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Messer SJ, Axell RG, Colah S, White PA, Ryan M, Page AA, Parizkova B, Valchanov K, White CW, Freed DH, Ashley E, Dunning J, Goddard M, Parameshwar J, Watson CJ, Krieg T, Ali A, Tsui S, Large SR. Functional assessment and transplantation of the donor heart after circulatory death. J Heart Lung Transplant 2016; 35:1443-1452. [PMID: 27916176 DOI: 10.1016/j.healun.2016.07.004] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 06/06/2016] [Accepted: 07/13/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND After a severe shortage of brain-dead donors, the demand for heart transplantation has never been greater. In an attempt to increase organ supply, abdominal and lung transplant programs have turned to the donation after circulatory-determined death (DCD) donor. However, because heart function cannot be assessed after circulatory death, DCD heart transplantation was deemed high risk and never adopted routinely. We report a novel method of functional assessment of the DCD heart resulting in a successful clinical program. METHODS Normothermic regional perfusion (NRP) was used to restore function to the arrested DCD heart within the donor after exclusion of the cerebral circulation. After weaning from support, DCD hearts underwent functional assessment with cardiac-output studies, echocardiography, and pressure-volume loops. In the feasibility phase, hearts were transported perfused before evaluation of function in modified working mode extracorporeally. After the establishment of a reliable assessment technique, hearts with demonstrable good function were then selected for clinical transplantation. RESULTS NRP was instituted in 13 adult DCD donors, median age of 33 years (interquartile range [IQR], 28-38 years), after a median ischemic time from withdrawal to perfusion of 24 minutes (IQR, 21-29; range, 17-146 minutes). Two of 4 hearts in the feasibility phase were unsuitable for transplantation after functional assessment. Nine DCD hearts were transplanted in the clinical phase, with 100% survival. The median intensive care duration was 5 days (IQR, 4-5 days), with 2 patients requiring mechanical support. There were no episodes of rejection (total, 1,436 patient-days; range, 48-297). During the same period, we performed 20 standard heart transplants using brain-dead donors. CONCLUSIONS NRP allows rapid reperfusion and functional assessment of the DCD donor heart, ensuring only viable hearts are selected for transplantation. This technique minimizes the risk of primary graft dysfunction and maximizes confidence in DCD heart transplantation, realizing a 45% increase in our heart transplant activity.
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Affiliation(s)
- Simon J Messer
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Richard G Axell
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Simon Colah
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Paul A White
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Marian Ryan
- Eastern Region Specialist Nurses in Organ Donation, NHS Blood and Transplant, Cambridge, United Kingdom
| | - Aravinda A Page
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Barbora Parizkova
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Kamen Valchanov
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Christopher W White
- Division of Cardiac Surgery, University of Alberta Hospital, Manankowiski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, University of Alberta Hospital, Manankowiski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Euan Ashley
- Falk Cardiovascular Research Center, Stanford University School of Medicine, Palo Alto, California
| | - John Dunning
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Martin Goddard
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Jayan Parameshwar
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Christopher J Watson
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Thomas Krieg
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Ayyaz Ali
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Steven Tsui
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom
| | - Stephen R Large
- Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom.
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Messer S, Ardehali A, Tsui S. Normothermic donor heart perfusion: current clinical experience and the future. Transpl Int 2014; 28:634-42. [PMID: 24853906 DOI: 10.1111/tri.12361] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 03/05/2014] [Accepted: 05/19/2014] [Indexed: 11/28/2022]
Abstract
Following the first successful heart transplant in 1967, more than 100,000 heart transplants have been carried out worldwide. These procedures have mostly relied on cold ischaemic preservation of the donor heart because this simple technique is inexpensive and relatively reliable. However, the well-known limitations of cold ischaemic preservation imposes significant logistical challenges to heart transplantation which put a ceiling on the immediate success on this life-saving therapy, and limits the number of donor hearts that can be safely transplanted annually. Although the theoretical advantages of normothermic donor heart perfusion have been recognised for over a century, the technology to transport donor hearts in this state has only been developed within the last decade. The Organ Care System (OCS) which is designed and manufactured by TransMedics Inc. is currently the only commercially available device with this capability. This article reviews the history of normothermic heart perfusion and the clinical experience with the TransMedics OCS to date. We have also attempted to speculate on the future possibilities of this innovative and exciting technology.
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Affiliation(s)
- Simon Messer
- Transplant Unit, Papworth Hospital, Cambridgeshire, UK
| | - Abbas Ardehali
- Division of Cardiothoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Steven Tsui
- Transplant Unit, Papworth Hospital, Cambridgeshire, UK
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