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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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Honarmand K, Alshamsi F, Foroutan F, Rochwerg B, Belley-Cote E, Mclure G, D'Aragon F, Ball IM, Sener A, Selzner M, Guyatt G, Meade MO. Antemortem Heparin in Organ Donation After Circulatory Death Determination: A Systematic Review of the Literature. Transplantation 2021; 105:e337-e346. [PMID: 33901108 DOI: 10.1097/tp.0000000000003793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Donation after circulatory death determination frequently involves antemortem heparin administration to mitigate peri-arrest microvascular thrombosis. We systematically reviewed the literature to: (1) describe heparin administration practices and (2) explore the effects on transplant outcomes. We searched MEDLINE and EMBASE for studies reporting donation after circulatory death determination heparin practices including use, dosage, and timing (objective 1). To explore associations between antemortem heparin and transplant outcomes (objective 2), we (1) summarized within-study comparisons and (2) used meta-regression analyses to examine associations between proportions of donors that received heparin and transplant outcomes. We assessed risk of bias using the Newcastle Ottawa Scale and applied the GRADE methodology to determine certainty in the evidence. For objective 1, among 55 eligible studies, 48 reported heparin administration to at least some donors (range: 15.8%-100%) at variable doses (up to 1000 units/kg) and times relative to withdrawal of life-sustaining therapy. For objective 2, 7 studies that directly compared liver transplants with and without antemortem heparin reported lower rates of primary nonfunction, hepatic artery thrombosis, graft failure at 5 y, or recipient mortality (low certainty of evidence). In contrast, meta-regression analysis of 32 liver transplant studies detected no associations between the proportion of donors that received heparin and rates of early allograft dysfunction, primary nonfunction, hepatic artery thrombosis, biliary ischemia, graft failure, retransplantation, or patient survival (very low certainty of evidence). In conclusion, antemortem heparin practices vary substantially with an uncertain effect on transplant outcomes. Given the controversies surrounding antemortem heparin, clinical trials may be warranted.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Farid Foroutan
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Cote
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Graham Mclure
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Frederick D'Aragon
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Ian M Ball
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Alp Sener
- Department of Surgery and Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Markus Selzner
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Maureen O Meade
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
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Saemann L, Wenzel F, Kohl M, Korkmaz-Icöz S, Hoorn F, Loganathan S, Guo Y, Ding Q, Zhou P, Veres G, Karck M, Szabó G. Monitoring of perfusion quality and prediction of donor heart function during ex-vivo machine perfusion by myocardial microcirculation versus surrogate parameters. J Heart Lung Transplant 2021; 40:387-391. [PMID: 33726982 DOI: 10.1016/j.healun.2021.02.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/25/2021] [Accepted: 02/19/2021] [Indexed: 11/27/2022] Open
Abstract
Currently, lactate (Lac) is used to evaluate machine perfusion (MP) of hearts, donated after circulatory death (DCD). We hypothesize that monitoring of myocardial microcirculation (mLDP) by Laser-Doppler-Perfusion is superior to Lac to evaluate perfusion and predict contractility. In a pig model, DCD-hearts were perfused 4 hours followed by reperfusion and left ventricular contractility measurement. Lac and mLDP were measured every 30 min in successfully (N = 9) and unsuccessfully (N = 7) maintained hearts. Successfully maintained hearts showed decreasing Lac (5.6 to 2.8 mmol/L) and slightly downregulated (92%) mLDP. In unsuccessfully maintained hearts Lac first decreased (5.1 to 3.8 mmol/L) followed by increase and mLDP dropped to 39%. In a single-variable regression only mLDP showed a significant r² for systolic (0.514, p = 0.045) and diastolic (0.501, p = 0.049) parameters. The combination of mLDP and Lac (r2 = 0.876, p = 0.005) showed best results. mLDP seems to be superior to Lac to show perfusion disorders and predict DCD-heart contractility.
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Affiliation(s)
- Lars Saemann
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany; Department of Cardiac Surgery, University of Halle, Halle, Germany; Faculty Medical and Life Sciences, Furtwangen University, Villingen-Schwenningen, Germany.
| | - Folker Wenzel
- Faculty Medical and Life Sciences, Furtwangen University, Villingen-Schwenningen, Germany
| | - Matthias Kohl
- Faculty Medical and Life Sciences, Furtwangen University, Villingen-Schwenningen, Germany
| | - Sevil Korkmaz-Icöz
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Fabio Hoorn
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany; Faculty Medical and Life Sciences, Furtwangen University, Villingen-Schwenningen, Germany
| | - Sivakkanan Loganathan
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany; Department of Cardiac Surgery, University of Halle, Halle, Germany; Department of Anesthesiology, Ruhr-University Bochum, St. Josef- and St. Elisabeth Hospital, Bochum, Germany
| | - Yuxing Guo
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Qingwei Ding
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Pengyu Zhou
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gábor Veres
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany; Department of Cardiac Surgery, University of Halle, Halle, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gábor Szabó
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany; Department of Cardiac Surgery, University of Halle, Halle, Germany
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Saemann L, Guo Y, Ding Q, Zhou P, Karck M, Szabó G, Wenzel F. Machine perfusion of circulatory determined death hearts: A scoping review. Transplant Rev (Orlando) 2020; 34:100551. [PMID: 32498975 DOI: 10.1016/j.trre.2020.100551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/25/2020] [Accepted: 04/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ex vivo machine perfusion (EVMP) is reported to can successfully be applied for donor heart preservation. To respond to the organ shortage, some centres also accept hearts from marginal donors such as non-heart beating donors (NHBD) or hearts donated after cardiac death (DCD) for heart transplantation (HTx). Clinical as well as preclinical science on EVMP of DCD hearts seems to be promising but the ideal perfusion practice itself appears unclear. OBJECTIVES In accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA), this systematic review scopes all EVMP techniques for human and animal DCD heart preservation and addresses three specific questions, which refer to (a) the perfusion solutions, (b) the perfusion parameters and respective target values and (c) if possible, a direct comparison between cold static storage (CSS) and EVMP. RESULTS Search results predominantly consisted of animal studies. Either perfusion with a crystalloid or blood-based solution, each with cardioplegic or non-cardioplegic properties was used. Some perfusates were supplemented with specific pharmacological medication to block pathophysiological pathways, which are involved in ischemia/reperfusion injury or edema formation. Besides normothermic EVMP with oxygenated blood, a wide range of temperature was applied in all approaches, with the lowest temperature at 4 °C. Pressure controlled anterograde Langendorff perfusion was applied mostly. If investigated, crystalloid machine perfusion was presented superior to CSS. CONCLUSIONS Only blood based EVMP was introduced into clinical practice. More research, clinical as well as preclinical, is needed to develop the ideal EVMP technique, in terms of blood or crystalloid perfusion.
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Affiliation(s)
- Lars Saemann
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany; Faculty Medical and Life Sciences, Furtwangen University, Jakob-Kienzle-Straße 17, Villingen-Schwenningen 78054, Germany.
| | - Yuxing Guo
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Qingwei Ding
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Pengyu Zhou
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Gábor Szabó
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 326, Heidelberg 69120, Germany
| | - Folker Wenzel
- Faculty Medical and Life Sciences, Furtwangen University, Jakob-Kienzle-Straße 17, Villingen-Schwenningen 78054, Germany.
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Niederberger P, Farine E, Raillard M, Dornbierer M, Freed DH, Large SR, Chew HC, MacDonald PS, Messer SJ, White CW, Carrel TP, Tevaearai Stahel HT, Longnus SL. Heart Transplantation With Donation After Circulatory Death. Circ Heart Fail 2020; 12:e005517. [PMID: 30998395 DOI: 10.1161/circheartfailure.118.005517] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Heart transplantation remains the preferred option for improving quality of life and survival for patients suffering from end-stage heart failure. Unfortunately, insufficient supply of cardiac grafts has become an obstacle. Increasing organ availability with donation after circulatory death (DCD) may be a promising option to overcome the organ shortage. Unlike conventional donation after brain death, DCD organs undergo a period of warm, global ischemia between circulatory arrest and graft procurement, which raises concerns for graft quality. Nonetheless, the potential of DCD heart transplantation is being reconsidered, after reports of more than 70 cases in Australia and the United Kingdom over the past 3 years. Ensuring optimal patient outcomes and generalized adoption of DCD in heart transplantation, however, requires further development of clinical protocols, which in turn require a better understanding of cardiac ischemia-reperfusion injury and the various possibilities to limit its adverse effects. Thus, we aim to provide an overview of the knowledge obtained with preclinical studies in animal models of DCD heart transplantation, to facilitate and promote the most effective and efficient advancement in preclinical research. A literature search of the PubMed database was performed to identify all relevant preclinical studies in DCD heart transplantation. Specific aspects relevant for DCD heart transplantation were analyzed, including animal models, graft procurement and storage conditions, cardioprotective approaches, and graft evaluation strategies. Several potential therapeutic strategies for optimizing graft quality are identified, and recommendations for further preclinical research are provided.
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Affiliation(s)
- Petra Niederberger
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Emilie Farine
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Mathieu Raillard
- Experimental Surgery Unit (ESI), Experimental Surgery Unit, Department for BioMedical Research and Vetsuisse Faculty, Department of Clinical Veterinary Medicine, Institute of Anaesthesiology and Pain Therapy, University of Bern, Switzerland (M.R.)
| | - Monika Dornbierer
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Darren H Freed
- Cardiac Surgery, University of Alberta, Edmonton, Canada (D.H.F., C.W.W.)
| | - Stephen R Large
- Department of Transplantation, Royal Papworth Hospital, Papworth Everard, Cambridge, United Kingdom (S.R.L., S.J.M.)
| | - Hong C Chew
- St Vincent's Hospital, University of New South Wales, Victor Chang Cardiac Research Institute, Sydney, Australia (H.C.C., P.S.M.)
| | - Peter S MacDonald
- St Vincent's Hospital, University of New South Wales, Victor Chang Cardiac Research Institute, Sydney, Australia (H.C.C., P.S.M.)
| | - Simon J Messer
- Department of Transplantation, Royal Papworth Hospital, Papworth Everard, Cambridge, United Kingdom (S.R.L., S.J.M.)
| | | | - Thierry P Carrel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Hendrik T Tevaearai Stahel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Sarah L Longnus
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
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Gomes BS, Neto BPS, Lopes EM, Cunha FVM, Araújo AR, Wanderley CWS, Wong DVT, Júnior RCPL, Ribeiro RA, Sousa DP, Venes R Medeiros J, Oliveira RCM, Oliveira FA. Anti-inflammatory effect of the monoterpene myrtenol is dependent on the direct modulation of neutrophil migration and oxidative stress. Chem Biol Interact 2017; 273:73-81. [PMID: 28559105 DOI: 10.1016/j.cbi.2017.05.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 05/15/2017] [Accepted: 05/19/2017] [Indexed: 12/27/2022]
Abstract
Myrtenol is a bicyclic monoterpene with anti-inflammatory properties. However, the mechanisms involved are partially unknown. Here, we investigated the effect of myrtenol during experimental chronic arthritis and the possible modulating activity of oxidative stress and neutrophil migration. Complete Freund's Adjuvant (CFA)-sensitized rats were treated with vehicle (1 mL/kg, po), myrtenol (12.5, 25 or 50 mg/kg, po), indomethacin (10 mg/kg, po) or dexamethasone (0.4 mg/kg) followed by intra-articular injection of CFA (0.5 mg/mL, 50 μL per joint). Then, paw edema and articular incapacitation (paw elevation time) were evaluated for 14 days. On the last day, a blood concentration superoxide dismutase (SOD) and nitrite was determined. In another experimental setting, human neutrophils were incubated with vehicle (sterile saline, 1 mL) or myrtenol (10-100 ng/mL) and the in vitro chemotaxis to N-formylmethionine-leucyl-phenylalanine (fMLP) (10-7 M/well) was evaluated. In addition, antiinflammatory effect of myrtenol was investigated in carrageenan-induced peritonitis. We found that CFA induced a prominent paw swelling and incapacitation of the joint, which were significantly prevented by myrtenol (P < 0.05). In addition, blood accumulation nitrite was attenuated by myrtenol when compared with vehicle-treated CFA group (P < 0.05). Furthermore, plasma levels of SOD were significantly increased by myrtenol versus vehicle-treated CFA group (P < 0.05). Moreover, fMLP-triggered neutrophil chemotaxis and carrageenan-induced peritonitis were markedly prevented by myrtenol (P < 0.05). Therefore, myrtenol showed anti-inflammatory and antinociceptive effects on experimental chronic arthritis, which seems to be related to the direct modulation of neutrophil migration and antioxidant activity.
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Affiliation(s)
- Bruno S Gomes
- Medicinal Plants Research Center, Federal University of Piauí, Teresina, Piauí, Brazil.
| | - Benedito P S Neto
- Medicinal Plants Research Center, Federal University of Piauí, Teresina, Piauí, Brazil
| | - Everton M Lopes
- Medicinal Plants Research Center, Federal University of Piauí, Teresina, Piauí, Brazil
| | - Francisco V M Cunha
- Medicinal Plants Research Center, Federal University of Piauí, Teresina, Piauí, Brazil
| | - Alyne R Araújo
- Medicinal Plants Research Center, Federal University of Piauí, Teresina, Piauí, Brazil
| | - Carlos W S Wanderley
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Deysi V T Wong
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Roberto César P L Júnior
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Ronaldo A Ribeiro
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil
| | - Damião P Sousa
- Department of Pharmaceutical Sciences, Federal University of Parnaíba, João Pessoa, Paraíba, Brazil
| | - Jand Venes R Medeiros
- Medicinal Plants Research Center, Federal University of Piauí, Teresina, Piauí, Brazil
| | - Rita C M Oliveira
- Medicinal Plants Research Center, Federal University of Piauí, Teresina, Piauí, Brazil
| | - Francisco A Oliveira
- Medicinal Plants Research Center, Federal University of Piauí, Teresina, Piauí, Brazil
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Desrois M, Piccardo A, Zogheib E, Dalmasso C, Lan C, Fourré D, Cozzone P, Caus T, Bernard M. Heart Donation After Cardiac Death: Preliminary Study on an Isolated, Perfused Swine Heart After 20 Minutes of Normothermic Ischemia. Transplant Proc 2014; 46:3314-8. [DOI: 10.1016/j.transproceed.2014.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 04/22/2014] [Indexed: 10/24/2022]
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Longnus SL, Mathys V, Dornbierer M, Dick F, Carrel TP, Tevaearai HT. Heart transplantation with donation after circulatory determination of death. Nat Rev Cardiol 2014; 11:354-63. [DOI: 10.1038/nrcardio.2014.45] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Advances in heart transplantation: The year in review. J Heart Lung Transplant 2011; 30:241-6. [DOI: 10.1016/j.healun.2010.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Accepted: 10/22/2010] [Indexed: 12/19/2022] Open
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