospital Essen, West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine, Essen, Germany
| | - Tienush Rassaf
- University Hospital Essen, West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine, Essen, Germany
| | - Arjang Ruhparwar
- University Hospital Essen, West German Heart and Vascular Center, Department of Thoracic and Cardiovascular Surgery, Essen, Germany
| | - Bastian Schmack
- University Hospital Essen, West German Heart and Vascular Center, Department of Thoracic and Cardiovascular Surgery, Essen, Germany
| | - Alexander Weymann
- University Hospital Essen, West German Heart and Vascular Center, Department of Thoracic and Cardiovascular Surgery, Essen, Germany
| | | | - Markus Kamler
- University Hospital Essen, West German Heart and Vascular Center, Department of Thoracic and Cardiovascular Surgery, Essen, Germany
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Sponga S, Vendramin I, Salman J, Ferrara V, De Manna ND, Lechiancole A, Warnecke G, Dralov A, Haverich A, Ius F, Bortolotti U, Livi U, Avsar M. Heart Transplantation in High-Risk Recipients Employing Donor Marginal Grafts Preserved With Ex-Vivo Perfusion. Transpl Int 2023; 36:11089. [PMID: 37547752 PMCID: PMC10401590 DOI: 10.3389/ti.2023.11089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 07/10/2023] [Indexed: 08/08/2023]
Abstract
Extending selection criteria to face donor organ shortage in heart transplantation (HTx) may increase the risk of mortality. Ex-vivo normothermic perfusion (EVP) limits ischemic time allowing assessment of graft function. We investigated the outcome of HTx in 80 high-risk recipients transplanted with marginal donor and EVP-preserved grafts, from 2016 to 2021. The recipients median age was 57 years (range, 13-75), with chronic renal failure in 61%, impaired liver function in 11% and previous cardiac surgery in 90%; 80% were mechanically supported. Median RADIAL score was 3. Mean graft ischemic time was 118 ± 25 min, "out-of-body" time 420 ± 66 min and median cardiopulmonary bypass (CPB) time 228 min (126-416). In-hospital mortality was 11% and ≥moderate primary graft dysfunction 16%. At univariable analysis, CPB time and high central venous pressure were risk factors for mortality. Actuarial survival at 1 and 3 years was 83% ± 4%, and 72% ± 7%, with a median follow-up of 16 months (range 2-43). Recipient and donor ages, pre-HTx extracorporeal life support and intra-aortic balloon pump were risk factors for late mortality. In conclusion, the use of EVP allows extension of the graft pool by recruitment of marginal donors to successfully perform HTx even in high-risk recipients.
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Affiliation(s)
- Sandro Sponga
- Department of Medicine, University of Udine, Udine, Italy
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Igor Vendramin
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | | | | | | | - Gregor Warnecke
- Department of Cardiac Surgery, Heidelberg Medical School, Heidelberg, Germany
| | - Andriy Dralov
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Uberto Bortolotti
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Ugolino Livi
- Department of Medicine, University of Udine, Udine, Italy
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
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20
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Thiessen C, Wisel SA, Roll GR. Simultaneous thoracic and abdominal donation after circulatory death organ recovery: the abdominal surgeon's perspective. Curr Opin Organ Transplant 2023; 28:139-144. [PMID: 36603197 PMCID: PMC9994842 DOI: 10.1097/mot.0000000000001045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF THE REVIEW To summarize the international experience with heart-liver (joint) donation after circulatory death (DCD) procurements and to explore the technical challenges in joint abdominal and thoracic DCD procurement. RECENT FINDINGS Following completion of the Donors After Circulatory Death Heart Trial in the US, combined thoracic and abdominal DCD is poised to become the standard of care, expanding access to life-saving heart and lung allografts. DCD heart procurement relies on collection of donor blood for priming of the normothermic perfusion pump, which delays cooling of abdominal organs and increases risk of ischemic injury. We review the effect of donor ischemia time on abdominal organs, with several proposed technical solutions to optimize transplant outcomes for all organs. SUMMARY The strategies reviewed in this manuscript may inform clinical decision-making, preoperative coordination between thoracic and abdominal procurement teams, and surgical technique for joint DCD procurements. Several approaches to organ procurement organization (OPO) and national policy, as well as future areas of focus for research are proposed.
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Affiliation(s)
- Carrie Thiessen
- Division of Transplantation, University of Wisconsin, Madison, Wisconsin
| | - Steven A. Wisel
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles
| | - Garrett R. Roll
- Division of Transplantation, University of California, San Francisco, San Francisco, California, USA
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21
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Kothari P. Ex-Vivo Preservation of Heart Allografts—An Overview of the Current State. J Cardiovasc Dev Dis 2023; 10:jcdd10030105. [PMID: 36975869 PMCID: PMC10054234 DOI: 10.3390/jcdd10030105] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/17/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
As heart transplantation continues to be the gold-standard therapy for end-stage heart failure, the supply-demand imbalance of available organs worsens. Until recently, there have been no advances in increasing the donor pool, as prolonged cold ischemic time excludes the use of certain donors. The TransMedics Organ Care System (OCS) allows for ex-vivo normothermic perfusion, which allows for a reduction of cold ischemic time and allows for long-distance procurements. Furthermore, the OCS allows for real-time monitoring and assessment of allograft quality, which can be crucial for extended-criteria donors or donation after cardiac death (DCD) donors. Conversely, the XVIVO device allows for hypothermic perfusion to preserve allografts. Despite their limitations, these devices have the potential to alleviate the supply-demand imbalance in donor availability.
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Affiliation(s)
- Perin Kothari
- School of Medicine, Stanford University, Stanford, CA 94305, USA
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22
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Ex Vivo Heart Perfusion for Cardiac Transplantation Allowing for Prolonged Perfusion Time and Extension of Distance Traveled for Procurement of Donor Hearts: An Initial Experience in the United States. Transplant Direct 2023; 9:e1455. [PMID: 36845853 PMCID: PMC9949869 DOI: 10.1097/txd.0000000000001455] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 02/25/2023] Open
Abstract
Scarcity of donor hearts continues to be a challenge for heart transplantation (HT). The recently Food and Drug Administration-approved Organ Care System (OCS; Heart, TransMedics) for ex vivo organ perfusion enables extension of ex situ intervals and thus may expand the donor pool. Because postapproval real-world outcomes of OCS in HT are lacking, we report our initial experience. Methods We retrospectively reviewed consecutive patients who received HT at our institution in the post-Food and Drug Administration approval period from May 1 to October 15, 2022. Patients were divided into 2 groups: OCS versus conventional technique. Baseline characteristics and outcomes were compared. Results A total of 21 patients received HT during this period, 8 using OCS and 13 conventional techniques. All hearts were from donation after brain death donors. The indication for OCS was an expected ischemic time of >4 h. Baseline characteristics in the 2 groups were comparable. The mean distance traveled for heart recovery was significantly higher in the OCS group (OCS, 845 ± 337, versus conventional, 186 ± 188 mi; P < 0.001), as was the mean total preservation time (6.5 ± 0.7 versus 2.5 ± 0.7 h; P < 0.001). The mean OCS time was 5.1 ± 0.7 h. In-hospital survival in the OCS group was 100% compared with 92.3% in the conventional group (P = 0.32). Primary graft dysfunction was similar in both groups (OCS 12.5% versus conventional 15.4%; P = 0.85). No patient in the OCS group required venoarterial extracorporeal membrane oxygenation support after transplant compared with 1 in the conventional group (0% versus 7.7%; P = 0.32). The mean intensive care unit length of stay after transplant was comparable. Conclusions OCS allowed utilization of donors from extended distances that otherwise would not be considered because ischemic time would be prohibitive by conventional technique.
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23
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Conway J, Hong Y, Pidborochynski T, Freed DH. The Impact of Ex Situ Heart Perfusion in Pediatric Transplantation: An Analysis of the United Network for Organ Sharing Registry. ASAIO J 2023; 69:205-209. [PMID: 35439190 DOI: 10.1097/mat.0000000000001738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Ex situ heart perfusion (ESHP) has increased the pool of donors in adults. However, this is not true in pediatrics due to lack of devices. Therefore, we sought to understand organ refusal in pediatrics and estimate donor heart usage with ESHP. Donor hearts offered to pediatrics were identified from the United Network for Organ Sharing (UNOS) Database (2000-2019). A linear regression model was built to predict average travel speed, and the extended maximum permitted distance with ESHP was calculated. This extended distance was compared with the policy for maximum travel distance. There were 33,708 donor offers (n = 10,807 hearts) to pediatric programs (24.1% [n = 2,604] transplanted). Six percent of the offers (n = 1,832) (n = 771 hearts) were turned down due to distance, with 676 of the hearts never transplanted. Based on the modeling and using an ESHP time of 5.5 hours, 84% (n = 570/676) of hearts turned down as distance could be utilized by pediatric programs. This proportion increased to 100% with 10 hours of support time. By addressing prolonged ischemic time due to distance, ESHP has the potential to increase the number of donors utilized in pediatric candidates. While no device exists for pediatrics, this analysis lends support to the importance of developing this technology.
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Affiliation(s)
- Jennifer Conway
- From the Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Yongzhe Hong
- Division of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Tara Pidborochynski
- Department of Pediatrics, Division of Pediatric Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
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Copeland H, Knezevic I, Baran DA, Rao V, Pham M, Gustafsson F, Pinney S, Lima B, Masetti M, Ciarka A, Rajagopalan N, Torres A, Hsich E, Patel JK, Goldraich LA, Colvin M, Segovia J, Ross H, Ginwalla M, Sharif-Kashani B, Farr MA, Potena L, Kobashigawa J, Crespo-Leiro MG, Altman N, Wagner F, Cook J, Stosor V, Grossi PA, Khush K, Yagdi T, Restaino S, Tsui S, Absi D, Sokos G, Zuckermann A, Wayda B, Felius J, Hall SA. Donor heart selection: Evidence-based guidelines for providers. J Heart Lung Transplant 2023; 42:7-29. [PMID: 36357275 PMCID: PMC10284152 DOI: 10.1016/j.healun.2022.08.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 01/31/2023] Open
Abstract
The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.
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Affiliation(s)
- Hannah Copeland
- Department of Cardiovascular and Thoracic Surgery Lutheran Hospital, Fort Wayne, Indiana; Indiana University School of Medicine-Fort Wayne, Fort Wayne, Indiana.
| | - Ivan Knezevic
- Transplantation Centre, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - David A Baran
- Department of Medicine, Division of Cardiology, Sentara Heart Hospital, Norfolk, Virginia
| | - Vivek Rao
- Peter Munk Cardiac Centre Toronto General Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Michael Pham
- Sutter Health California Pacific Medical Center, San Francisco, California
| | - Finn Gustafsson
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Sean Pinney
- University of Chicago Medicine, Chicago, Illinois
| | - Brian Lima
- Medical City Heart Hospital, Dallas, Texas
| | - Marco Masetti
- Heart Failure and Heart Transplant Unit IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Agnieszka Ciarka
- Department of Cardiovascular Diseases, Katholieke Universiteit Leuven, Leuven, Belgium; Institute of Civilisation Diseases and Regenerative Medicine, University of Information Technology and Management, Rzeszow, Poland
| | | | - Adriana Torres
- Los Cobos Medical Center, Universidad El Bosque, Bogota, Colombia
| | | | | | | | | | - Javier Segovia
- Cardiology Department, Hospital Universitario Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Heather Ross
- University of Toronto, Toronto, Ontario, Canada; Sutter Health California Pacific Medical Center, San Francisco, California
| | - Mahazarin Ginwalla
- Cardiovascular Division, Palo Alto Medical Foundation/Sutter Health, Burlingame, California
| | - Babak Sharif-Kashani
- Department of Cardiology, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - MaryJane A Farr
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Luciano Potena
- Heart Failure and Heart Transplant Unit IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | | | | | | | | | | | - Valentina Stosor
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Kiran Khush
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Tahir Yagdi
- Department of Cardiovascular Surgery, Ege University School of Medicine, Izmir, Turkey
| | - Susan Restaino
- Division of Cardiology Columbia University, New York, New York; New York Presbyterian Hospital, New York, New York
| | - Steven Tsui
- Department of Cardiothoracic Surgery Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Daniel Absi
- Department of Cardiothoracic and Transplant Surgery, University Hospital Favaloro Foundation, Buenos Aires, Argentina
| | - George Sokos
- Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Brian Wayda
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Joost Felius
- Baylor Scott & White Research Institute, Dallas, Texas; Texas A&M University Health Science Center, Dallas, Texas
| | - Shelley A Hall
- Texas A&M University Health Science Center, Dallas, Texas; Division of Transplant Cardiology, Mechanical Circulatory Support and Advanced Heart Failure, Baylor University Medical Center, Dallas, Texas
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25
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Qi X, Hatami S, Bozso S, Buchko M, Forgie KA, Olafson C, Khan M, Himmat S, Wang X, Nobes DS, Acker JP, Nagendran J, Freed DH. The evaluation of constant coronary artery flow versus constant coronary perfusion pressure during normothermic ex situ heart perfusion. J Heart Lung Transplant 2022; 41:1738-1750. [PMID: 36137869 DOI: 10.1016/j.healun.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 08/10/2022] [Accepted: 08/10/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Evidence suggests that hearts that are perfused under ex-situ conditions lose normal coronary vasomotor tone and experience contractile failure over a few hours. We aimed to evaluate the effect of different coronary perfusion strategies during ex situ heart perfusion on cardiac function and coronary vascular tone. METHODS Porcine hearts (n = 6 each group) were perfused in working mode for 6 hours with either constant aortic diastolic pressure (40 mmHg) or constant coronary flow rate (500 mL/min). Functional and metabolic parameters, cytokine profiles, cardiac and vascular injury, coronary artery function and oxidative stress were compared between groups. RESULTS Constant coronary flow perfusion demonstrated better functional preservation and less edema formation (Cardiac index: flow control = 8.33 vs pressure control = 6.46 mL·min-1·g-1, p = 0.016; edema formation: 7.92% vs 19.80%, p < 0.0001). Pro-inflammatory cytokines, platelet activation as well as endothelial activation were lower in the flow control group. Similarly, less cardiac and endothelial injury was observed in the constant coronary flow group. Evaluation of coronary artery function showed there was loss of coronary autoregulation in both groups. Oxidative stress was induced in the coronary arteries and was relatively lower in the flow control group. CONCLUSIONS A strategy of controlled coronary flow during ex situ heart perfusion provides superior functional preservation and less edema formation, together with less myocardial damage, leukocyte, platelet, endothelial activation, and oxidative stress. There was loss of coronary autoregulation and decrease of coronary vascular resistance during ESHP irrespective of coronary flow control strategy. Inflammation and oxidative stress state in the coronary vasculature may play a role.
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Affiliation(s)
- Xiao Qi
- Departments of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Sanaz Hatami
- Departments of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Sabin Bozso
- Departments of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Max Buchko
- Departments of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Keir A Forgie
- Departments of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Carly Olafson
- Centre for Innovation, Canadian Blood Services, Edmonton, AB, Canada
| | - Mubashir Khan
- Departments of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Sayed Himmat
- Departments of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Xiuhua Wang
- Departments of Surgery, University of Alberta, Edmonton, AB, Canada
| | - David S Nobes
- Department of Mechanical Engineering, Faculty of Engineering, University of Alberta, AB, Canada
| | - Jason P Acker
- Department of Laboratory Medicine and Pathology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada; Centre for Innovation, Canadian Blood Services, Edmonton, AB, Canada
| | - Jayan Nagendran
- Departments of Surgery, University of Alberta, Edmonton, AB, Canada; Alberta Transplant Institute Edmonton, AB, Canada; Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Darren H Freed
- Departments of Surgery, University of Alberta, Edmonton, AB, Canada; Physiology, University of Alberta, Edmonton, AB, Canada; Biomedical Engineering, University of Alberta, Edmonton, AB, Canada; Alberta Transplant Institute Edmonton, AB, Canada; Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada.
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26
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Significance of HLA-matching and anti-HLA antibodies in heart transplant patients receiving induction therapy? Transpl Immunol 2022; 75:101706. [PMID: 36113729 DOI: 10.1016/j.trim.2022.101706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/29/2022] [Accepted: 08/29/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Though Human Leukocyte Antigen (HLA) matching benefits are demonstrated in renal transplantation, evidence in heart transplantation is lacking, and its clinical feasibility is uncertain. Post-transplantation anti-HLA antibodies are being increasingly studied in organ transplantation, with diverging conclusions between transplantated organs. METHODS We analyzed retrospectively the influence of HLA matching and anti-HLA antibodies on overall survival, acute rejection and chronic allograft vasculopathy in 309 patients receiving induction therapy and triple-drug immunosuppression. RESULTS The average number of HLA-A/B/DR mismatches between donor and recipient was 4.9 ± 1. The majority of mismatches was for Class I HLA-A/B with an average of 3.3, then for Class I HLA-DR with an average of 1.6. Overall, the HLA-A/-B/-DR mismatches had no influence on the cardiac allograft survival (p = 0.28). However, HLA-DR mismatches were negatively correlated to severe cellular and/or humoral allograft rejection (p = 0.04). Our analysis found anti-HLA antibodies in 27% of recipients, de novo anti-HLA antibodies in 16% of recipients, and donor-specific anti-HLA (DSA) antibodies in 8% of recipients. Furthermore, de novo DSA had no influence on the 5-year survival (78% with DSA vs. 92% without DSA; p = 0.49), which may be masked by the limited number of recipients in analysis By univariable analysis, anti-HLA antibodies (preexisting or de novo) unrelated or related to the donor had no influence on severe cellular and/or humoral rejection or on chronic allograft vasculopathy. CONCLUSIONS HLA-DR mismatch was negatively correlated to severe cellular and/or humoral allograft rejection but had no influence on cardiac allograft survival. In this study, anti-HLA antibodies (preexisting or de novo) unrelated or related to the donor had no influence on cellular and/or humoral rejection or on chronic allograft vasculopathy. The results of this study add to the controversy on the impact of allo-antibodies in heart transplant recipients receiving induction therapy and contemporary immunosuppression.
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27
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Wisneski A, Smith JW, Nguyen TC, Fiedler AG. Molecules, Machines, and the Perfusate Milieu: Organ Preservation and Emerging Concepts for Heart Transplant. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:363-367. [PMID: 36271669 DOI: 10.1177/15569845221127305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Andrew Wisneski
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, CA, USA
| | - Jason W Smith
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, CA, USA
| | - Tom C Nguyen
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, CA, USA
| | - Amy G Fiedler
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, CA, USA
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28
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Expanding Donor Heart Utilization Through Machine Perfusion Technologies. CURRENT TRANSPLANTATION REPORTS 2022. [DOI: 10.1007/s40472-022-00375-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Abstract
Purpose of Review
Recent advances in donor heart preservation have allowed the utilization of hearts that would typically be discarded due to prolonged ischemic times or donation via the circulatory death pathway. This review will discuss recent advances in donor heart preservation including optimization of machine perfusion technologies and future strategies of potential benefit for the donor heart and transplant outcomes.
Recent Findings
Improvements in organ preservation strategies have enabled retrieval of donor hearts that were not ideal for static cold storage. Machine perfusion (normothermic and hypothermic) and normothermic regional perfusion have ultimately expanded the donor pool for adult heart transplantation. Xenotransplantation has also incorporated machine perfusion for porcine donor heart preservation.
Summary
Traditional static cold storage is feasible for non-complex donors and transplants. Machine perfusion has enabled increased donor heart utilization however optimal preservation strategies are dependent on the donor criteria, predicted ischemic times and surgical complexity.
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29
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Alomari M, Garg P, Yazji JH, Wadiwala IJ, Alamouti-fard E, Hussain MWA, Elawady MS, Jacob S. Is the Organ Care System (OCS) Still the First Choice With Emerging New Strategies for Donation After Circulatory Death (DCD) in Heart Transplant? Cureus 2022; 14:e26281. [PMID: 35754437 PMCID: PMC9229932 DOI: 10.7759/cureus.26281] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 12/14/2022] Open
Abstract
The scarcity of donor hearts continues to be a challenge in transplants for advanced heart failure patients. With an increasing number of patients on the waiting list for a heart transplant, the discrepancy in the number between donors and recipients is gradually increasing and poses a new challenge that plagues the healthcare systems when it comes to the heart. Several technologies have been developed to expand the donor pool in recent years. One such method is the organ care system (OCS). The standard method of organ preservation is the static cold storage (SCS) method which allows up to four hours of safe preservation of the heart. However, beyond four hours of cold ischemia, the incidence of primary graft dysfunction increases significantly. OCS keeps the heart perfused close to the physiological state beyond the four hours with superior results, which allows us to travel further and longer distances, leading to expansion in the donor pool. In this review, we discuss the OCS system, its advantages, and shortcomings.
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30
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Olkowicz M, Ribeiro RVP, Yu F, Alvarez JS, Xin L, Yu M, Rosales R, Adamson MB, Bissoondath V, Smolenski RT, Billia F, Badiwala MV, Pawliszyn J. Dynamic Metabolic Changes During Prolonged Ex Situ Heart Perfusion Are Associated With Myocardial Functional Decline. Front Immunol 2022; 13:859506. [PMID: 35812438 PMCID: PMC9267769 DOI: 10.3389/fimmu.2022.859506] [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: 01/21/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
Ex situ heart perfusion (ESHP) was developed to preserve and evaluate donated hearts in a perfused beating state. However, myocardial function declines during ESHP, which limits the duration of perfusion and the potential to expand the donor pool. In this research, we combine a novel, minimally-invasive sampling approach with comparative global metabolite profiling to evaluate changes in the metabolomic patterns associated with declines in myocardial function during ESHP. Biocompatible solid-phase microextraction (SPME) microprobes serving as chemical biopsy were used to sample heart tissue and perfusate in a translational porcine ESHP model and a small cohort of clinical cases. In addition, six core-needle biopsies of the left ventricular wall were collected to compare the performance of our SPME sampling method against that of traditional tissue-collection. Our state-of-the-art metabolomics platform allowed us to identify a large number of significantly altered metabolites and lipid species that presented comparable profile of alterations to conventional biopsies. However, significant discrepancies in the pool of identified analytes using two sampling methods (SPME vs. biopsy) were also identified concerning mainly compounds susceptible to dynamic biotransformation and most likely being a result of low-invasive nature of SPME. Overall, our results revealed striking metabolic alterations during prolonged 8h-ESHP associated with uncontrolled inflammation not counterbalanced by resolution, endothelial injury, accelerated mitochondrial oxidative stress, the disruption of mitochondrial bioenergetics, and the accumulation of harmful lipid species. In conclusion, the combination of perfusion parameters and metabolomics can uncover various mechanisms of organ injury and recovery, which can help differentiate between donor hearts that are transplantable from those that should be discarded.
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Affiliation(s)
- Mariola Olkowicz
- Department of Chemistry, University of Waterloo, Waterloo, ON, Canada
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Krakow, Poland
| | - Roberto Vanin Pinto Ribeiro
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Frank Yu
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Juglans Souto Alvarez
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Liming Xin
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Miao Yu
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Roizar Rosales
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Mitchell Brady Adamson
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Ved Bissoondath
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | | | - Filio Billia
- Toronto General Hospital Research Institute (TGHRI), University Health Network, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
| | - Mitesh Vallabh Badiwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Ted Roger’s Center for Heart Research, University Health Network, Toronto, ON, Canada
| | - Janusz Pawliszyn
- Department of Chemistry, University of Waterloo, Waterloo, ON, Canada
- *Correspondence: Janusz Pawliszyn,
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31
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Normothermic Ex Situ Heart Perfusion With the Organ Care System for Cardiac Transplantation: A Meta-analysis. Transplantation 2022; 106:1745-1753. [PMID: 35618669 DOI: 10.1097/tp.0000000000004167] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Heart transplantation (HTx) is, at present, the most effective therapy for end-stage heart failure patients; however, the number of patients on the waiting list is rising globally, further increasing the gap between demand and supply of donors for HTx. First studies using the Organ Care System (OCS) for normothermic machine perfusion show promising results yet are limited in sample size. This article presents a meta-analysis of heart donation either after brain death (OCS-DBD) or circulatory death (OCS-DCD) on using OCS versus static cold storage used for HTx. METHODS A systematic literature search was performed for articles discussing the use of normothermic ex situ heart perfusion in adult patients. Thirty-day survival outcomes were pooled, and odds ratios were calculated using random-effects models. Long-term survival was visualized with Kaplan-Meier curves, hazard ratios were calculated and pooled using fixed-effects models, and secondary outcomes were analyzed. RESULTS A total of 12 studies were included, with 741 patients undergoing HTx, of which 260 with the OCS (173 DBD and 87 DCD). No differences were found between the 3 groups for early and late survival outcomes or for secondary outcomes. CONCLUSIONS OCS outcomes, for both DBD and DCD hearts, appeared similar as for static cold storage. Therefore, OCS is a safe and effective technique to enlarge the cardiac donor pool in both DBD and DCD, with additional benefits for long-distance transport and surgically complex procedures.
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32
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Chen Q, Singer-Englar T, Kobashigawa JA, Roach A, Emerson D, Megna D, Ramzy D, Catarino P, Patel JK, Kittleson M, Czer L, Chikwe J, Esmailian F. Long-term outcomes after heart transplantation using ex vivo allograft perfusion in standard risk donors: A single-center experience. Clin Transplant 2022; 36:e14591. [PMID: 35030278 PMCID: PMC11144456 DOI: 10.1111/ctr.14591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/20/2021] [Accepted: 01/10/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The Organ Care System (OCS) is an ex vivo perfusion platform for donor heart preservation. Short/mid-term post-transplant outcomes after its use are comparable to standard cold storage (CS). We evaluated long-term outcomes following its use. METHODS Between 2011 and 2013, 38 patients from a single center were randomized as a part of the PROCEED II trial to receive allografts preserved with CS (n = 19) or OCS (n = 19). Endpoints included 8-year survival, survival free from graft-related deaths, freedom from cardiac allograft vasculopathy (CAV), non-fatal major adverse cardiac events (NF-MACE), and rejections. RESULTS Eight-year survival was 57.9% in the OCS group and 73.7% in the CS group (p = .24). Freedom from CAV was 89.5% in the OCS group and 67.8% in the CS group (p = .13). Freedom from NF-MACE was 89.5% in the OCS group and 67.5% in the CS group (p = .14). Eight-year survival free from graft-related death was equivalent between the two groups (84.2% vs. 84.2%, p = .93). No differences in rejection episodes were observed (all p > .5). CONCLUSIONS In select patients receiving OCS preserved allografts, late post-transplant survival trended lower than those transplanted with an allograft preserved with CS. This is based on a small single-center series, and larger numbers are needed to confirm these findings.
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Affiliation(s)
- Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Tahli Singer-Englar
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jon A. Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Amy Roach
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dominick Megna
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Danny Ramzy
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Pedro Catarino
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jignesh K. Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michelle Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lawrence Czer
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Fardad Esmailian
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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33
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Kirste G. Cold but not too cold: advances in hypothermic and normothermic organ perfusion. KOREAN JOURNAL OF TRANSPLANTATION 2022; 36:2-14. [PMID: 35769433 PMCID: PMC9235527 DOI: 10.4285/kjt.22.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 11/24/2022] Open
Abstract
Transplantation is the method of choice and, in many cases, the only method of treatment for patients with end-stage organ disease. Excellent results have been achieved, and the main focus today is to extend the number of available donors. The use of extended-criteria donors or donors after circulatory death is standard, but is accompanied by an increased risk of ischemia reperfusion injury. This review presents newly developed machine perfusion techniques using hypothermic, subnormothermic, or normothermic conditions, with or without oxygenation. Possibilities for treatment and quality assessment in decision-making about organ acceptability are also discussed.
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Affiliation(s)
- Guenter Kirste
- Department of Surgery, University Hospital of Freiburg, Albert Ludwig University of Freiburg, Freiburg im Breisgau, Germany
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34
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Załęska-Kocięcka M, Dutton J, Morosin M, Garda RF, Piotrowska K, Lees N, Aw TC, Sáez DG, Simon AR, Stock U, Doce AH. Prognostic significance of serum lactate following cardiac transplantation. Biomark Med 2022; 16:599-611. [PMID: 35322701 DOI: 10.2217/bmm-2021-1041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Hyperlactatemia is common post-heart transplantation. Lactate measurements in the first 24 h were analyzed with respect to mortality. Methods: A total of 153 consecutive cardiac transplant patients were reviewed. Recipients of organs maintained in a state of ex vivo perfusion were included. Results: A total of 143 heart recipients were included. Hyperlactatemia (>2 mmol/l) was present in all patients. Despite maximum lactate and lactate clearance being significantly higher in nonsurvivors (p = 0.002, p = 0.004), neither receiver operator curve analysis nor multivariate logistic regression showed association with 1-year mortality. In comparison, the minimum lactate was significantly associated with mortality (area under the curve 0.728 [p < 0.001]; odds ratio 1.28 [95% 1.01-162; p = 0.04]). Conclusion: The minimum lactate, a surrogate of persistent hyperlactatemia, was demonstrated to be superior compared with maximum lactate and lactate clearance in determining patient prognosis.
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Affiliation(s)
- Marta Załęska-Kocięcka
- Department of Anaesthesia & Critical Care, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Uxbridge, UB9 6JH, UK.,Department of Anaesthesia & Critical Care, National Institute of Cardiology, Warsaw, 04-628, Poland
| | - Jonathan Dutton
- Department of Anaesthesia & Critical Care, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Uxbridge, UB9 6JH, UK
| | - Marco Morosin
- Department of Anaesthesia & Critical Care, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, SW3 6NP, UK
| | - Rita Fernandez Garda
- Department of Anaesthesia & Critical Care, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Uxbridge, UB9 6JH, UK
| | - Katarzyna Piotrowska
- Department of Quantitative Methods & Information Technology Kozminsky University, Warsaw, 03-301, Poland
| | - Nicholas Lees
- Department of Anaesthesia & Critical Care, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Uxbridge, UB9 6JH, UK
| | - T C Aw
- Department of Anaesthesia & Critical Care, Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, SW3 6NP, UK
| | - Diana García Sáez
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Uxbridge, UB9 6JH, UK
| | - Andre R Simon
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Uxbridge, UB9 6JH, UK
| | - Ulrich Stock
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Uxbridge, UB9 6JH, UK
| | - Ana Hurtado Doce
- Department of Anaesthesia & Critical Care, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Uxbridge, UB9 6JH, UK
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35
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Qin G, Jernryd V, Sjöberg T, Steen S, Nilsson J. Machine Perfusion for Human Heart Preservation: A Systematic Review. Transpl Int 2022; 35:10258. [PMID: 35401041 PMCID: PMC8983812 DOI: 10.3389/ti.2022.10258] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/27/2022] [Indexed: 01/02/2023]
Abstract
Currently, static cold storage (SCS) of hearts from donations after brainstem death remains the standard clinically. However, machine perfusion (MP) is considered an approach for donor organ management to extend the donor pool and/or increase the utilization rate. This review summarizes and critically assesses the available clinical data on MP in heart transplantation. We searched Medline (PubMed), Cochrane, Embase, and clinicaltrials.gov, along with reference lists of the included publications and identified 40 publications, including 18 articles, 17 conference abstracts, and five ongoing clinical trials. Two types of MP were used: hypothermic MP (HMP) and normothermic MP (NMP). Three studies evaluated HMP, and 32 evaluated NMP. Independent of the system, MP resulted in clinical outcomes comparable to traditional SCS. However, NMP seemed especially beneficial for high-risk cases and donation after circulatory death (DCD) hearts. Based on currently available data, MP is non-inferior to standard SCS. Additionally, single-centre studies suggest that NMP could preserve the hearts from donors outside standard acceptability criteria and DCD hearts with comparable results to SCS. Finally, HMP is theoretically safer and simpler to use than NMP. If a machine malfunction or user error occurs, NMP, which perfuses a beating heart, would have a narrower margin of safety. However, further well-designed studies need to be conducted to draw clear conclusions.
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Affiliation(s)
- Guangqi Qin
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Victoria Jernryd
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Trygve Sjöberg
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Stig Steen
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Johan Nilsson
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University and Skane University Hospital, Lund, Sweden
- Department of Translational Medicine, Thoracic Surgery and Bioinformatics, Lund University, Lund, Sweden
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36
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Blitzer D, Copeland H. Next steps in heart transplantation: Diagnosing and treating PGD, where are we? J Card Surg 2022; 37:1299-1300. [PMID: 35236001 DOI: 10.1111/jocs.16363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 11/28/2022]
Abstract
In this issue of the Journal of Cardiac Surgery, Settepani et al. perform a single center analysis of clinical outcomes for primary graft dysfunction (PGD) in patients undergoing orthotopic heart transplantation. The results of this study underscore the necessity to be proactive in the attempt to prevent PGD to give transplant recipients the best chance at a positive outcome. Further study of PGD should be directed to better understand the underlying pathophysiology and potentially lead to such targeted therapeutic management.
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Affiliation(s)
- David Blitzer
- New York-Presbyterian, Columbia University Medical Center, New York, New York, USA
| | - Hannah Copeland
- Department of Cardiothoracic Surgery, Heart Transplantation, Mechanical Circulatory Support and ECMO, Lutheran Hospital Fort Wayne, Indiana University School of Medicine - Fort Wayne (IUSM-FW), Fort Wayne, Indiana, USA
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37
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Settepani F, Pedrazzini GL, Olivieri GM, Merlanti B, Cannata A, Lanfranconi M, Frigerio M, Russo CF. Long-term effects of primary graft dysfunction after heart transplantation. J Card Surg 2022; 37:1290-1298. [PMID: 35229361 DOI: 10.1111/jocs.16364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/28/2022] [Accepted: 02/04/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND We studied the incidence of primary graft dysfunction (PGD), its impact on in-hospital and follow-up outcomes and searched for independent risk factors. METHODS During an 18-year period, 508 individuals underwent heart transplantation at our institution. Patients were diagnosed with none, mild, moderate or severe PGD according to ISHLT criteria. RESULTS Thirty-eight patients (7.5%) met the ISHLT criteria for mild PGD, 92 (18.1%) for moderate PGD and 23 (4.5%) for severe PGD. Patients were classified into none/mild PGD (77.4%) and moderate/severe PGD (22.6%) groups. In-hospital mortality was 12.4% (7.8% for none/mild PGD and 28.7% for moderate/severe PGD; p < .001). Survival at 1, 5, and 15 years was 85.5 ± 1.9% versus 67.2 ± 4.5%, 80 ± 2.2% versus 63.5 ± 4.7%, and 60.4 ± 3.6% versus 45.9 ± 8.4%, respectively (p < .001). Excluding the events occurring during the first month of follow-up, survival was comparable between the two groups (93.1 ± 1.4% vs. 94.7 ± 2.6 at 1 year and 65.6 ± 3.8% vs. 70.4 ± 10.4% at 15 years, respectively; p = .88). Upon multivariate logistic regression analysis preoperative mechanical circulatory support (odds ratio [OR] = 5.86) and preoperative intra-aortic balloon pump (IABP) (OR = 9.58) were independently associated with moderate/severe PGD. CONCLUSIONS Our results confirm that PGD is associated with poor in-hospital outcome. The poor outcome does not extend beyond the first month of follow-up, with comparable survival between patients with none/mild PGD and moderate/severe PGD in the short and long-term. Mechanical circulatory support and preoperative IABP were found to be independent risk factors for moderate/severe PGD.
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Affiliation(s)
- Fabrizio Settepani
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, Niguarda Hospital, Milan, Italy
| | - Giovanna L Pedrazzini
- Intensive Care Unit, Cardio-Thoraco-Vascular Department, Niguarda Hospital, Milan, Italy
| | - Guido M Olivieri
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, Niguarda Hospital, Milan, Italy
| | - Bruno Merlanti
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, Niguarda Hospital, Milan, Italy
| | - Aldo Cannata
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, Niguarda Hospital, Milan, Italy
| | - Marco Lanfranconi
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, Niguarda Hospital, Milan, Italy
| | - Maria Frigerio
- Cardiology 2 Unit, Cardio-Thoraco-Vascular Department, Niguarda Hospital, Milan, Italy
| | - Claudio F Russo
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, Niguarda Hospital, Milan, Italy
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38
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Ex-Vivo Preservation with the Organ Care System in High Risk Heart Transplantation. Life (Basel) 2022; 12:life12020247. [PMID: 35207534 PMCID: PMC8877453 DOI: 10.3390/life12020247] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 11/17/2022] Open
Abstract
Objective: Ex vivo organ perfusion is an advanced preservation technique that allows graft assessment and extended ex situ intervals. We hypothesized that its properties might be especially beneficial for high-risk recipients and/or donors with extended criteria. Methods: We reviewed the outcomes of 119 consecutive heart transplant patients, which were divided into two groups: A (OCS) vs. B (conventional). Ex vivo organ perfusion was performed using the Organ Care System (OCS). Indications for OCS-usage were expected ischemic time of >4 h or >2 h plus given extended donor criteria. Results: Both groups included mostly redo cases (A: 89.7% vs. B: 78.4%; p = 0.121). Incidences of donors with previous cardiac arrest (%) (A: 32.4 vs. B: 22.2; p < 0.05) or LV-hypertrophy (%) (A: 19.1 vs. B: 8.3; p = 0.119) were also increased in Group A. Ex situ time (min) was significantly longer in Group A (A: 381 (74) vs. B: 228 (43); p < 0.05). Ventilation time (days) (A: 10.0 (19.9) vs. B: 24.3 (43.2); p = 0.057), postoperative need for ECLS (%) (A: 25.0 vs. B: 39.2; p = 0.112) and postoperative dialysis (chronic) (%) (A: 4.4 vs. B: 27.5; p < 0.001) were numerically better in the OCS group, without any difference in the occurrence of early graft rejection. The 30-d-survival (A: 92.4% vs. B: 90.2%; p = 0.745) and mid-term survival were statistically not different between both groups. Conclusions: OCS heart allowed safe transplantation of surgically complex recipients with excellent one-year outcomes, despite long preservation times and unfavourable donor characteristics. Furthermore, we observed trends towards decreased ventilation times and fewer ECLS treatments. In times of reduced organ availability and increasing recipient complexity, OCS heart is a valuable instrument that enables otherwise infeasible allocations and contributes to increase surgical safety.
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39
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Coniglio AC, Patel CB, Kittleson M, Schlendorf K, Schroder JN, DeVore AD. Innovations in Heart Transplantation: A Review. J Card Fail 2021; 28:467-476. [PMID: 34752907 DOI: 10.1016/j.cardfail.2021.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/04/2021] [Accepted: 10/08/2021] [Indexed: 01/15/2023]
Abstract
Advanced heart failure affects tens of thousands of people in the United States alone with high morbidity and mortality. Cardiac transplantation offers the best treatment strategy but has been historically limited by donor availability. Recently, there have been significant advances in organ allocation, donor-recipient matching, organ preservation and expansion of the donor pool. The current heart allocation system prioritizes the sickest patients to minimize waitlist mortality. Advances in donor organ selection including predicted heart mass calculations and more sophisticated antibody detection methods for allosensitized patients offer more effective matching of donors and recipients. Innovations in organ preservation such as with organ preservation systems have geographically widened the donor pool. The use of hepatitis C donors is possible with the advent of effective direct-acting antiviral agents to cure donor-transmitted hepatitis C. Finally, further expansion of the donor pool is occurring with the utilization of higher-risk donors with advanced age, medical comorbidities, and left ventricular dysfunction and advances in donation after circulatory death. This review provides an update on the new technologies and transplantation strategies that serve to widen the donor pool and more effectively match donors and recipients so that heart transplant candidates may derive the best outcomes from heart transplantation.
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Affiliation(s)
- Amanda C Coniglio
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Chetan B Patel
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | | | | | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Adam D DeVore
- Department of Medicine, Duke University School of Medicine, Durham, NC.
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40
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van Suylen V, Vandendriessche K, Neyrinck A, Nijhuis F, van der Plaats A, Verbeken EK, Vermeersch P, Meyns B, Mariani MA, Rega F, Erasmus ME. Oxygenated machine perfusion at room temperature as an alternative for static cold storage in porcine donor hearts. Artif Organs 2021; 46:246-258. [PMID: 34633676 PMCID: PMC9298357 DOI: 10.1111/aor.14085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 06/15/2021] [Accepted: 10/05/2021] [Indexed: 01/06/2023]
Abstract
Background There is a continued interest in ex situ heart perfusion as an alternative strategy for donor heart preservation. We hypothesize that oxygenated machine perfusion of donor hearts at a temperature that avoids both normothermia and deep hypothermia offers adequate and safe preservation. Methods Cardioplegia‐arrested porcine donor hearts were randomly assigned to six hours of preservation using cold storage (CS, n = 5) or machine perfusion using an oxygenated acellular perfusate at 21°C (MP, n = 5). Subsequently, all grafts were evaluated using the Langendorff method for 120 min. Metabolic parameters and histology were analyzed. Systolic function was assessed by contractility and elastance. Diastolic function was assessed by lusitropy and stiffness. Results For both groups, in vivo baseline and post‐Langendorff biopsies were comparable, as were lactate difference and myocardial oxygen consumption. Injury markers gradually increased and were comparable. Significant weight gain was seen in MP (p = 0.008). Diastolic function was not impaired in MP, and lusitropy was superior from 30 min up to 90 min of reperfusion. Contractility was superior in MP during the first hour of evaluation. Conclusion We conclude that the initial functional outcome of MP‐preserved hearts was transiently superior compared to CS, with no histological injury post‐Langendorff. Our machine perfusion strategy could offer feasible and safe storage of hearts prior to transplantation. Future studies are warranted for further optimization.
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Affiliation(s)
- Vincent van Suylen
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Arne Neyrinck
- Laboratory of Experimental Thoracic Surgery, Department of Clinical and Experimental Medicine, Catholic University Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Erik K Verbeken
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Histopathology, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Vermeersch
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Filip Rega
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Michiel E Erasmus
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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41
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Hess NR, Kilic A. Heart transplantation in the current era: Thinking outside the box of normal donor criteria. J Card Surg 2021; 36:4830-4831. [PMID: 34558099 DOI: 10.1111/jocs.16022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiac Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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42
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Pinnelas R, Kobashigawa JA. Ex vivo normothermic perfusion in heart transplantation: a review of the TransMedics ® Organ Care System. Future Cardiol 2021; 18:5-15. [PMID: 34503344 DOI: 10.2217/fca-2021-0030] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Cardiac transplantation is the gold standard for treatment for select patients with end-stage heart failure, yet donor supply is limited. Ex vivo machine perfusion is an emerging technology capable of safely preserving organs and expanding the viable donor pool. The TransMedics® Organ Care System™ is an investigational device which mimics physiologic conditions while maintaining the heart in a warm, beating state rather than cold storage. The use of Organ Care System allows increased opportunities for using organs from marginal donors, distant procurement sites, donation after cardiac death, and in recipients with complex anatomy. In the future, bioengineering technologies including use of mesenchymal stem cells, viral vector delivery of gene therapy, and alternate devices may further broaden the field of ex vivo machine perfusion.
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43
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Al-Adhami A, Avtaar Singh SS, De SD, Singh R, Panjrath G, Shah A, Dalzell JR, Schroder J, Al-Attar N. Primary Graft Dysfunction after Heart Transplantation - Unravelling the Enigma. Curr Probl Cardiol 2021; 47:100941. [PMID: 34404551 DOI: 10.1016/j.cpcardiol.2021.100941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/09/2021] [Indexed: 11/03/2022]
Abstract
Primary graft dysfunction (PGD) remains the main cause of early mortality following heart transplantation despite several advances in donor preservation techniques and therapeutic strategies for PGD. With that aim of establishing the aetiopathogenesis of PGD and the preferred management strategies, the new consensus definition has paved the way for multiple contemporaneous studies to be undertaken and accurately compared. This review aims to provide a broad-based understanding of the pathophysiology, clinical presentation and management of PGD.
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Affiliation(s)
- Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK; Institute of Cardiovascular and Medical Sciences (ICAMS), University of Glasgow.
| | - Sudeep Das De
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ramesh Singh
- Mechanical Circulatory Support, Inova Health System, Falls Church, Virginia
| | - Gurusher Panjrath
- Heart Failure and Mechanical Circulatory Support Program, George Washington University Hospital, Washington, DC
| | - Amit Shah
- Advanced Heart Failure and Cardiac Transplant Unit, Fiona Stanley Hospital, Perth, Australia
| | - Jonathan R Dalzell
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, UK
| | - Jacob Schroder
- Heart Transplantation Program, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Nawwar Al-Attar
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK; Institute of Cardiovascular and Medical Sciences (ICAMS), University of Glasgow
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44
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Sponga S, Benedetti G, de Manna ND, Ferrara V, Vendramin I, Lechiancole A, Maiani M, Nalon S, Nalli C, Di Nora C, Bortolotti U, Livi U. Heart transplant outcomes in patients with mechanical circulatory support: cold storage versus normothermic perfusion organ preservation. Interact Cardiovasc Thorac Surg 2021; 32:476-482. [PMID: 33221874 DOI: 10.1093/icvts/ivaa280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 09/22/2020] [Accepted: 09/27/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Patients with mechanical circulatory support bridged to a heart transplant (HTx) are at higher risk of postoperative graft dysfunction. In this subset, a mode of graft preservation that shortens graft ischaemia should be beneficial. METHODS The outcomes of 38 patients on mechanical circulatory support (extracorporeal life support, left ventricular assist device and biventricular assist device) who received a HTx between 2015 and 2020 were analysed according to the method of graft preservation: cold storage (CS) group, 24 (63%) or ex vivo perfusion (EVP) group, 14 (37%). RESULTS The median age was 57 (range 30-73) vs 64 (35-75) years (P = 0.10); 88% were men (P = 0.28); extracorporeal life support was more frequent in the CS group (54% vs 36%; P = 0.27) versus left ventricular and biventricular assist devices in the EVP group (46% vs 64%; P = 0.27). Clamping time was shorter in the EVP group (P < 0.001) and ischaemic time >4 h was higher in the CS group (P = 0.01). Thirty-day mortality was 13% (0-27%) in the CS group and 0% (P = 0.28) in the EVP group. A significantly lower primary graft failure [7% (0-23%) vs 42% (20-63%); P = 0.03] was observed in the EVP group. Survival at 1 year was 79 ± 8% (63-95%) in the CS group and 84 ± 10% (64-104%) in the EVP group (P = 0.95). CONCLUSIONS Our results support the use of ex vivo graft perfusion in patients on mechanical circulatory support as a bridge to a HTx. This technique, by shortening graft ischaemic time, seems to improve post-HTx outcomes.
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Affiliation(s)
- Sandro Sponga
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | | | | | - Veronica Ferrara
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Igor Vendramin
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | | | - Massimo Maiani
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Sandro Nalon
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Chiara Nalli
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Concetta Di Nora
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Uberto Bortolotti
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Ugolino Livi
- Cardiothoracic Department, University Hospital of Udine, Udine, Italy
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45
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Rotar EP, Kron IL. Commentary: Planes, trains, and automobiles-Effective use of prolonged ex vivo heart preservation. J Card Surg 2021; 36:2596-2597. [PMID: 33783039 PMCID: PMC8187278 DOI: 10.1111/jocs.15520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 11/26/2022]
Abstract
Throughout the world, a shortage of donor organs has prompted development of unique strategies to expand the donor pool. Here, we review a report by Medressova and colleagues to the Journal of Cardiac Surgery detailing the 3-year follow-up of a patient who successfully underwent a heart transplant after 17 hours of ex-vivo preservation.
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Affiliation(s)
- Evan P. Rotar
- Division of Thoracic and Cardiovascular Surgery, Department
of Surgery, University of Virginia, Charlottesville, VA
| | - Irving L. Kron
- Division of Thoracic and Cardiovascular Surgery, Department
of Surgery, University of Virginia, Charlottesville, VA
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Heart Transplantation in Adult Congenital Heart Disease with the Organ Care System Use: A 4-Year Single-Center Experience. ASAIO J 2021; 67:862-868. [PMID: 34039886 DOI: 10.1097/mat.0000000000001482] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Recent advances in the management of patients with adult congenital heart disease (ACHD) have led to an increased number of patients who may develop heart failure and require heart transplantation (HTx). The purpose of this study was to evaluate early and mid-term postoperative outcomes after HTx with the use of Organ Care System (OCS) in a cohort of ACHD patients transplanted at our tertiary center. All consecutive HTx performed from January 2015 to January 2019 at our institution were analyzed. Donor and recipient preoperative characteristics, intraoperative course, and perioperative clinical outcomes were evaluated. Nine patients with median age of 44 years (range 17-61 years) underwent isolated HTx for end-stage ACHD during the study period. Mean cold ischemic time was 84 ± 17 minutes. Postoperatively, four patients (44%) needed venoarterial extracorporeal membrane oxygenation (1-7 days). One patient (11%) required surgical re-exploration for bleeding. Thirty-day and 1-year mortality were 11% and 22%, respectively. In our experience, despite the challenges of transplantation in ACHD, these patients can be successfully transplanted with the use of the OCS in a highly specialized center. Careful donor and recipient selection are of paramount importance.
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Tchouta LN, Alghanem F, Rojas-Pena A, Bartlett RH. Prolonged (≥24 Hours) Normothermic (≥32 °C) Ex Vivo Organ Perfusion: Lessons From the Literature. Transplantation 2021; 105:986-998. [PMID: 33031222 DOI: 10.1097/tp.0000000000003475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
For 2 centuries, researchers have studied ex vivo perfusion intending to preserve the physiologic function of isolated organs. If it were indeed possible to maintain ex vivo organ viability for days, transplantation could become an elective operation with clinicians methodically surveilling and reconditioning allografts before surgery. To this day, experimental reports of successfully prolonged (≥24 hours) organ perfusion are rare and have not translated into clinical practice. To identify the crucial factors necessary for successful perfusion, this review summarizes the history of prolonged normothermic ex vivo organ perfusion. By examining successful techniques and protocols used, this review outlines the essential elements of successful perfusion, limitations of current perfusion systems, and areas where further research in preservation science is required.
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Affiliation(s)
- Lise N Tchouta
- Department of Surgery, Columbia University Medical Center, New York, NY
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Fares Alghanem
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Central Michigan University College of Medicine, Mount Pleasant, MI
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Rhee Y, Kim HJ, Kim JJ, Kim MS, Lee SE, Yun TJ, Lee JW, Jung SH. Primary Graft Dysfunction After Isolated Heart Transplantation - Incidence, Risk Factors, and Clinical Implications Based on a Single-Center Experience. Circ J 2021; 85:1451-1459. [PMID: 33867405 DOI: 10.1253/circj.cj-20-0960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Since the international consensus on primary graft dysfunction (PGD) following heart transplantation (HT) was reported in 2014, few clinical studies have been reported. We aimed to analyze the incidence, predictive factors, and clinical implications of PGD following the International Society of Heart and Lung Transplant criteria in a single center.Methods and Results:This study enrolled 570 consecutive adult patients undergoing isolated HT between November 1992 and December 2017. Under a new set of criteria, PGD-left ventricle (PGD-LV) occurred in 35 patients (6.1%; mild, n=1 [0.2%]; moderate, n=14 [2.5%]; severe, n=20 [3.5%]), whereas PGD-right ventricle (PGD-RV) occurred in 3 (0.5%). Multivariable analysis demonstrated that preoperative admission (odds ratio [OR] 4.20; 95% confidence interval [CI] 1.24-14.26; P=0.021), preoperative extracorporeal membrane oxygenation (OR 4.03; 95% CI 1.75-9.26; P=0.001), and prolonged total ischemic time (OR 1.09; 95% CI 1.02-1.15; P=0.006) were significant predictors of moderate to severe PGD-LV. Moderate to severe PGD-LV was an independent and significant risk factor for early death (OR 55.64; 95% CI 11.65-265.73; P<0.001), with its effects extending up to 3 months after HT. CONCLUSIONS Moderate to severe PGD-LV, as defined by the new guidelines, is an important predictor of early mortality, with effects extending up to 3 months after HT. Efforts to reduce the occurrence of moderate to severe PGD-LV may lead to better outcomes.
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Affiliation(s)
- Younju Rhee
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jae-Joong Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine
| | - Min-Seok Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine
| | - Sang Eun Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine
| | - Tae-Jin Yun
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
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Johnstad CM, Fiedler AG. Coronary angiography utilization in the evaluation of a potential heart donor by age: a narrative review. J Thorac Dis 2021; 13:1864-1868. [PMID: 33841974 PMCID: PMC8024806 DOI: 10.21037/jtd-20-2547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Heart transplant is the gold standard treatment for patients with heart failure. The limitation to providing heart transplantation to patients suffering from end stage heart disease is the stable organ supply within the United States despite increasing demand. Transplant centers across the United States have begun to expand traditional cardiac donor selection metrics previously utilized. As a result, the use of extended criteria donors, such as older donors, those with longer ischemic times, and donors considered high risk has increased. Current guidelines suggest that coronary angiography be performed when evaluating a donor above the age of 45. Angiographic guidelines for evaluation of the donor heart are based specifically on age, with little evidence based guidance surrounding the use of angiography in a younger donor with comorbidities or increased risk behavior which may lead to premature coronary artery disease. Recently, we have seen an increase in younger heart donors, many of whom have succumbed due to drug overdose with ensuing high risk behaviors. Given the increased risk nature of these donors, consideration of performing coronary angiography is determined by clinical “gestalt” of the transplant center evaluating the heart for use, which may lead to underutilization of donor organs without evidence to support the practice. Here, we review the guidelines, literature, and controversy surrounding the use of coronary angiography in evaluating donor hearts for transplantation.
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Affiliation(s)
| | - Amy G Fiedler
- Division of Cardiothoracic Surgery, University of Wisconsin, Madison, WI, USA
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50
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Bona M, Wyss RK, Arnold M, Méndez-Carmona N, Sanz MN, Günsch D, Barile L, Carrel TP, Longnus SL. Cardiac Graft Assessment in the Era of Machine Perfusion: Current and Future Biomarkers. J Am Heart Assoc 2021; 10:e018966. [PMID: 33522248 PMCID: PMC7955334 DOI: 10.1161/jaha.120.018966] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Heart transplantation remains the treatment of reference for patients experiencing end‐stage heart failure; unfortunately, graft availability through conventional donation after brain death is insufficient to meet the demand. Use of extended‐criteria donors or donation after circulatory death has emerged to increase organ availability; however, clinical protocols require optimization to limit or prevent damage in hearts possessing greater susceptibility to injury than conventional grafts. The emergence of cardiac ex situ machine perfusion not only facilitates the use of extended‐criteria donor and donation after circulatory death hearts through the avoidance of potentially damaging ischemia during graft storage and transport, it also opens the door to multiple opportunities for more sensitive monitoring of graft quality. With this review, we aim to bring together the current knowledge of biomarkers that hold particular promise for cardiac graft evaluation to improve precision and reliability in the identification of hearts for transplantation, thereby facilitating the safe increase in graft availability. Information about the utility of potential biomarkers was categorized into 5 themes: (1) functional, (2) metabolic, (3) hormone/prohormone, (4) cellular damage/death, and (5) inflammatory markers. Several promising biomarkers are identified, and recommendations for potential improvements to current clinical protocols are provided.
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Affiliation(s)
- Martina Bona
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Rahel K Wyss
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Maria Arnold
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Natalia Méndez-Carmona
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Maria N Sanz
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Dominik Günsch
- Department of Anesthesiology and Pain Medicine/Institute for Diagnostic, Interventional and Paediatric Radiology Bern University HospitalInselspitalUniversity of Bern Switzerland
| | - Lucio Barile
- Laboratory for Cardiovascular Theranostics Cardiocentro Ticino Foundation and Faculty of Biomedical Sciences Università Svizzera Italiana Lugano Switzerland
| | - Thierry P Carrel
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
| | - Sarah L Longnus
- Department of Cardiovascular Surgery InselspitalBern University Hospital Bern Switzerland.,Department for BioMedical Research University of Bern Switzerland
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