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Peled Y, Kittleson MM. Discovering the limits of the possible: Two can play that game. J Heart Lung Transplant 2024; 43:1263-1265. [PMID: 38705501 DOI: 10.1016/j.healun.2024.04.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 04/25/2024] [Indexed: 05/07/2024] Open
Affiliation(s)
- Yael Peled
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, 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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Zhou AL, Rizaldi AA, Akbar AF, Ruck JM, King EA, Kilic A. Outcomes following concomitant multiorgan heart transplantation from circulatory death donors: The United States experience. J Heart Lung Transplant 2024; 43:1252-1262. [PMID: 38548240 DOI: 10.1016/j.healun.2024.03.013] [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: 09/11/2023] [Revised: 02/03/2024] [Accepted: 03/16/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Donation after circulatory death (DCD) has reemerged as a method of expanding the donor heart pool. Given the high waitlist mortality of multiorgan heart candidates, we evaluated waitlist outcomes associated with willingness to consider DCD offers and post-transplant outcomes following DCD transplant for these candidates. METHODS We identified adult multiorgan heart candidates and recipients between January 1, 2020 and March 31, 2023 nationally. Among candidates that met inclusion criteria, we compared the cumulative incidence of transplant, with waitlist death/deterioration as a competing risk, by willingness to consider DCD offers. Among recipients of DCD versus brain death (DBD) transplants, we compared perioperative outcomes and post-transplant survival. RESULTS Of 1,802 heart-kidney, 266 heart-liver, and 440 heart-lung candidates, 15.8%, 12.4%, and 31.1%, respectively, were willing to consider DCD offers. On adjusted analysis, willingness to consider DCD offers was associated with higher likelihood of transplant for all multiorgan heart candidates and decreased likelihood of waitlist deterioration for heart-lung candidates. Of 1,100 heart-kidney, 173 heart-liver, and 159 heart-lung recipients, 5.4%, 2.3%, and 2.5%, respectively, received DCD organs. Recipients of DCD and DBD heart-kidney transplants had a similar likelihood of perioperative outcomes and 1-year survival. All other DCD multiorgan heart recipients have survived to the last follow-up. CONCLUSIONS Multiorgan heart candidates who were willing to consider DCD offers had favorable waitlist outcomes, and heart-kidney recipients of DCD transplants had similar post-transplant outcomes to recipients of DBD transplants. We recommend the use of DCD organs to increase the donor pool for these high-risk candidates.
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Affiliation(s)
- Alice L Zhou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Alexandra A Rizaldi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Armaan F Akbar
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jessica M Ruck
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Elizabeth A King
- Division of Transplant Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
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3
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Hubacher V, Egle M, Graf S, Arnold M, Segiser A, Sanz MN, Casoni D, Garcia Casalta L, Nettelbeck K, Mihalj M, Siepe M, Kadner A, Longnus S. Open- vs. closed-chest pig models of donation after circulatory death. Front Cardiovasc Med 2024; 11:1325160. [PMID: 38938649 PMCID: PMC11210375 DOI: 10.3389/fcvm.2024.1325160] [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: 10/20/2023] [Accepted: 05/27/2024] [Indexed: 06/29/2024] Open
Abstract
Background During donation after circulatory death (DCD), cardiac grafts are exposed to potentially damaging conditions that can impact their quality and post-transplantation outcomes. In a clinical DCD setting, patients have closed chests in most cases, while many experimental models have used open-chest conditions. We therefore aimed to investigate and characterize differences in open- vs. closed-chest porcine models. Methods Withdrawal of life-sustaining therapy (WLST) was simulated in anesthetized juvenile male pigs by stopping mechanical ventilation following the administration of a neuromuscular block. Functional warm ischemic time (fWIT) was defined to start when systolic arterial pressure was <50 mmHg. Hemodynamic changes and blood chemistry were analyzed. Two experimental groups were compared: (i) an open-chest group with sternotomy prior to WLST and (ii) a closed-chest group with sternotomy after fWIT. Results Hemodynamic changes during the progression from WLST to fWIT were initiated by a rapid decline in blood oxygen saturation and a subsequent cardiovascular hyperdynamic (HD) period characterized by temporary elevations in heart rates and arterial pressures in both groups. Subsequently, heart rate and systolic arterial pressure decreased until fWIT was reached. Pigs in the open-chest group displayed a more rapid transition to the HD phase after WLST, with peak heart rate and peak rate-pressure product occurring significantly earlier. Furthermore, the HD phase duration tended to be shorter and less intense (lower peak rate-pressure product) in the open-chest group than in the closed-chest group. Discussion Progression from WLST to fWIT was more rapid, and the hemodynamic changes tended to be less pronounced in the open-chest group than in the closed-chest group. Our findings support clear differences between open- and closed-chest models of DCD. Therefore, recommendations for clinical DCD protocols based on findings in open-chest models must be interpreted with care.
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Affiliation(s)
- Valentin Hubacher
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Manuel Egle
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Selianne Graf
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Maria Arnold
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Adrian Segiser
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Maria Nieves Sanz
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Daniela Casoni
- Experimental Surgery Facility (ESF), Experimental Animal Center, Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Luisana Garcia Casalta
- Experimental Surgery Facility (ESF), Experimental Animal Center, Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Kay Nettelbeck
- Experimental Surgery Facility (ESF), Experimental Animal Center, Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Maks Mihalj
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas Health Science Center at Houston, Texas Medical Center, Houston, TX, United States
| | - Matthias Siepe
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Kadner
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sarah Longnus
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
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4
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Sonnenberg EM, Abu-Gazala S, Bittermann T, Abt PL. Following the Flow: Changes in Organ Preservation Methods Require Changes in Our Data Collection. Transplantation 2024; 108:1265-1268. [PMID: 38291568 DOI: 10.1097/tp.0000000000004920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
| | - Samir Abu-Gazala
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
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5
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Bommareddi S, Lima B, Shah AS, Trahanas JM. Thoraco-abdominal normothermic regional perfusion for thoracic transplantation in the United States: current state and future directions. Curr Opin Organ Transplant 2024; 29:180-185. [PMID: 38483139 DOI: 10.1097/mot.0000000000001143] [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: 04/30/2024]
Abstract
PURPOSE OF REVIEW To provide an update regarding the state of thoracoabdominal normothermic regional perfusion (taNRP) when used for thoracic organ recovery. RECENT FINDINGS taNRP is growing in its utilization for thoracic organ recovery from donation after circulatory death donors, partly because of its cost effectiveness. taNRP has been shown to yield cardiac allograft recipient outcomes similar to those of brain-dead donors. Regarding the use of taNRP to recover donor lungs, United Network for Organ Sharing (UNOS) analysis shows that taNRP recovered lungs are noninferior, and taNRP has been used to consistently recover excellent lungs at high volume centers. Despite its growth, ethical debate regarding taNRP continues, though clinical data now supports the notion that there is no meaningful brain perfusion after clamping the aortic arch vessels. SUMMARY taNRP is an excellent method for recovering both heart and lungs from donation after circulatory death donors and yields satisfactory recipient outcomes in a cost-effective manner. taNRP is now endorsed by the American Society of Transplant Surgeons, though ethical debate continues.
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Affiliation(s)
- Swaroop Bommareddi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Hess NR, Hong Y, Yoon P, Bonatti J, Sultan I, Serna-Gallegos D, Chu D, Hickey GW, Keebler ME, Kaczorowski DJ. Donation after circulatory death improves probability of heart transplantation in waitlisted candidates and results in post-transplant outcomes similar to those achieved with brain-dead donors. J Thorac Cardiovasc Surg 2024; 167:1845-1860.e12. [PMID: 37714368 DOI: 10.1016/j.jtcvs.2023.09.012] [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: 05/04/2023] [Revised: 08/14/2023] [Accepted: 09/04/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVE To quantitate the impact of heart donation after circulatory death (DCD) donor utilization on both waitlist and post-transplant outcomes in the United States. METHODS The United Network for Organ Sharing database was queried to identify all adult waitlisted and transplanted candidates between October 18, 2018, and December 31, 2022. Waitlisted candidates were stratified according to whether they had been approved for donation after brain death (DBD) offers only or also approved for DCD offers. The cumulative incidence of transplantation was compared between the 2 cohorts. In a post-transplant analysis, 1-year post-transplant survival was compared between unmatched and propensity-score-matched cohorts of DBD and DCD recipients. RESULTS A total of 14,803 candidates were waitlisted, including 12,287 approved for DBD donors only and 2516 approved for DCD donors. Overall, DCD approval was associated with an increased sub-hazard ratio (HR) for transplantation and a lower sub-HR for delisting owing to death/deterioration after risk adjustment. In a subgroup analysis, candidates with blood type B and status 4 designation received the greatest benefit from DCD approval. A total of 12,238 recipients underwent transplantation, 11,636 with DBD hearts and 602 with DCD hearts. Median waitlist times were significantly shorter for status 3 and status 4 recipients receiving DCD hearts. One-year post-transplant survival was comparable between unmatched and propensity score-matched cohorts of DBD and DCD recipients. CONCLUSIONS The use of DCD hearts confers a higher probability of transplantation and a lower incidence of death/deterioration while on the waitlist, particularly among certain subpopulations such as status 4 candidates. Importantly, the use of DCD donors results in similar post-transplant survival as DBD donors.
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Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Yeahwa Hong
- Department of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Pyongsoo Yoon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Johannes Bonatti
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Gavin W Hickey
- Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Mary E Keebler
- Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - David J Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Truby LK, Kwee LC, Bowles DE, Casalinova S, Ilkayeva O, Muehlbauer MJ, Huebner JL, Holley CL, DeVore AD, Patel CB, Kang L, Pla MM, Gross R, McGarrah RW, Schroder JN, Milano CA, Shah SH. Metabolomic profiling during ex situ normothermic perfusion before heart transplantation defines patterns of substrate utilization and correlates with markers of allograft injury. J Heart Lung Transplant 2024; 43:716-726. [PMID: 38065238 DOI: 10.1016/j.healun.2023.12.002] [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: 04/05/2023] [Revised: 11/21/2023] [Accepted: 12/02/2023] [Indexed: 12/22/2023] Open
Abstract
BACKGROUND Cardiac metabolism is altered in heart failure and ischemia-reperfusion injury states. We hypothesized that metabolomic profiling during ex situ normothermic perfusion before heart transplantation (HT) would lend insight into myocardial substrate utilization and report on subclinical and clinical allograft dysfunction risk. METHODS Metabolomic profiling was performed on serial samples of ex situ normothermic perfusate assaying biomarkers of myocardial injury in lactate and cardiac troponin I (TnI) as well as metabolites (66 acylcarnitines, 15 amino acids, nonesterified fatty acids [NEFA], ketones, and 3-hydroxybutyrate). We tested for change over time in injury biomarkers and metabolites, along with differential changes by recovery strategy (donation after circulatory death [DCD] vs donation after brain death [DBD]). We examined associations between metabolites, injury biomarkers, and primary graft dysfunction (PGD). Analyses were performed using linear mixed models adjusted for recovery strategy, assay batch, donor-predicted heart mass, and time. RESULTS A total of 176 samples from 92 ex situ perfusion runs were taken from donors with a mean age of 35 (standard deviation 11.3) years and a median total ex situ perfusion time of 234 (interquartile range 84) minutes. Lactate trends over time differed significantly by recovery strategy, while TnI increased during ex situ perfusion regardless of DCD vs DBD status. We found fuel substrates were rapidly depleted during ex situ perfusion, most notably the branched-chain amino acids leucine/isoleucine, as well as ketones, 3-hydroxybutyrate, and NEFA (least squares [LS] mean difference from the first to last time point -1.7 to -4.5, false discovery rate q < 0.001). Several long-chain acylcarnitines (LCAC), including C16, C18, C18:1, C18:2, C18:3, C20:3, and C20:4, increased during the perfusion run (LS mean difference 0.42-0.67, q < 0.001). Many LCACs were strongly associated with lactate and TnI. The change over time of many LCACs was significantly different for DCD vs DBD, suggesting differential trends in fuel substrate utilization by ischemic injury pattern. Changes in leucine/isoleucine, arginine, C12:1-OH/C10:1-DC, and C16-OH/C14-DC were associated with increased odds of moderate-severe PGD. Neither end-of-run nor change in lactate or TnI was associated with PGD. CONCLUSIONS Metabolomic profiling of ex situ normothermic perfusion solution reveals a pattern of fuel substrate utilization that correlates with subclinical and clinical allograft dysfunction. This study highlights a potential role for interventions focused on fuel substrate modification in allograft conditioning during ex situ perfusion to improve allograft outcomes.
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Affiliation(s)
- Lauren K Truby
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Dawn E Bowles
- Duke University Medical Center, Durham, North Carolina
| | | | - Olga Ilkayeva
- Duke Molecular Physiology Institute, Durham, North Carolina
| | | | | | | | - Adam D DeVore
- Duke University Medical Center, Durham, North Carolina
| | | | - Lillian Kang
- Duke University Medical Center, Durham, North Carolina
| | | | - Ryan Gross
- Duke University Medical Center, Durham, North Carolina
| | | | | | | | - Svati H Shah
- Duke Molecular Physiology Institute, Durham, North Carolina.
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Hong Y, Hess NR, Ziegler LA, Chu D, Yoon PD, Bonatti JO, Serna-Gallegos DR, Sultan I, Kaczorowski DJ. Can we safely expand the donation after circulatory death donor heart pool by extending the donor age limit? J Thorac Cardiovasc Surg 2024:S0022-5223(24)00295-2. [PMID: 38688447 DOI: 10.1016/j.jtcvs.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE This study evaluates the impact of donor age on outcomes following donation after circulatory death heart transplantation. METHODS The United Network for Organ Sharing registry was queried to analyze adult recipients who underwent isolated donation after circulatory heart transplantation from January 1, 2019, to September 30, 2023. The cohort was stratified into 2 groups according to donor age, where advanced donor age was defined as 40 years or more. Outcomes were 90-day and 1-year post-transplant survival. Propensity score matching was performed. Subgroup analysis was performed to evaluate the effects of recipient age on 90-day survival among the recipients with advanced-age donors. RESULTS A total of 994 recipients were included in the study period, and 161 patients (17.1%) received allografts from advanced-age donors. During the study period, the annual incidence of donation after circulatory heart transplantation with advanced-age donors substantially increased. The recipients with advanced-age donors had similar 90-day and 1-year post-transplant survivals compared with the recipients with younger donors. The comparable 90-day survival persisted in a propensity score-matched comparison. In the subgroup analysis among the recipients with advanced-age donors, the recipients aged 60 years or more had significantly reduced 90-day survival compared with the recipients aged less than 60 years. CONCLUSIONS The use of appropriately selected donation after circulatory donors aged 40 years or more has similar survival compared with that of younger donors. With careful candidate risk stratification and selection, consideration of using donation after circulatory donors aged more than 40 years may further ameliorate ongoing organ shortage with comparable early post-transplant outcomes.
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Affiliation(s)
- Yeahwa Hong
- Department of Cardiothoracic Surgery at the University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Nicholas R Hess
- Department of Cardiothoracic Surgery at the University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Luke A Ziegler
- Department of Cardiothoracic Surgery at the University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Danny Chu
- Department of Cardiothoracic Surgery at the University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Pyongsoo D Yoon
- Department of Cardiothoracic Surgery at the University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Johannes O Bonatti
- Department of Cardiothoracic Surgery at the University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek R Serna-Gallegos
- Department of Cardiothoracic Surgery at the University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery at the University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - David J Kaczorowski
- Department of Cardiothoracic Surgery at the University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Egle M, Mendez-Carmona N, Segiser A, Graf S, Siepe M, Longnus S. Hypothermic Oxygenated Perfusion Improves Vascular and Contractile Function by Preserving Endothelial Nitric Oxide Production in Cardiac Grafts Obtained With Donation After Circulatory Death. J Am Heart Assoc 2024; 13:e033503. [PMID: 38606732 DOI: 10.1161/jaha.123.033503] [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: 12/14/2023] [Accepted: 03/01/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Cardiac donation after circulatory death is a promising option to increase graft availability. Graft preservation with 30 minutes of hypothermic oxygenated perfusion (HOPE) before normothermic machine perfusion may improve cardiac recovery as compared with cold static storage, the current clinical standard. We investigated the role of preserved nitric oxide synthase activity during HOPE on its beneficial effects. METHODS AND RESULTS Using a rat model of donation after circulatory death, hearts underwent in situ ischemia (21 minutes), were explanted for a cold storage period (30 minutes), and then reperfused under normothermic conditions (60 minutes) with left ventricular loading. Three cold storage conditions were compared: cold static storage, HOPE, and HOPE with Nω-nitro-L-arginine methyl ester (nitric oxide synthase inhibitor). To evaluate potential confounding effects of high coronary flow during early reperfusion in HOPE hearts, bradykinin was administered to normalize coronary flow to HOPE levels in 2 additional groups (cold static storage and HOPE with Nω-nitro-L-arginine methyl ester). Cardiac recovery was significantly improved in HOPE versus cold static storage hearts, as determined by cardiac output, left ventricular work, contraction and relaxation rates, and coronary flow (P<0.05). Furthermore, HOPE attenuated postreperfusion calcium overload. Strikingly, the addition of Nω-nitro-L-arginine methyl ester during HOPE largely abolished its beneficial effects, even when early reperfusion coronary flow was normalized to HOPE levels. CONCLUSIONS HOPE provides superior preservation of ventricular and vascular function compared with the current clinical standard. Importantly, HOPE's beneficial effects require preservation of nitric oxide synthase activity during the cold storage. Therefore, the application of HOPE before normothermic machine perfusion is a promising approach to optimize graft recovery in donation after circulatory death cardiac grafts.
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Affiliation(s)
- Manuel Egle
- Department of Cardiac Surgery Inselspital, Bern University Hospital, University of Bern Switzerland
- Department for BioMedical Research University of Bern Switzerland
- Graduate School for Cellular and Biomedical Sciences University of Bern Switzerland
| | - Natalia Mendez-Carmona
- Department of Cardiac Surgery Inselspital, Bern University Hospital, University of Bern Switzerland
- Department for BioMedical Research University of Bern Switzerland
| | - Adrian Segiser
- Department of Cardiac Surgery Inselspital, Bern University Hospital, University of Bern Switzerland
- Department for BioMedical Research University of Bern Switzerland
| | - Selianne Graf
- Department of Cardiac Surgery Inselspital, Bern University Hospital, University of Bern Switzerland
- Department for BioMedical Research University of Bern Switzerland
- Graduate School for Cellular and Biomedical Sciences University of Bern Switzerland
| | - Matthias Siepe
- Department of Cardiac Surgery Inselspital, Bern University Hospital, University of Bern Switzerland
| | - Sarah Longnus
- Department of Cardiac Surgery Inselspital, Bern University Hospital, University of Bern Switzerland
- Department for BioMedical Research University of Bern Switzerland
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10
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Arnold M, Do P, Davidson SM, Large SR, Helmer A, Beer G, Siepe M, Longnus SL. Metabolic Considerations in Direct Procurement and Perfusion Protocols with DCD Heart Transplantation. Int J Mol Sci 2024; 25:4153. [PMID: 38673737 PMCID: PMC11050041 DOI: 10.3390/ijms25084153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024] Open
Abstract
Heart transplantation with donation after circulatory death (DCD) provides excellent patient outcomes and increases donor heart availability. However, unlike conventional grafts obtained through donation after brain death, DCD cardiac grafts are not only exposed to warm, unprotected ischemia, but also to a potentially damaging pre-ischemic phase after withdrawal of life-sustaining therapy (WLST). In this review, we aim to bring together knowledge about changes in cardiac energy metabolism and its regulation that occur in DCD donors during WLST, circulatory arrest, and following the onset of warm ischemia. Acute metabolic, hemodynamic, and biochemical changes in the DCD donor expose hearts to high circulating catecholamines, hypoxia, and warm ischemia, all of which can negatively impact the heart. Further metabolic changes and cellular damage occur with reperfusion. The altered energy substrate availability prior to organ procurement likely plays an important role in graft quality and post-ischemic cardiac recovery. These aspects should, therefore, be considered in clinical protocols, as well as in pre-clinical DCD models. Notably, interventions prior to graft procurement are limited for ethical reasons in DCD donors; thus, it is important to understand these mechanisms to optimize conditions during initial reperfusion in concert with graft evaluation and re-evaluation for the purpose of tailoring and adjusting therapies and ensuring optimal graft quality for transplantation.
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Affiliation(s)
- Maria Arnold
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department for BioMedical Research, University of Bern, 3008 Bern, Switzerland
| | - Peter Do
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Sean M. Davidson
- The Hatter Cardiovascular Institute, University College London, London WC1E 6HX, UK
| | - Stephen R. Large
- Royal Papworth Hospital, Biomedical Campus, Cambridge CB2 0AY, UK
| | - Anja Helmer
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department for BioMedical Research, University of Bern, 3008 Bern, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, 3012 Bern, Switzerland
| | - Georgia Beer
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department for BioMedical Research, University of Bern, 3008 Bern, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, 3012 Bern, Switzerland
| | - Matthias Siepe
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Sarah L. Longnus
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department for BioMedical Research, University of Bern, 3008 Bern, Switzerland
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11
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Cui EY, Gouchoe DA, Salmon-Rekhi ST, Whitson BA, Black SM. An Unexpected Partnership: Alexis Carrel, Charles Lindbergh, and Normothermic Machine Perfusion. ASAIO J 2024:00002480-990000000-00459. [PMID: 38595100 DOI: 10.1097/mat.0000000000002205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Organ transplantation is a triumph of modern medicine which represents a culmination of science and imagination, saving thousands of lives a year. However, transplantation is severely limited by suitable donor allografts. To expand the donor pool and make transplantation achievable for all, normothermic machine perfusion (NMP) is being employed more frequently. Normothermic machine perfusion involves the utilization of a device to approximate the physiology of the human body, preserve organs outside of the donor, and provide a dynamic assessment platform to determine organ suitability for transplantation. As NMP technology advances, it will soon be possible to genetically modify and actively repair these organs. Although its application to the field of transplantation is relatively new, the concept, foundation, and development of NMP can be traced back to the pioneering work of the surgeon-scientist, Alexis Carrel and the famous aviator, Charles Lindbergh in the 1930s. Their collaboration resulted in the Carrel-Lindbergh Perfusion device, an early perfusion device that was able to keep organs alive ex vivo for weeks and is most appropriately viewed as a precursor to modern machine perfusion technologies. As NMP technology becomes more advanced and refined, it is important to acknowledge the historical context in which these technologies emerged.
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Affiliation(s)
- Ervin Y Cui
- From the Division of Cardiac Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Doug A Gouchoe
- From the Division of Cardiac Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
- Department of Surgery, The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Suhavi T Salmon-Rekhi
- Department of Surgery, The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bryan A Whitson
- From the Division of Cardiac Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
- Department of Surgery, The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sylvester M Black
- From the Division of Cardiac Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio
- Department of Surgery, The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Department of Surgery, Comprehensive Transplant Center, The Ohio State University Wexner Medical Center, Columbus, Ohio
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12
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Zong J, Ye W, Yu J, Zhang X, Cui J, Chen Z, Li Y, Wang S, Ran S, Niu Y, Luo Z, Li X, Zhao J, Hao Y, Xia J, Wu J. Outcomes of Heart Transplantation From Donation After Circulatory Death: An Up-to-Date Systematic Meta-analysis. Transplantation 2024:00007890-990000000-00720. [PMID: 38578698 DOI: 10.1097/tp.0000000000005017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
BACKGROUND Donation after circulatory death (DCD) heart transplantation (HTx) significantly expands the donor pool and reduces waitlist mortality. However, high-level evidence-based data on its safety and effectiveness are lacking. This meta-analysis aimed to compare the outcomes between DCD and donation after brain death (DBD) HTxs. METHODS Databases, including MEDLINE, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials, were systematically searched for randomized controlled trials and observational studies reporting the outcomes of DCD and DBD HTxs published from 2014 onward. The data were pooled using random-effects models. Risk ratios (RRs) with 95% confidence intervals (CIs) were used as the summary measures for categorical outcomes and mean differences were used for continuous outcomes. RESULTS Twelve eligible studies were included in the meta-analysis. DCD HTx was associated with lower 1-y mortality rate (DCD 8.13% versus DBD 10.24%; RR = 0.75; 95% CI, 0.59-0.96; P = 0.02) and 5-y mortality rate (DCD 14.61% versus DBD 20.57%; RR = 0.72; 95% CI, 0.54-0.97; P = 0.03) compared with DBD HTx. CONCLUSIONS Using the current DCD criteria, HTx emerges as a promising alternative to DBD transplantation. The safety and feasibility of DCD hearts deserve further exploration and investigation.
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Affiliation(s)
- Junjie Zong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Center for Translational Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Weicong Ye
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Center for Translational Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jizhang Yu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xi Zhang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jikai Cui
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhang Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Center for Translational Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yuan Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Song Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shuan Ran
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yuqing Niu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zilong Luo
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaohan Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jiulu Zhao
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yanglin Hao
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jiahong Xia
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Center for Translational Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, Hubei, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei, China
- Institute of Translational Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jie Wu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Center for Translational Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, Hubei, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei, China
- Institute of Translational Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Trela KC, Salerno CT, Chuba E, Dhawan R. Donation After Circulatory Death Heart Transplantation: A Narrative Review. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00237-4. [PMID: 38981770 DOI: 10.1053/j.jvca.2024.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/10/2024] [Accepted: 03/31/2024] [Indexed: 07/11/2024]
Abstract
Heart transplantation is the definitive treatment for refractory, end-stage heart failure. The number of patients awaiting transplantation far exceeds available organs. In an effort to expand the donor pool, donation after circulatory death (DCD) heart transplantation has garnered renewed interest. Unlike donation after brain death, DCD donors do not meet the criteria for brain death and are dependent on life-sustaining therapies. Procurement can include a direct strategy or a normothermic regional perfusion, whereby there is restoration of perfusion to the organ before explantation. There are new developments in cold storage and ex vivo perfusion strategies. Since its inception, there has been a steady improvement in post-transplant outcomes, largely attributed to advancements in operative and procurement strategies. In this narrative review, the authors address the unique considerations of DCD heart transplantation, including withdrawal of care, the logistics of procuring and resuscitating organs, outcomes compared with standard donation after brain death, and ethical considerations.
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Affiliation(s)
- Kristin Constantine Trela
- Department of Anesthesia and Critical Care Medicine, University of Chicago, Chicago, IL, United States.
| | - Christopher T Salerno
- Section of Cardiothoracic Surgery, University of Chicago, Chicago, IL, United States
| | - Emuejevoke Chuba
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Richa Dhawan
- Department of Anesthesia and Critical Care Medicine, University of Chicago, Chicago, IL, United States
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14
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Graf S, Biemmi V, Arnold M, Segiser A, Müller A, Méndez‐Carmona N, Egle M, Siepe M, Barile L, Longnus S. Macrophage-derived extracellular vesicles alter cardiac recovery and metabolism in a rat heart model of donation after circulatory death. J Cell Mol Med 2024; 28:e18281. [PMID: 38652092 PMCID: PMC11037406 DOI: 10.1111/jcmm.18281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 02/11/2024] [Accepted: 03/14/2024] [Indexed: 04/25/2024] Open
Abstract
Conditions to which the cardiac graft is exposed during transplantation with donation after circulatory death (DCD) can trigger the recruitment of macrophages that are either unpolarized (M0) or pro-inflammatory (M1) as well as the release of extracellular vesicles (EV). We aimed to characterize the effects of M0 and M1 macrophage-derived EV administration on post-ischaemic functional recovery and glucose metabolism using an isolated rat heart model of DCD. Isolated rat hearts were subjected to 20 min aerobic perfusion, followed by 27 min global, warm ischaemia or continued aerobic perfusion and 60 min reperfusion with or without intravascular administration of EV. Four experimental groups were compared: (1) no ischaemia, no EV; (2) ischaemia, no EV; (3) ischaemia with M0-macrophage-dervied EV; (4) ischaemia with M1-macrophage-derived EV. Post-ischaemic ventricular and metabolic recovery were evaluated. During reperfusion, ventricular function was decreased in untreated ischaemic and M1-EV hearts, but not in M0-EV hearts, compared to non-ischaemic hearts (p < 0.05). In parallel with the reduced functional recovery in M1-EV versus M0-EV ischaemic hearts, rates of glycolysis from exogenous glucose and oxidative metabolism tended to be lower, while rates of glycogenolysis and lactate release tended to be higher. EV from M0- and M1-macrophages differentially affect post-ischaemic cardiac recovery, potentially by altering glucose metabolism in a rat model of DCD. Targeted EV therapy may be a useful approach for modulating cardiac energy metabolism and optimizing graft quality in the setting of DCD.
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Affiliation(s)
- Selianne Graf
- Department of Cardiac SurgeryInselspital Bern University Hospital, University of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
- Graduate School of Cellular and Biomedical SciencesUniversity of BernBernSwitzerland
| | - Vanessa Biemmi
- Laboratory for Cardiovascular TheranosticsCardiocentro Ticino Institute‐EOCLuganoSwitzerland
| | - Maria Arnold
- Department of Cardiac SurgeryInselspital Bern University Hospital, University of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Adrian Segiser
- Department of Cardiac SurgeryInselspital Bern University Hospital, University of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Anja Müller
- Department of Cardiac SurgeryInselspital Bern University Hospital, University of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Natalia Méndez‐Carmona
- Department of Cardiac SurgeryInselspital Bern University Hospital, University of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Manuel Egle
- Department of Cardiac SurgeryInselspital Bern University Hospital, University of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
- Graduate School of Cellular and Biomedical SciencesUniversity of BernBernSwitzerland
| | - Matthias Siepe
- Department of Cardiac SurgeryInselspital Bern University Hospital, University of BernBernSwitzerland
| | - Lucio Barile
- Laboratory for Cardiovascular TheranosticsCardiocentro Ticino Institute‐EOCLuganoSwitzerland
| | - Sarah Longnus
- Department of Cardiac SurgeryInselspital Bern University Hospital, University of BernBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
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15
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Dann TM, Spencer BL, Wilhelm SK, Drake SK, Bartlett RH, Rojas-Pena A, Drake DH. Donor heart refusal after circulatory death: An analysis of United Network for Organ Sharing refusal codes. JTCVS OPEN 2024; 18:91-103. [PMID: 38690428 PMCID: PMC11056494 DOI: 10.1016/j.xjon.2024.02.010] [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: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 05/02/2024]
Abstract
Objective Donor hearts procured after circulatory death (DCD) may significantly increase the number of hearts available for transplantation. The purpose of this study was to analyze current DCD and brain-dead donor (DBD) heart transplantation rates and characterize organ refusal using the most up-to-date United Network for Organ Sharing (UNOS) and Organ Procurement and Transplantation Network data. Methods We analyzed UNOS and Organ Procurement and Transplantation Network DBD and DCD candidate, transplantation, and demographic data from 2020 through 2022 and 2022 refusal code data to characterize DCD heart use and refusal. Subanalyses were performed to characterize DCD donor demographics and regional transplantation rate variance. Results DCD hearts were declined 3.37 times more often than DBD hearts. The most frequently used code for DCD refusal was neurologic function, related to concerns of a prolonged dying process and organ preservation. In 2022, 92% (1329/1452) of all DCD refusals were attributed to neurologic function. When compared with DBD, DCD donor hearts were more frequently declined as the result of prolonged warm ischemic time (odds ratio, 5.65; 95% confidence interval, 4.07-7.86) and other concerns over organ preservation (odds ratio, 4.06; 95% confidence interval, 3.33-4.94). Transplantation rate variation was observed between demographic groups and UNOS regions. DCD transplantation rates are currently experiencing second order polynomial growth. Conclusions DCD donor hearts are declined more frequently than DBD. DCD heart refusals result from concerns over a prolonged dying process and organ preservation. Heart transplantation rates may be substantially improved by ex situ hemodynamic assessment, adoption of normothermic regional perfusion guidelines, and quality initiatives.
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Affiliation(s)
- Tyler M. Dann
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, Mich
| | - Brianna L. Spencer
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, Mich
| | - Spencer K. Wilhelm
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, Mich
| | - Sarah K. Drake
- Information School, University of Wisconsin, Madison, Wis
| | - Robert H. Bartlett
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, Mich
| | - Alvaro Rojas-Pena
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, Mich
- Department of Surgery, Section of Transplantation, University of Michigan Medical School, Ann Arbor, Mich
| | - Daniel H. Drake
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, Mich
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Mich
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16
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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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17
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Urban M, Ryan TR, Um JY, Siddique A, Castleberry AW, Lowes BD. Financial impact of donation after circulatory death heart transplantation: A single-center analysis. Clin Transplant 2024; 38:e15296. [PMID: 38545928 DOI: 10.1111/ctr.15296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/02/2024] [Accepted: 03/08/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Clinical success of donation after circulatory death (DCD) heart transplantation is leading to growing adoption of this technique. In comparison to procurement from a brain-dead donor, DCD requires additional resources. The economic impact of DCD heart transplantation from the hospital perspective is not well known. METHODS We compared the financial data of patients who received DCD allografts to those who received a DBD organ at our institution from January 1, 2021 to December 31, 2022. We also compared the cost of ex-situ machine perfusion to in-situ organ perfusion employed during DCD recovery. RESULTS We performed 58 DBD and 22 DCD heart-alone transplantations during the study period. Out of 22 DCD grafts, 16 were recovered with thoracoabdominal normothermic regional perfusion (TA-NRP) and six with direct procurement followed by normothermic machine perfusion (DP-NMP). The contribution margin per case for DBD versus DCD was $234,362 and $235,440 (P = .72). The direct costs did not significantly differ between the two groups ($171,949 and 186,250; P = .49). In comparing the two methods of procuring hearts from DCD donors, the direct cost of TA-NRP was $155,955 in comparison to $223,399 for DP-NMP (P = .21). This difference translated into a clinically meaningful but not statistically significant greater contribution margin for TA-NRP ($242, 657 vs. $175,768; P = .34). CONCLUSIONS Our data showed that the adoption of DCD procurement did not have a negative financial impact on the contribution margin in our institution. Programs considering starting DCD heart transplantation, and those who are currently performing DCD procurement should evaluate their own financial situation.
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Affiliation(s)
- Marian Urban
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, USA
| | - Timothy R Ryan
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, USA
| | - John Y Um
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, USA
| | - Aleem Siddique
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, USA
| | - Anthony W Castleberry
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, USA
| | - Brian D Lowes
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, USA
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Kaffka genaamd Dengler SE, Mishra M, van Tuijl S, de Jager SCA, Sluijter JPG, Doevendans PA, van der Kaaij NP. Validation of the slaughterhouse porcine heart model for ex-situ heart perfusion studies. Perfusion 2024; 39:555-563. [PMID: 36638055 PMCID: PMC10943619 DOI: 10.1177/02676591231152718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION To validate slaughterhouse hearts for ex-situ heart perfusion studies, we compared cold oxygenated machine perfusion in less expensive porcine slaughterhouse hearts (N = 7) to porcine hearts that are harvested following the golden standard in laboratory animals (N = 6). METHODS All hearts received modified St Thomas 2 crystalloid cardioplegia prior to 4 hours of cold oxygenated machine perfusion. Hearts were perfused with homemade modified Steen heart solution with a perfusion pressure of 20-25 mmHg to achieve a coronary flow between 100-200 mL/min. Reperfusion and testing was performed for 4 hours on a normothermic, oxygenated diluted whole blood loaded heart model. Survival was defined by a cardiac output above 3 L with a mean aortic pressure above 60 mmHg. RESULTS Both groups showed 100% functional survival, with laboratory hearts displaying superior cardiac function. Both groups showed similar decline in function over time. CONCLUSION We conclude that the slaughterhouse heart can be used as an alternative to laboratory hearts and provides a cost-effective method for future ex-situ heart perfusion studies.
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Affiliation(s)
| | - Mudit Mishra
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Laboratory of Experimental Cardiology, Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | | | - Saskia CA de Jager
- Laboratory of Experimental Cardiology, Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Joost PG Sluijter
- Laboratory of Experimental Cardiology, Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
- Netherlands Heart Institute, Moreelsepark 1, The Netherlands
| | - Niels P van der Kaaij
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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19
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Kobayashi Y, Li J, Parker M, Wang J, Nagy A, Fan CPS, Runeckles K, Okumura M, Kadowaki S, Honjo O. Impact of Hemoglobin Level in Ex Vivo Heart Perfusion on Donation After Circulatory Death Hearts: A Juvenile Porcine Experimental Model. Transplantation 2024:00007890-990000000-00683. [PMID: 38446085 DOI: 10.1097/tp.0000000000004954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
BACKGROUND Ex vivo heart perfusion (EVHP) of donation after circulatory death (DCD) hearts has become an effective strategy in adults; however, the small circulating volume in pediatrics poses the challenge of a low-hemoglobin (Hb) perfusate. We aimed to determine the impact of perfusate Hb levels during EVHP on DCD hearts using a juvenile porcine model. METHODS Sixteen DCD piglet hearts (11-14 kg) were reperfused for 4 h in unloaded mode followed by working mode. Metabolism, cardiac function, and cell damage were compared between the low-Hb (Hb, 5.0-5.9 g/dL; n = 8) and control (Hb, 7.5-8.4 g/dL; n = 8) groups. Between-group differences were evaluated using 2-sample t-tests or Fisher's Exact tests. RESULTS During unloaded mode, the low-Hb group showed lower myocardial oxygen consumption (P < 0.001), a higher arterial lactate level (P = 0.001), and worse systolic ventricular function (P < 0.001). During working mode, the low-Hb group had a lower cardiac output (mean, 71% versus 106% of normal cardiac output, P = 0.010) and a higher arterial lactate level (P = 0.031). Adjusted cardiac troponin-I (P = 0.112) did not differ between the groups. Morphological myocyte injury in the left ventricle was more severe in the low-Hb group (P = 0.028). CONCLUSIONS Low-Hb perfusate with inadequate oxygen delivery induced anaerobic metabolism, resulting in suboptimal DCD heart recovery and declined cardiac function. Arranging an optimal perfusate is crucial to organ protection, and further endeavors to refine the priming volume of EVHP or the transfusion strategy are required.
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Affiliation(s)
- Yasuyuki Kobayashi
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jing Li
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Marlee Parker
- Division of Perfusion Services, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jian Wang
- Division of Perfusion Services, The Hospital for Sick Children, Toronto, ON, Canada
| | - Anita Nagy
- Division of Pathology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Chun-Po Steve Fan
- Ted Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Kyle Runeckles
- Ted Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Michiru Okumura
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Sachiko Kadowaki
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
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20
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Krishnan A, Ruaengsri C, Guenthart BA, Shudo Y, Wang H, Ma MR, MacArthur JW, Hiesinger W, Woo YJ. Beating Heart Transplant Procedures Using Organs From Donors With Circulatory Death. JAMA Netw Open 2024; 7:e241828. [PMID: 38466306 DOI: 10.1001/jamanetworkopen.2024.1828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
Importance The use of ex vivo normothermic organ perfusion has enabled the use of deceased after circulatory death (DCD) donors for heart transplants. However, compared with conventional brain death donation, DCD heart transplantation performed with ex vivo organ perfusion involves an additional period of warm and cold ischemia, exposing the allograft to multiple bouts of ischemia reperfusion injury and may contribute to the high rates of extracorporeal membrane oxygenation usage after DCD heart transplantation. Objective To assess whether the beating heart method of DCD heart transplantation is safe and whether it has an acceptable rate of extracorporeal membrane oxygenation use postoperatively. Design, Setting, and Participants This case series includes 10 patients with end-stage heart failure undergoing DCD heart transplantation at a single academic medical center from October 1, 2022, to August 3, 2023. Data were analyzed from October 2022 to August 2023. Interventions Using a beating heart method of implantation of the donor allograft. Main Outcomes and Measures The main outcome was primary graft dysfunction necessitating postoperative initiation of mechanical circulatory support. Survival and initiation of mechanical circulatory support were secondary outcomes. Results In this case series, 10 consecutive patients underwent DCD heart transplantation via the beating heart method. Ten of 10 recipients were male (100%), the mean (SD) age was 51.2 (13.8) years, and 7 (70%) had idiopathic dilated cardiomyopathy. Ten patients (100%) survived, and 0 patients had initiation of extracorporeal membrane oxygenation postoperatively. No other mechanical circulatory support, including intra-aortic balloon pump, was initiated postoperatively. Graft survival was 100% (10 of 10 patients), and, at the time of publication, no patients have been listed for retransplantation. Conclusions and Relevance In this study of 10 patients undergoing heart transplantation, the beating heart implantation method for DCD heart transplantation was safe and may mitigate ischemia reperfusion injury, which may lead to lower rates of primary graft dysfunction necessitating extracorporeal membrane oxygenation. These results are relevant to institutions using DCD donors for heart transplantation.
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Affiliation(s)
- Aravind Krishnan
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Chawannuch Ruaengsri
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Brandon A Guenthart
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Yasuhiro Shudo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Hanjay Wang
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael R Ma
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - John Ward MacArthur
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
- Department of Bioengineering, Stanford University School of Engineering, Stanford, California
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21
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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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22
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Mondal NK, Li S, Elsenousi AE, Mattar A, Nordick KV, Lamba HK, Hochman-Mendez C, Rosengart TK, Liao KK. NADPH oxidase overexpression and mitochondrial OxPhos impairment are more profound in human hearts donated after circulatory death than brain death. Am J Physiol Heart Circ Physiol 2024; 326:H548-H562. [PMID: 38180451 DOI: 10.1152/ajpheart.00616.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/05/2023] [Accepted: 01/02/2024] [Indexed: 01/06/2024]
Abstract
This study investigated cardiac stress and mitochondrial oxidative phosphorylation (OxPhos) in human donation after circulatory death (DCD) hearts regarding warm ischemic time (WIT) and subsequent cold storage and compared them with that of human brain death donor (DBD) hearts. A total of 24 human hearts were procured for the research study-6 in the DBD group and 18 in the DCD group. DCD group was divided into three groups (n = 6) based on different WITs (20, 40, and 60 min). All hearts received del Nido cardioplegia before being placed in normal saline cold storage for 6 h. Left ventricular biopsies were performed at hours 0, 2, 4, and 6. Cardiac stress [nicotinamide adenine dinucleotide phosphate (NADPH) oxidase subunits: 47-kDa protein of phagocyte oxidase (p47phox), 91-kDa glycoprotein of phagocyte oxidase (gp91phox)] and mitochondrial oxidative phosphorylation [OxPhos, complex I (NADH dehydrogenase) subunit of ETC (CI)-complex V (ATP synthase) subunit of ETC (CV)] proteins were measured in cardiac tissue and mitochondria respectively. Modulation of cardiac stress and mitochondrial dysfunction were observed in both DCD and DBD hearts. However, DCD hearts suffered more cardiac stress (overexpressed NADPH oxidase subunits) and diminished mitochondrial OxPhos than DBD hearts. The severity of cardiac stress and impaired oxidative phosphorylation in DCD hearts correlated with the longer WIT and subsequent cold storage time. More drastic changes were evident in DCD hearts with a WIT of 60 min or more. Activation of NADPH oxidase via overproduction of p47phox and gp91phox proteins in cardiac tissue may be responsible for cardiac stress leading to diminished mitochondrial oxidative phosphorylation. These protein changes can be used as biomarkers for myocardium damage and might help assess DCD and DBD heart transplant suitability.NEW & NOTEWORTHY First human DCD heart research studied cardiac stress and mitochondrial dysfunction concerning WIT and the efficacy of del Nido cardioplegia as an organ procurement solution and subsequent cold storage. Mild to moderate cardiac stress and mitochondrial dysfunction were noticed in DCD hearts with WIT 20 and 40 min and cold storage for 4 and 2 h, respectively. These changes can serve as biomarkers, allowing interventions to preserve mitochondria and extend WIT in DCD hearts.
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Affiliation(s)
- Nandan K Mondal
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, United States
- Department of Regenerative Medicine Research, Texas Heart Institute, Houston, Texas, United States
| | - Shiyi Li
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, United States
| | - Abdussalam E Elsenousi
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, United States
| | - Aladdein Mattar
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, United States
| | - Katherine V Nordick
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, United States
| | - Harveen K Lamba
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, United States
| | - Camila Hochman-Mendez
- Department of Regenerative Medicine Research, Texas Heart Institute, Houston, Texas, United States
| | - Todd K Rosengart
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, United States
| | - Kenneth K Liao
- Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, United States
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23
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Ahmed HF, Kulshrestha K, Kennedy JT, Gomez-Guzman A, Greenberg JW, Hossain MM, Zhang Y, D'Alessandro DA, John R, Moazami N, Chin C, Ashfaq A, Zafar F, Morales DLS. Donation after circulatory death significantly reduces waitlist times while not changing post-heart transplant outcomes: A United Network for Organ Sharing Analysis. J Heart Lung Transplant 2024; 43:461-470. [PMID: 37863451 PMCID: PMC10922468 DOI: 10.1016/j.healun.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/02/2023] [Accepted: 10/10/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Recently, several centers in the United States have begun performing donation after circulatory death (DCD) heart transplants (HTs) in adults. We sought to characterize the recent use of DCD HT, waitlist time, and outcomes compared to donation after brain death (DBD). METHODS Using the United Network for Organ Sharing database, 10,402 adult (aged >18 years) HT recipients from January 2019 to June 2022 were identified: 425 (4%) were DCD and 9,977 (96%) were DBD recipients. Posttransplant outcomes in matched and unmatched cohorts and waitlist times were compared between groups. RESULTS DCD and DBD recipients had similar age (57 years for both, p = 0.791). DCD recipients were more likely White (67% vs 60%, p = 0.002), on left ventricular assist device (LVAD; 40% vs 32%, p < 0.001), and listed as status 4 to 6 (60% vs 24%, p < 0.001); however, less likely to require inotropes (22% vs 40%, p < 0.001) and preoperative extracorporeal membrane oxygenation (0.9% vs 6%, p < 0.001). DCD donors were younger (29 vs 32 years, p < 0.001) and had less renal dysfunction (15% vs 39%, p < 0.001), diabetes (1.9% vs 3.8%, p = 0.050), or hypertension (9.9% vs 16%, p = 0.001). In matched and unmatched cohorts, early survival was similar (p = 0.22). Adjusted waitlist time was shorter in DCD group (21 vs 31 days, p < 0.001) compared to DBD cohort and 5-fold shorter (DCD: 22 days vs DBD: 115 days, p < 0.001) for candidates in status 4 to 6, which was 60% of DCD cohort. CONCLUSIONS The community is using DCD mostly for those recipients who are expected to have extended waitlist times (e.g., durable LVADs, status >4). DCD recipients had similar posttransplant early survival and shorter adjusted waitlist time compared to DBD group. Given this early success, efforts should be made to expand the donor pool using DCD, especially for traditionally disadvantaged recipients on the waitlist.
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Affiliation(s)
- Hosam F Ahmed
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kevin Kulshrestha
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John T Kennedy
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Amalia Gomez-Guzman
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jason W Greenberg
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Md Monir Hossain
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David A D'Alessandro
- Division of Cardiothoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ranjit John
- Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Nader Moazami
- Department of Cardiothoracic Surgery, New York University (NYU) Langone Health, New York, New York
| | - Clifford Chin
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Awais Ashfaq
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Farhan Zafar
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David L S Morales
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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24
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Abstract
PURPOSE OF REVIEW The use of cardiac transplantation following circulatory death (DCD) has been limited worldwide. Concerns about cardiac function after warm ischemia and the potential for decreased graft function have been important considerations in this hesitancy. In addition, ethical and legal questions about the two widely used organ procurement methods have led to discussions and public education in many countries. RECENT FINDINGS Publication of a US randomized trial of cardiac transplantation following DCD has shown that it is both feasible and has similar short-term outcomes compared with cardiac transplantation following brain death (DBD). These data support those from both Australia and the UK who have largest experience to date. SUMMARY The adoption of cardiac transplantation following circulatory death has increased overall cardiac transplantation in those transplant centers who have incorporated these donors. Short term outcomes for DCD organ procurement methods are similar to those outcomes using DBD hearts. Continued study and standardization of warm ischemic times will allow for better comparisons of organ procurement techniques and organ optimization. The ethical concerns about procurement methods, in addition to a discussion of procurement costs and feasibility will need to be addressed further in the efforts to expand the organ pool and increase overall cardiac transplantation numbers.
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Affiliation(s)
- Savitri Fedson
- Michael E. DeBakey VA Medical Center, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
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25
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Royo-Villanova M, Miñambres E, Sánchez JM, Torres E, Manso C, Ballesteros MÁ, Parrilla G, de Paco Tudela G, Coll E, Pérez-Blanco A, Domínguez-Gil B. Maintaining the permanence principle of death during normothermic regional perfusion in controlled donation after the circulatory determination of death: Results of a prospective clinical study. Am J Transplant 2024; 24:213-221. [PMID: 37739346 DOI: 10.1016/j.ajt.2023.09.008] [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: 06/12/2023] [Revised: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Abstract
One concern about the use of normothermic regional perfusion (NRP) in controlled donation after the circulatory determination of death (cDCD) is that the brain may be perfused. We aimed to demonstrate that certain technical maneuvers preclude such brain perfusion. A nonrandomized trial was performed on cDCD donors. In abdominal normothermic regional perfusion (A-NRP), the thoracic aorta was blocked with an intra-aortic occlusion balloon. In thoracoabdominal normothermic regional perfusion (TA-NRP), the arch vessels were clamped and the cephalad ends vented to the atmosphere. The mean intracranial arterial blood pressure (ICBP) was invasively measured at the circle of Willis. Ten cDCD donors subject to A-NRP or TA-NRP were included. Mean ICBP and mean blood pressure at the thoracic and the abdominal aorta during the circulatory arrest were 17 (standard deviation [SD], 3), 17 (SD, 3), and 18 (SD, 4) mmHg, respectively. When A-NRP started, pressure at the abdominal aorta increased to 50 (SD, 13) mmHg, while the ICBP remained unchanged. When TA-NRP was initiated, thoracic aorta pressure increased to 71 (SD, 18) mmHg, but the ICBP remained unmodified. Recorded values of ICBP during NRP were 10 mmHg. In conclusion, appropriate technical measures applied during NRP preclude perfusion of the brain in cDCD. This study might help to expand NRP and increase the number of organs available for transplantation.
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Affiliation(s)
- Mario Royo-Villanova
- Donor Transplant Coordination Unit, Service of Intensive Care, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Eduardo Miñambres
- Donor Transplant Coordination Unit, Service of Intensive Care, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, Universidad de Cantabria, Santander, Spain.
| | - José Moya Sánchez
- Donor Transplant Coordination Unit, Service of Intensive Care, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Eduardo Torres
- Neuro-intervention Unit, Hospital Universitario de Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Clara Manso
- Service of Intensive Care, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - María Ángeles Ballesteros
- Donor Transplant Coordination Unit, Service of Intensive Care, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Guillermo Parrilla
- Interventional Neurovascular Unit, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Gonzalo de Paco Tudela
- Interventional Neurovascular Unit, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
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26
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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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27
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Saemann L, Wächter K, Georgevici AI, Pohl S, Hoorn F, Veres G, Korkmaz-Icöz S, Karck M, Simm A, Szabó G. Transcriptomic Changes in the Myocardium and Coronary Artery of Donation after Circulatory Death Hearts following Ex Vivo Machine Perfusion. Int J Mol Sci 2024; 25:1261. [PMID: 38279260 PMCID: PMC10816321 DOI: 10.3390/ijms25021261] [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: 11/24/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/28/2024] Open
Abstract
Donation after circulatory death (DCD) hearts are predominantly maintained by normothermic blood perfusion (NBP). Nevertheless, it was shown that hypothermic crystalloid perfusion (HCP) is superior to blood perfusion to recondition left ventricular (LV) contractility. However, transcriptomic changes in the myocardium and coronary artery in DCD hearts after HCP and NBP have not been investigated yet. In a pig model, DCD hearts were harvested and maintained for 4 h by NBP (DCD-BP group, N = 8) or HCP with oxygenated histidine-tryptophane-ketoglutarate (HTK) solution (DCD-HTK, N = 8) followed by reperfusion with fresh blood for 2 h. In the DCD group (N = 8), hearts underwent reperfusion immediately after procurement. In the control group (N = 7), no circulatory death was induced. We performed transcriptomics from LV myocardial and left anterior descending (LAD) samples using microarrays (25,470 genes). We applied the Boruta algorithm for variable selection to identify relevant genes. In the DCD-BP group, compared to DCD, six genes were regulated in the myocardium and 1915 genes were regulated in the LAD. In the DCD-HTK group, 259 genes were downregulated in the myocardium and 27 in the LAD; and 52 genes were upregulated in the myocardium and 765 in the LAD, compared to the DCD group. We identified seven genes of relevance for group identification: ITPRIP, G3BP1, ARRDC3, XPO6, NOP2, SPTSSA, and IL-6. NBP resulted in the upregulation of genes involved in mitochondrial calcium accumulation and ROS production, the reduction in microvascular endothelial sprouting, and inflammation. HCP resulted in the downregulation of genes involved in NF-κB-, STAT3-, and SASP-activation and inflammation.
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Affiliation(s)
- Lars Saemann
- Department of Cardiac Surgery, University Hospital Halle (Saale), University of Halle, 06120 Halle (Saale), Germany
- Department of Cardiac Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Kristin Wächter
- Department of Cardiac Surgery, University Hospital Halle (Saale), University of Halle, 06120 Halle (Saale), Germany
| | - Adrian-Iustin Georgevici
- Department of Cardiac Surgery, University Hospital Halle (Saale), University of Halle, 06120 Halle (Saale), Germany
- Department of Anaesthesiology, St. Josef Hospital, Ruhr-University Bochum, 44791 Bochum, Germany
| | - Sabine Pohl
- Department of Cardiac Surgery, University Hospital Halle (Saale), University of Halle, 06120 Halle (Saale), Germany
| | - Fabio Hoorn
- Department of Cardiac Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Gábor Veres
- Department of Cardiac Surgery, University Hospital Halle (Saale), University of Halle, 06120 Halle (Saale), Germany
- Department of Cardiac Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Sevil Korkmaz-Icöz
- Department of Cardiac Surgery, University Hospital Halle (Saale), University of Halle, 06120 Halle (Saale), Germany
- Department of Cardiac Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Andreas Simm
- Department of Cardiac Surgery, University Hospital Halle (Saale), University of Halle, 06120 Halle (Saale), Germany
| | - Gábor Szabó
- Department of Cardiac Surgery, University Hospital Halle (Saale), University of Halle, 06120 Halle (Saale), Germany
- Department of Cardiac Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany
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28
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Seefeldt JM, Libai Y, Berg K, Jespersen NR, Lassen TR, Dalsgaard FF, Ryhammer P, Pedersen M, Ilkjaer LB, Hu MA, Erasmus ME, Nielsen RR, Bøtker HE, Caspi O, Eiskjær H, Moeslund N. Effects of ketone body 3-hydroxybutyrate on cardiac and mitochondrial function during donation after circulatory death heart transplantation. Sci Rep 2024; 14:757. [PMID: 38191915 PMCID: PMC10774377 DOI: 10.1038/s41598-024-51387-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/04/2024] [Indexed: 01/10/2024] Open
Abstract
Normothermic regional perfusion (NRP) allows assessment of therapeutic interventions prior to donation after circulatory death transplantation. Sodium-3-hydroxybutyrate (3-OHB) increases cardiac output in heart failure patients and diminishes ischemia-reperfusion injury, presumably by improving mitochondrial metabolism. We investigated effects of 3-OHB on cardiac and mitochondrial function in transplanted hearts and in cardiac organoids. Donor pigs (n = 14) underwent circulatory death followed by NRP. Following static cold storage, hearts were transplanted into recipient pigs. 3-OHB or Ringer's acetate infusions were initiated during NRP and after transplantation. We evaluated hemodynamics and mitochondrial function. 3-OHB mediated effects on contractility, relaxation, calcium, and conduction were tested in cardiac organoids from human pluripotent stem cells. Following NRP, 3-OHB increased cardiac output (P < 0.0001) by increasing stroke volume (P = 0.006), dP/dt (P = 0.02) and reducing arterial elastance (P = 0.02). Following transplantation, infusion of 3-OHB maintained mitochondrial respiration (P = 0.009) but caused inotropy-resistant vasoplegia that prevented weaning. In cardiac organoids, 3-OHB increased contraction amplitude (P = 0.002) and shortened contraction duration (P = 0.013) without affecting calcium handling or conduction velocity. 3-OHB had beneficial cardiac effects and may have a potential to secure cardiac function during heart transplantation. Further studies are needed to optimize administration practice in donors and recipients and to validate the effect on mitochondrial function.
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Affiliation(s)
- Jacob Marthinsen Seefeldt
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark.
| | - Yaara Libai
- The Laboratory for Cardiovascular Precision Medicine, Rapport Faculty of Medicine, Technion and Rambam's Cardiovascular Research and Innovation Center, 2 Efron St, Haifa, Israel
| | - Katrine Berg
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Nichlas Riise Jespersen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Thomas Ravn Lassen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Frederik Flyvholm Dalsgaard
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
- Comparative Medicine Lab, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Pia Ryhammer
- Department of Anesthesiology, Regional Hospital Silkeborg, Falkevej 1A, 8600, Silkeborg, Denmark
| | - Michael Pedersen
- Comparative Medicine Lab, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Lars Bo Ilkjaer
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus N, Denmark
| | - Michiel A Hu
- Department of Cardiothoracic Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Michiel E Erasmus
- Department of Cardiothoracic Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Roni R Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Hans Erik Bøtker
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Oren Caspi
- The Laboratory for Cardiovascular Precision Medicine, Rapport Faculty of Medicine, Technion and Rambam's Cardiovascular Research and Innovation Center, 2 Efron St, Haifa, Israel
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Niels Moeslund
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus N, Denmark
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Kaffka Genaamd Dengler SE, Mishra M, Vervoorn MT, Kernkamp J, van Tuijl S, de Jager SCA, Sluijter JPG, Doevendans PA, van der Kaaij NP. Hemofiltration Improves Blood Perfusate Conditions Leading to Improved Ex Situ Heart Perfusion. ASAIO J 2024; 70:38-43. [PMID: 37816093 DOI: 10.1097/mat.0000000000002058] [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] [Indexed: 10/12/2023] Open
Abstract
The aim was to optimize the perfusate composition by including a hemofiltrator to the PhysioHeartplatform for ex situ heart perfusion of porcine slaughterhouse hearts. Fourteen hearts were harvested from Dutch Landrace pigs and slaughtered for human consumption. All hearts were preserved for 4 hours using static cold storage before reperfusion for 4 hours on the PhysioHeart platform. Seven hearts were assigned to the hemofiltration group, where a hemofiltrator was added to the perfusion circuit, while the control group did not receive hemofiltration. In the hemofiltration group, the perfusion fluid was filtrated for 1 hour with a flow of 1 L/hour before reperfusion. After mounting the heart, hemofiltration was maintained at 1 L/hour, and cardiac function and blood samples were analyzed at multiple time points. Preserved cardiac function was defined as a cardiac output >3.0 L/min with a mean aortic pressure >60 mm Hg and a left atrial pressure <15 mm Hg. Hemofiltration resulted in a significantly reduced potassium concentration at all time points ( p < 0.001), while sodium levels remained at baseline values ( p < 0.004). Furthermore, creatinine and ammonia levels decreased over time. Functional assessment demonstrated a reduced left atrial pressure ( p < 0.04) and a reduction of the required dobutamine dose to support myocardial function ( p < 0.003) in the hemofiltration group. Preserved cardiac function did not differ between groups. Hemofiltration results in an improved biochemical composition of the whole blood perfusate and preserves cardiac function better during normothermic perfusion based on a reduced left atrial pressure (LAP) and dobutamine requirement to support function.
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Affiliation(s)
| | - Mudit Mishra
- From the Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Laboratory of Experimental Cardiology, Department of Cardiology, University Medical Center Utrecht, Regenerative Medicine Center Utrecht, Circulatory Health Research Center, University Utrecht, Utrecht, the Netherlands
| | - Mats T Vervoorn
- From the Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jord Kernkamp
- From the Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Saskia C A de Jager
- Laboratory of Experimental Cardiology, Department of Cardiology, University Medical Center Utrecht, Regenerative Medicine Center Utrecht, Circulatory Health Research Center, University Utrecht, Utrecht, the Netherlands
| | - Joost P G Sluijter
- Laboratory of Experimental Cardiology, Department of Cardiology, University Medical Center Utrecht, Regenerative Medicine Center Utrecht, Circulatory Health Research Center, University Utrecht, Utrecht, the Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
| | - Niels P van der Kaaij
- From the Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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Alemany VS, Nomoto R, Saeed MY, Celik A, Regan WL, Matte GS, Recco DP, Emani SM, Del Nido PJ, McCully JD. Mitochondrial transplantation preserves myocardial function and viability in pediatric and neonatal pig hearts donated after circulatory death. J Thorac Cardiovasc Surg 2024; 167:e6-e21. [PMID: 37211245 DOI: 10.1016/j.jtcvs.2023.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/06/2023] [Accepted: 05/03/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Mitochondrial transplantation has been shown to preserve myocardial function and viability in adult porcine hearts donated after circulatory death (DCD) . Herein, we investigate the efficacy of mitochondrial transplantation for the preservation of myocardial function and viability in neonatal and pediatric porcine DCD heart donation. METHODS Circulatory death was induced in neonatal and pediatric Yorkshire pigs by cessation of mechanical ventilation. Hearts underwent 20 or 36 minutes of warm ischemia time (WIT), 10 minutes of cold cardioplegic arrest, and then were harvested for ex situ heart perfusion (ESHP). Following 15 minutes of ESHP, hearts received either vehicle (VEH) or vehicle containing isolated autologous mitochondria (MITO). A sham nonischemic group (SHAM) did not undergo WIT, mimicking donation after brain death heart procurement. Hearts underwent 2 hours each of unloaded and loaded ESHP perfusion. RESULTS Following 4 hours of ESHP perfusion, left ventricle developed pressure, dP/dt max, and fractional shortening were significantly decreased (P < .001) in DCD hearts receiving VEH compared with SHAM hearts. In contrast, DCD hearts receiving MITO exhibited significantly preserved left ventricle developed pressure, dP/dt max, and fractional shortening (P < .001 each vs VEH, not significant vs SHAM). Infarct size was significantly decreased in DCD hearts receiving MITO as compared with VEH (P < .001). Pediatric DCD hearts subjected to extended WIT demonstrated significantly preserved fractional shortening and significantly decreased infarct size with MITO (P < .01 each vs VEH). CONCLUSIONS Mitochondrial transplantation in neonatal and pediatric pig DCD heart donation significantly enhances the preservation of myocardial function and viability and mitigates against damage secondary to extended WIT.
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Affiliation(s)
- Victor S Alemany
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Rio Nomoto
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Mossab Y Saeed
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Aybuke Celik
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - William L Regan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Gregory S Matte
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Dominic P Recco
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Sitaram M Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - James D McCully
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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31
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Kwon JH, Usry B, Hashmi ZA, Bhandari K, Carnicelli AP, Tedford RJ, Welch BA, Shorbaji K, Kilic A. Donor utilization in heart transplant with donation after circulatory death in the United States. Am J Transplant 2024; 24:70-78. [PMID: 37517554 DOI: 10.1016/j.ajt.2023.07.019] [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: 03/20/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/01/2023]
Abstract
Heart transplantation using donation after circulatory death (DCD) was recently adopted in the United States. This study aimed to characterize organ yield from adult (≥18 years) DCD heart donors in the United States using the United Network for Organ Sharing registry. The registry does not identify potential donors who do not progress to circulatory death, and only those who progressed to death were included for analysis. Outcomes included organ recovery from the donor operating room and organ utilization for transplant. Multiple logistic regression was used to identify predictors of heart recovery and utilization. Among 558 DCD procurements, recovery occurred in 89.6%, and 92.5% of recovered hearts were utilized for transplant. Of 506 DCD procurements with available data, 65.0% were classified as direct procurement and perfusion and 35.0% were classified as normothermic regional perfusion (NRP). Logistic regression identified that NRP, shorter agonal time, younger donor age, and highest volume of organ procurement organizations were independently associated with increased odds for heart recovery. NRP independently predicted heart utilization after recovery. DCD heart utilization in the United States is satisfactory and consistent with international experience. NRP procurements have a higher yield for DCD heart transplantation compared with direct procurement and perfusion, which may reflect differences in donor assessment and acceptance criteria.
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Affiliation(s)
- Jennie H Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Benjamin Usry
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Zubair A Hashmi
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Krishna Bhandari
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Anthony P Carnicelli
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ryan J Tedford
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brett A Welch
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
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Jou S, Mendez SR, Feinman J, Mitrani LR, Fuster V, Mangiola M, Moazami N, Gidea C. Heart transplantation: advances in expanding the donor pool and xenotransplantation. Nat Rev Cardiol 2024; 21:25-36. [PMID: 37452122 DOI: 10.1038/s41569-023-00902-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023]
Abstract
Approximately 65 million adults globally have heart failure, and the prevalence is expected to increase substantially with ageing populations. Despite advances in pharmacological and device therapy of heart failure, long-term morbidity and mortality remain high. Many patients progress to advanced heart failure and develop persistently severe symptoms. Heart transplantation remains the gold-standard therapy to improve the quality of life, functional status and survival of these patients. However, there is a large imbalance between the supply of organs and the demand for heart transplants. Therefore, expanding the donor pool is essential to reduce mortality while on the waiting list and improve clinical outcomes in this patient population. A shift has occurred to consider the use of organs from donors with hepatitis C virus, HIV or SARS-CoV-2 infection. Other advances in this field have also expanded the donor pool, including opt-out donation policies, organ donation after circulatory death and xenotransplantation. We provide a comprehensive overview of these various novel strategies, provide objective data on their safety and efficacy, and discuss some of the unresolved issues and controversies of each approach.
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Affiliation(s)
- Stephanie Jou
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA.
| | - Sean R Mendez
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
| | - Jason Feinman
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
| | - Lindsey R Mitrani
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
| | - Valentin Fuster
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
| | - Massimo Mangiola
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Nader Moazami
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA
| | - Claudia Gidea
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
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Merani S, Urban M, Westphal SG, Dong J, Miles CD, Maskin A, Hoffman A, Langnas AN. Improved Early Post-Transplant Outcomes and Organ Use in Kidney Transplant Using Normothermic Regional Perfusion for Donation after Circulatory Death: National Experience in the US. J Am Coll Surg 2024; 238:107-118. [PMID: 37772721 DOI: 10.1097/xcs.0000000000000880] [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] [Indexed: 09/30/2023]
Abstract
BACKGROUND Normothermic regional perfusion (NRP) is a technique that is intended to enhance organ transplant outcomes from donation circulatory death (DCD) donors. STUDY DESIGN A retrospective analysis of data from the Scientific Registry of Transplant Recipients was performed. DCD donors were screened for inclusion based on date of donation 2020 or later, and whether the heart was also recovered for transplantation. We grouped donors as either donation after brain death or DCD. DCD donors were further divided into groups including those in which the heart was not recovered for transplant (Non-Heart DCD) and those in which it was, based on recovery technique (thoracoabdominal-NRP [TA-NRP] Heart DCD and Super Rapid Recovery Heart DCD). RESULTS A total of 219 kidney transplant recipients receiving organs from TA-NRP Heart DCD donors were compared to 436 SRR Super Rapid Recovery DCD, 10,630 Super Rapid Recovery non-heart DCD, and 27,820 donations after brain death recipients. Kidney transplant recipients of TA-NRP DCD allografts experienced shorter length of stay, lower rates of delayed graft function, and lower serum creatinine at the time of discharge when compared with recipients of other DCD allografts. CONCLUSIONS Our analysis demonstrates superior early kidney allograft function when TA-NRP is used for DCD organ recovery.
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Affiliation(s)
- Shaheed Merani
- From the Division of Transplant, Department of Surgery (Merani, Maskin, Hoffman, Langnas), University of Nebraska Medical Center, Omaha, NE
| | - Marian Urban
- Division of Cardiothoracic Surgery, Department of Surgery (Urban), University of Nebraska Medical Center, Omaha, NE
| | - Scott G Westphal
- Division of Nephrology Department of Medicine (Westphal, Dong, Miles), University of Nebraska Medical Center, Omaha, NE
| | - James Dong
- Division of Nephrology Department of Medicine (Westphal, Dong, Miles), University of Nebraska Medical Center, Omaha, NE
- Department of Biostatistics (Dong), University of Nebraska Medical Center, Omaha, NE
| | - Clifford D Miles
- Division of Nephrology Department of Medicine (Westphal, Dong, Miles), University of Nebraska Medical Center, Omaha, NE
| | - Alexander Maskin
- From the Division of Transplant, Department of Surgery (Merani, Maskin, Hoffman, Langnas), University of Nebraska Medical Center, Omaha, NE
| | - Arika Hoffman
- From the Division of Transplant, Department of Surgery (Merani, Maskin, Hoffman, Langnas), University of Nebraska Medical Center, Omaha, NE
| | - Alan N Langnas
- From the Division of Transplant, Department of Surgery (Merani, Maskin, Hoffman, Langnas), University of Nebraska Medical Center, Omaha, NE
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Li SS, Funamoto M, Osho AA, Rabi SA, Paneitz D, Singh R, Michel E, Lewis GD, D'Alessandro DA. Acute rejection in donation after circulatory death (DCD) heart transplants. J Heart Lung Transplant 2024; 43:148-157. [PMID: 37717931 PMCID: PMC10873067 DOI: 10.1016/j.healun.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/25/2023] [Accepted: 09/06/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Donation after circulatory death (DCD) heart transplantation has promising early survival, but the effects on rejection remain unclear. METHODS The United Network for Organ Sharing database was queried for adult heart transplants from December 1, 2019, to December 31, 2021. Multiorgan transplants and loss to follow-up were excluded. The primary outcome was acute rejection, comparing DCD and donation after brain death (DBD) transplants. RESULTS A total of 292 DCD and 5,582 DBD transplants met study criteria. Most DCD transplants were transplanted at status 3-4 (61.0%) compared to 58.6% of DBD recipients at status 1-2. DCD recipients were less likely to be hospitalized at transplant (26.7% vs 58.3%, p < 0.001) and to require intra-aortic balloon pumping (IABP; 9.6% vs 28.9%, p < 0.001), extracorporeal membrane oxygenation (ECMO; 0.3% vs 5.9%, p < 0.001) or temporary left ventricular assist device (LVAD; 1.0% vs 2.7%, p < 0.001). DCD recipients were more likely to have acute rejection prior to discharge (23.3% vs 18.4%, p = 0.044) and to be hospitalized for rejection (23.4% vs 11.4%, p = 0.003) at a median follow-up of 15 months; the latter remained significant after propensity matching. On multivariable logistic regression, DCD donation was an independent predictor of acute rejection (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.00-2.15, p = 0.048) and hospitalization for rejection (OR 2.03, 95% CI 1.06-3.70, p = 0.026). On center-specific subgroup analysis, DCD recipients continued to have higher rates of hospitalization for rejection (23.4% vs 13.8%, p = 0.043). CONCLUSIONS DCD recipients are more likely to experience acute rejection. Early survival is similar between DCD and DBD recipients, but long-term implications of increased early rejection in DCD recipients require further investigation.
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Affiliation(s)
- Selena S Li
- Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts.
| | | | - Asishana A Osho
- Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Seyed A Rabi
- Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Dane Paneitz
- Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ruby Singh
- Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Eriberto Michel
- Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Gregory D Lewis
- Cardiology, Massachusetts General Hospital, Boston, Massachusetts
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35
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Srivastava PK, Kittleson MM. Modern advances in heart transplantation. Prog Cardiovasc Dis 2024; 82:147-156. [PMID: 38244826 DOI: 10.1016/j.pcad.2024.01.012] [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: 01/14/2024] [Accepted: 01/14/2024] [Indexed: 01/22/2024]
Abstract
Heart transplantation (HTx) is the only definitive therapy for patients with end stage heart disease. With the increasing global prevalence of heart failure, the demand for HTx has continued to grow and outpace supply. In this paper, we will review advances in the field of HTx along the clinical journey of a HTx recipient. Starting with the sensitized patient, we discuss current methods to define sensitization, and assays to help identify clinically relevant anti-HLA antibodies. Desensitization strategies targeting all levels of the adaptive immune system are discussed with emphasis on novel techniques such as anti-CD 38 blockade and use of the Immunoglobulin G-Degrading Enzyme of Streptococcus Pyogenes. We next discuss donor procurement and the resurgence of donation after circulatory death as a viable strategy to significantly and safely increase the donor pool. Post-transplant, we evaluate non-invasive surveillance techniques including gene expression profiling and donor-derived cell-free DNA. Last, we discuss the ground-breaking developments in the field of xenotransplantation.
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Affiliation(s)
- Pratyaksh K Srivastava
- Department of Cardiology, Smidt Heart Institute at Cedars-Sinai, Los Angeles, CA, United States of America
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute at Cedars-Sinai, Los Angeles, CA, United States of America.
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36
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Joshi Y, Macdonald PS. Heart Transplantation From DCD Donors Enters the Mainstream. Transplantation 2023; 107:2449-2450. [PMID: 38010153 DOI: 10.1097/tp.0000000000004761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Affiliation(s)
- Yashutosh Joshi
- Heart Transplant Unit, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- Faculty of Medicine, St Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
| | - Peter S Macdonald
- Heart Transplant Unit, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- Faculty of Medicine, St Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
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37
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Louca JO, Manara A, Messer S, Öchsner M, McGiffin D, Austin I, Bell E, Leboff S, Large S. Getting out of the box: the future of the UK donation after circulatory determination of death heart programme. EClinicalMedicine 2023; 66:102320. [PMID: 38024476 PMCID: PMC10679474 DOI: 10.1016/j.eclinm.2023.102320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 12/01/2023] Open
Abstract
Heart failure imposes a significant burden on all health care systems and has a 5-year mortality of 50%. Heart transplantation and ventricular assist device (VAD) implantation are the definitive therapies for end stage heart disease, although transplantation appears to offer superior long-term survival and quality of life over VAD implantation. Transplantation is limited by a shortage in donor hearts, resulting in considerable waiting list mortality. Donation after circulatory determination of death (DCD) offers a significant uplift in the number of donors for heart transplantation. The outcomes both from the UK and internationally have been exciting, with outcomes at least as good as conventional donation after brain death (DBD) transplantation. Currently, DCD hearts are reperfused using ex-situ machine perfusion (ESMP). Whilst ESMP has enabled the development of DCD transplantation, it comes at significant cost, with the per run cost of approximately GBP £90,000. In-situ perfusion of the heart, otherwise known as thoraco-abdominal normothermic regional perfusion (taNRP) is cheaper, but there are ethical concerns regarding the potential to restore cerebral perfusion in the donor. We must determine whether there is any cerebral circulation during in-situ perfusion of the heart to ensure that it does not invalidate the diagnosis of death and potentially violate the dead donor rule. Besides this, there is a need for a randomised controlled trial to definitively determine whether taNRP offers any clinical advantages over ex-situ machine perfusion. This viewpoint article explores these issues in more detail.
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Affiliation(s)
- John Onsy Louca
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0SP, UK
| | - Alex Manara
- The Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, BS 10 5NB, UK
| | - Simon Messer
- Golden Jubilee Hospital, Agamermnon Street, Glasgow, G81 4DY, UK
| | - Marco Öchsner
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0SP, UK
| | - David McGiffin
- The Alfred and Monash University, Australia 55 Commercial Rd, Melbourne, VIC, 3004, Australia
| | - Isabel Austin
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0SP, UK
| | - Eliza Bell
- Royal Papworth Hospital Biomedical Campus, Cambridge, CB2 0AY, UK
| | - Savanna Leboff
- Royal Papworth Hospital Biomedical Campus, Cambridge, CB2 0AY, UK
| | - Stephen Large
- Royal Papworth Hospital Biomedical Campus, Cambridge, CB2 0AY, UK
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38
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Pai V, Asgari E, Berman M, Callaghan C, Corris P, Large S, Messer S, Nasralla D, Parmar J, Watson C, O'Neill S. The British Transplantation Society guidelines on cardiothoracic organ transplantation from deceased donors after circulatory death. Transplant Rev (Orlando) 2023; 37:100794. [PMID: 37660415 DOI: 10.1016/j.trre.2023.100794] [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: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/05/2023]
Abstract
Maximising organ utilisation from donation after circulatory death (DCD) donors could help meet some of the shortfall in organ supply, but it represents a major challenge, particularly as organ donors and transplant recipients become older and more medically complex over time. Success is dependent upon establishing common practices and accepted protocols that allow the safe sharing of DCD organs and maximise the use of the DCD donor pool. The British Transplantation Society 'Guideline on transplantation from deceased donors after circulatory death' has recently been updated. This manuscript summarises the relevant recommendations from chapters specifically related to transplantation of cardiothoracic organs.
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Affiliation(s)
| | | | | | | | - Paul Corris
- Newcastle University and Institute of Transplantation, Freeman Hospital, Newcastle, UK
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39
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O'Neill S, Asgari E, Callaghan C, Gardiner D, Hartog H, Iype S, Manara A, Nasralla D, Oniscu GC, Watson C. The British transplantation society guidelines on organ donation from deceased donors after circulatory death. Transplant Rev (Orlando) 2023; 37:100791. [PMID: 37598591 DOI: 10.1016/j.trre.2023.100791] [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: 08/08/2023] [Revised: 08/11/2023] [Accepted: 08/11/2023] [Indexed: 08/22/2023]
Abstract
Recipient outcomes after transplantation with organs from donation after circulatory death (DCD) donors can compare favourably and even match recipient outcomes after transplantation with organs from donation after brain death donors. Success is dependent upon establishing common practices and accepted protocols that allow the safe sharing of DCD organs and maximise the use of the DCD donor pool. The British Transplantation Society 'Guideline on transplantation from deceased donors after circulatory death' has recently been updated. This manuscript summarises the relevant recommendations from chapters specifically related to organ donation.
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Affiliation(s)
- Stephen O'Neill
- Consultant Transplant Surgeon, Belfast City Hospital, Belfast, Northern Ireland.
| | - Ellie Asgari
- Consultant Nephrologist, Guy's Hospital, London, England
| | - Chris Callaghan
- Consultant Transplant Surgeon, Guy's Hospital, London, England
| | - Dale Gardiner
- Consultant Intensivist, Queen's Medical Centre, Nottingham, England
| | - Hermien Hartog
- Consultant Transplant Surgeon, Queen Elizabeth Hospital, Birmingham, England
| | - Satheesh Iype
- Consultant Transplant Surgeon, Royal Free Hospital, London, England
| | - Alex Manara
- Consultant Intensivist, Southmead Hospital, Bristol, England
| | - David Nasralla
- Consultant Transplant Surgeon, Royal Free Hospital, London, England
| | - Gabi C Oniscu
- Consultant Transplant Surgeon, Royal Infirmary, Edinburgh, Scotland
| | - Chris Watson
- Consultant Transplant Surgeon, Addenbrooke's Hospital, Cambridge, England
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40
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Fiedler A, Miller PN, Smith JW. Expanding the Donation After Circulatory Death Transplant Pool in the United States. Ann Thorac Surg 2023; 116:1121-1123. [PMID: 37660964 DOI: 10.1016/j.athoracsur.2023.08.020] [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: 06/21/2023] [Revised: 08/12/2023] [Accepted: 08/21/2023] [Indexed: 09/05/2023]
Affiliation(s)
- Amy Fiedler
- Cardiac Surgery and Heart Transplant Programs, Department of Surgery, University of California, San Francisco, California
| | - Phoebe N Miller
- Department of Surgery, University of California, San Francisco, California.
| | - Jason W Smith
- Cardiac Surgery and Heart Transplant Programs, Department of Surgery, University of California, San Francisco, California
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41
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Urban M, Castleberry AW, Siddique A, Lowes BD, Stoller DA, Lundgren SW, Um JY. Utilization of Paragonix Sherpapak Cardiac Transport System for the Preservation of Donor Hearts After Circulatory Death. Transplant Proc 2023; 55:1997-2002. [PMID: 37739830 DOI: 10.1016/j.transproceed.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/04/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Donation after circulatory death (DCD) heart transplantation is being increasingly adopted by transplant centers. The optimal method of DCD heart preservation during transport after in situ thoracoabdominal normothermic regional perfusion (TA-NRP) is not known. METHODS We evaluated our experience with the Paragonix SherpaPak Cardiac Transport System (SCTS) for the transport of DCD cardiac allografts after TA-NRP recovery between January 2021 and December 2022. We collected and evaluated donor characteristics, allograft ischemic intervals, and recipient baseline demographic and clinical variables, and short-term outcomes. RESULTS Twelve recipients received DCD grafts recovered with TA-NRP and transported in SCTS during the study period. The median age of 10 male and 2 female donors was 32 years (min 15, max 38). The median duration of functional warm ischemia was 12 minutes (min 8, max 22). Hearts were preserved in SCTS for a median of 158 minutes (min 37, max 224). Median recipient age was 61 years (min 28, max 70). Ten recipients (83%) survived to hospital discharge, with one death attributable to graft dysfunction (8%). The median vasoactive-inotropic (VIS) score at 72 hours post-transplantation of the entire cohort was 6 (min 0, max 15). The median length of intensive care unit stay in hospital survivors was 5 days (min 3, max 17) days and hospital stay 17 days (min 9, max 37). CONCLUSIONS The Paragonix SCTS provides efficacious preservation of DCD grafts for ≥3.5 hours. Organs transported with this device showed satisfactory post-transplantation function.
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Affiliation(s)
- Marian Urban
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Anthony W Castleberry
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Aleem Siddique
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Brian D Lowes
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Douglas A Stoller
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Scott W Lundgren
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - John Y Um
- Department of Surgery, Division of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
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Secanella L, Alconchel F, López-Monclús J, Toledo-Martínez E, Barrios O, Ramírez P, Jiménez-Garrido MC, Rodríguez-Sanjuán JC, Royo-Villanova M, Moreno-González G, Lladó L. Outcomes of liver transplantation with thoracoabdominal normothermic regional perfusion: a matched-controlled initial experience in Spain. FRONTIERS IN TRANSPLANTATION 2023; 2:1280454. [PMID: 38993919 PMCID: PMC11235216 DOI: 10.3389/frtra.2023.1280454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 10/16/2023] [Indexed: 07/13/2024]
Abstract
Thoracoabdominal (TA) normothermic regional perfusion (NRP) should allow the safe recovery of heart and liver grafts simultaneously in the context of controlled donation after circulatory death (cDCD). We present the initial results of cDCD liver transplantation with simultaneous liver and heart procurement in Spain until October 2021. Outcomes were compared with a matched cohort of cDCD with abdominal NRP (A-NRP) from participating institutions. Primary endpoints comprised early allograft dysfunction (EAD) or primary non-function (PNF), and the development of ischemic-type biliary lesions (ITBL). Six transplants were performed using cDCD with TA-NRP during the study period. Donors were significantly younger in the TA-NRP group than in the A-NRP group (median 45.6 years and 62.9 years respectively, p = 0.011), with a median functional warm ischemia time of 12.5 min in the study group and 13 min in the control group. Patient characteristics, procurement times, and surgical baseline characteristics did not differ significantly between groups. No patient in the study group developed EAD or PNF, and over a median follow-up of 9.8 months, none developed ITBL or graft loss. Extending A-NRP to TA-NRP for cardiac procurement may be technically challenging, but it is both feasible and safe, showing comparable postoperative outcomes to A-NRP.
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Affiliation(s)
- Luis Secanella
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y Digestiva, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Felipe Alconchel
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Virgen de la Arrixaca), Murcia, Spain
| | - Javier López-Monclús
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Trasplante Hepático, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Enrique Toledo-Martínez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Oriana Barrios
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y Digestiva, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Pablo Ramírez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Virgen de la Arrixaca), Murcia, Spain
| | - Manuel Cecilio Jiménez-Garrido
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Trasplante Hepático, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Mario Royo-Villanova
- Servicio de Medicina Intensiva, Coordinación de Trasplantes, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Virgen de la Arrixaca), Murcia, Spain
| | - Gabriel Moreno-González
- Servicio de Medicina Intensiva, Coordinación de Trasplantes, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Laura Lladó
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y Digestiva, Hospital Universitari de Bellvitge, Barcelona, Spain
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43
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Siddique A, Parekh KR, Huddleston SJ, Shults A, Locke JE, Keshavamurthy S, Schwartz G, Hartwig MG, Whitson BA. A call to action in thoracic transplant surgical training. J Heart Lung Transplant 2023; 42:1627-1631. [PMID: 37268052 DOI: 10.1016/j.healun.2023.05.017] [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: 12/12/2022] [Revised: 05/19/2023] [Accepted: 05/30/2023] [Indexed: 06/04/2023] Open
Abstract
Thoracic organ recovery and implantation is increasing in complexity. Simultaneously the logistic burden and associated cost is rising. An electronic survey distributed to the surgical directors of thoracic transplant programs in the United States indicated dissatisfaction amongst 72% of respondents with current procurement training and 85% of respondents favored a process for certification in thoracic organ transplantation. These responses highlight concerns for the current paradigm of training in thoracic transplantation. We discuss the implications of advancements in organ retrieval and implant for surgical training and propose that the thoracic transplant community might address the need through formalized training in procurement and certification in thoracic transplantation.
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Affiliation(s)
- A Siddique
- University of Nebraska Medical Center, Department of Surgery, Division of Cardiothoracic Surgery, Omaha, Nebraska.
| | - K R Parekh
- University of Iowa Hospitals and Clinics, Department of Cardiothoracic Surgery, Carver College of Medicine, Iowa City, Iowa
| | - S J Huddleston
- University of Minnesota, Department of Surgery, Division of Cardiothoracic Surgery
| | - A Shults
- American Society of Thoracic Surgeons, Arlington, Virginia
| | - J E Locke
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, Alabama
| | - S Keshavamurthy
- University of Kentucky College of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Lexington, Kentucky
| | - G Schwartz
- Baylor University Medical Center, Department of Thoracic Surgery, Dallas, Texas
| | - M G Hartwig
- Duke University Health System, Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Durham, North Carolina
| | - B A Whitson
- The Ohio State University Wexner Medical Center, Department of Surgery, Division of Cardiac Surgery, Columbus, Ohio
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44
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Vervoorn MT, Amelink JJGJ, Ballan EM, Doevendans PA, Sluijter JPG, Mishra M, Boink GJJ, Bowles DE, van der Kaaij NP. Gene therapy during ex situ heart perfusion: a new frontier in cardiac regenerative medicine? Front Cardiovasc Med 2023; 10:1264449. [PMID: 37908499 PMCID: PMC10614057 DOI: 10.3389/fcvm.2023.1264449] [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: 07/20/2023] [Accepted: 10/02/2023] [Indexed: 11/02/2023] Open
Abstract
Ex situ organ preservation by machine perfusion can improve preservation of organs for transplantation. Furthermore, machine perfusion opens up the possibilities for selective immunomodulation, creation of tolerance to ischemia-reperfusion injury and/or correction of a pathogenic genetic defect. The application of gene modifying therapies to treat heart diseases caused by pathogenic mutations during ex situ heart perfusion seems promising, especially given the limitations related to delivery of vectors that were encountered during clinical trials using in vivo cardiac gene therapy. By isolating the heart in a metabolically and immunologically favorable environment and preventing off-target effects and dilution, it is possible to directly control factors that enhance the success rate of cardiac gene therapy. A literature search of PubMed and Embase databases was performed to identify all relevant studies regarding gene therapy during ex situ heart perfusion, aiming to highlight important lessons learned and discuss future clinical prospects of this promising approach.
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Affiliation(s)
- Mats T. Vervoorn
- Division of Heart & Lungs, Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jantijn J. G. J. Amelink
- Division of Heart & Lungs, Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Elisa M. Ballan
- Division of Heart & Lungs, Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
- Laboratory of Experimental Cardiology, Division Heart & Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
- Netherlands Heart Institute, Utrecht, Netherlands
| | - Pieter A. Doevendans
- Netherlands Heart Institute, Utrecht, Netherlands
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, Utrecht, Netherlands
| | - Joost P. G. Sluijter
- Laboratory of Experimental Cardiology, Division Heart & Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
- Regenerative Medicine Utrecht, Circulatory Health Research Center, University Utrecht, Utrecht, Netherlands
| | - Mudit Mishra
- Laboratory of Experimental Cardiology, Division Heart & Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Gerard J. J. Boink
- Amsterdam Cardiovascular Sciences, Department of Medical Biology, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Amsterdam Cardiovascular Sciences, Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Dawn E. Bowles
- Divison of Surgical Sciences, Department of Surgery, Duke University School of Medicine, Durham, NC, United States
| | - Niels P. van der Kaaij
- Division of Heart & Lungs, Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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45
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Siddiqi HK, Trahanas J, Xu M, Wells Q, Farber-Eger E, Pasrija C, Amancherla K, Debose-Scarlett A, Brinkley DM, Lindenfeld J, Menachem JN, Ooi H, Pedrotty D, Punnoose L, Rali AS, Sacks S, Wigger M, Zalawadiya S, McMaster W, Devries S, Shah A, Schlendorf K. Outcomes of Heart Transplant Donation After Circulatory Death. J Am Coll Cardiol 2023; 82:1512-1520. [PMID: 37793748 DOI: 10.1016/j.jacc.2023.08.006] [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: 06/21/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Heart transplantation using donation after circulatory death (DCD) allografts is increasingly common, expanding the donor pool and reducing transplant wait times. However, data remain limited on clinical outcomes. OBJECTIVES We sought to compare 6-month and 1-year clinical outcomes between recipients of DCD hearts, most of them recovered with the use of normothermic regional perfusion (NRP), and recipients of donation after brain death (DBD) hearts. METHODS We conducted a single-center retrospective observational study of all adult heart-only transplants from January 2020 to January 2023. Recipient and donor data were abstracted from medical records and the United Network for Organ Sharing registry, respectively. Survival analysis and Cox regression were used to compare the groups. RESULTS During the study period, 385 adults (median age 57.4 years [IQR: 48.0-63.7 years]) underwent heart-only transplantation, including 122 (32%) from DCD donors, 83% of which were recovered with the use of NRP. DCD donors were younger and had fewer comorbidities than DBD donors. DCD recipients were less often hospitalized before transplantation and less likely to require pretransplantation temporary mechanical circulatory support compared with DBD recipients. There were no significant differences between groups in 1-year survival, incidence of severe primary graft dysfunction, treated rejection during the first year, or likelihood of cardiac allograft vasculopathy at 1 year after transplantation. CONCLUSIONS In the largest single-center comparison of DCD and DBD heart transplantations to date, outcomes among DCD recipients are noninferior to those of DBD recipients. This study adds to the published data supporting DCD donors as a safe means to expand the heart donor pool.
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Affiliation(s)
- Hasan K Siddiqi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - John Trahanas
- Department of Cardiothoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Quinn Wells
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric Farber-Eger
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chetan Pasrija
- Department of Cardiothoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kaushik Amancherla
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alexandra Debose-Scarlett
- Department of Cardiothoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - D Marshall Brinkley
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan N Menachem
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Henry Ooi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Medicine, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Dawn Pedrotty
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Medicine, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Lynn Punnoose
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aniket S Rali
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Suzanne Sacks
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark Wigger
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Medicine, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sandip Zalawadiya
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William McMaster
- Department of Cardiothoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Steven Devries
- Department of Cardiothoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish Shah
- Department of Cardiothoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly Schlendorf
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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46
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Kagawa H, Goodwin M, Stehlik J, Campsen J, Baker T, Selzman CH. A Case Report of Triple Organ Transplantation From a Donor After Circulatory Death Using Thoraco-Abdominal Normothermic Regional Perfusion. Transplant Proc 2023; 55:1883-1887. [PMID: 37612153 DOI: 10.1016/j.transproceed.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023]
Abstract
Organ transplantation with donation after circulatory death can potentially increase the donor pool. Here, we report the rare case of triple-organ (heart/liver/kidney) transplantation from a donor after circulatory death using thoraco-abdominal normothermic regional perfusion. The recipient was a 61-year-old man with end-stage heart failure, liver failure, and kidney failure secondary to arrhythmogenic right ventricular dysplasia. He received a heart/liver/kidney transplantation from a donor after circulatory death. The course was complicated with primary graft dysfunction of the heart that resolved on postoperative day 3. The patient was discharged on postoperative day 39. He has no evidence for rejection on heart biopsy, and all 3 organs exhibit stable function. The use of donation after cardiac death donors greatly increases the donor pool and should be considered for patients requiring multiorgan transplantation. The use of thoraco-abdominal normothermic reperfusion is not only a feasible method for multiorgan procurement but also provides enhanced protection for all transplanted organs.
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Affiliation(s)
- Hiroshi Kagawa
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Matthew Goodwin
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jeffrey Campsen
- Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Talia Baker
- Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
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47
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Cheshire C, Messer S, Martinez L, Vokshi I, Ali J, Cernic S, Page A, Andal R, Berman M, Kaul P, Osman M, Rafiq M, Goddard M, Tweed K, Jenkins D, Tsui S, Large S, Kydd A, Lewis C, Parameshwar J, Pettit S, Bhagra S. Graft function and incidence of cardiac allograft vasculopathy in donation after circulatory-determined death heart transplant recipients. Am J Transplant 2023; 23:1570-1579. [PMID: 37442277 DOI: 10.1016/j.ajt.2023.07.003] [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: 02/14/2023] [Revised: 07/02/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023]
Abstract
Experience in donation after circulatory-determined death (DCD) heart transplantation (HTx) is expanding. There is limited information on the functional outcomes of DCD HTx recipients. We sought to evaluate functional outcomes in our cohort of DCD recipients. We performed a single-center, retrospective, observational cohort study comparing outcomes in consecutive DCD and donation after brain death (DBD) HTx recipients between 2015 and 2019. Primary outcome was allograft function by echocardiography at 12 and 24 months. Secondary outcomes included incidence of cardiac allograft vasculopathy, treated rejection, renal function, and survival. Seventy-seven DCD and 153 DBD recipients were included. There was no difference in left ventricular ejection fraction at 12 months (59% vs 59%, P = .57) and 24 months (58% vs 58%, P = .87). There was no significant difference in right ventricular function at 12 and 24 months. Unadjusted survival between DCD and DBD recipients at 5 years (85.7% DCD and 81% DBD recipients; P = .45) was similar. There were no significant differences in incidence of cardiac allograft vasculopathy (odds ratio 1.59, P = .21, 95% confidence interval 0.77-3.3) or treated rejection (odds ratio 0.60, P = .12, 95% confidence interval 0.32-1.15) between DBD and DCD recipients. Post-transplant renal function was similar at 1 and 2 years. In conclusion, cardiac allografts from DCD donors perform similarly to a contemporary population of DBD allografts in the medium term.
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Affiliation(s)
- Caitlin Cheshire
- Department of Cardiology, Alfred Health, Melbourne, Australia; Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Simon Messer
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Luis Martinez
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Ismail Vokshi
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Jason Ali
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Sendi Cernic
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Aravinda Page
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Ryan Andal
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Marius Berman
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Pradeep Kaul
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Mohamed Osman
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Muhammad Rafiq
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Martin Goddard
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Katharine Tweed
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - David Jenkins
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Steven Tsui
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Stephen Large
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Anna Kydd
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Clive Lewis
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Jayan Parameshwar
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Stephen Pettit
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
| | - Sai Bhagra
- Transplant Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom.
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48
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Kwon JH, Blanding WM, Shorbaji K, Scalea JR, Gibney BC, Baliga PK, Kilic A. Waitlist and Transplant Outcomes in Organ Donation After Circulatory Death: Trends in the United States. Ann Surg 2023; 278:609-620. [PMID: 37334722 DOI: 10.1097/sla.0000000000005947] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
OBJECTIVES To summarize waitlist and transplant outcomes in kidney, liver, lung, and heart transplantation using organ donation after circulatory death (DCD). BACKGROUND DCD has expanded the donor pool for solid organ transplantation, most recently for heart transplantation. METHODS The United Network for Organ Sharing registry was used to identify adult transplant candidates and recipients in the most recent allocation policy eras for kidney, liver, lung, and heart transplantation. Transplant candidates and recipients were grouped by acceptance criteria for DCD versus brain-dead donors [donation after brain death (DBD)] only and DCD versus DBD transplant, respectively. Propensity matching and competing-risks regression was used to model waitlist outcomes. Survival was modeled using propensity matching and Kaplan-Meier and Cox regression analysis. RESULTS DCD transplant volumes have increased significantly across all organs. Liver candidates listed for DCD organs were more likely to undergo transplantation compared with propensity-matched candidates listed for DBD only, and heart and liver transplant candidates listed for DCD were less likely to experience death or clinical deterioration requiring waitlist inactivation. Propensity-matched DCD recipients demonstrated an increased mortality risk up to 5 years after liver and kidney transplantation and up to 3 years after lung transplantation compared with DBD. There was no difference in 1-year mortality between DCD and DBD heart transplantation. CONCLUSIONS DCD continues to expand access to transplantation and improves waitlist outcomes for liver and heart transplant candidates. Despite an increased risk for mortality with DCD kidney, liver, and lung transplantation, survival with DCD transplant remains acceptable.
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Affiliation(s)
- Jennie H Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Walker M Blanding
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Joseph R Scalea
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC
| | - Barry C Gibney
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Prabhakar K Baliga
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
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49
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DeFilippis EM, Nikolova A, Holzhauser L, Khush KK. Understanding and Investigating Sex-Based Differences in Heart Transplantation: A Call to Action. JACC. HEART FAILURE 2023; 11:1181-1188. [PMID: 37589612 DOI: 10.1016/j.jchf.2023.06.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 06/20/2023] [Accepted: 06/22/2023] [Indexed: 08/18/2023]
Abstract
Women represent only about 25% of heart transplant recipients annually. Although the number of women living with advanced heart failure remains unknown, epidemiologic research suggests that more women should be receiving advanced heart failure therapies. Sex differences in risk factors, presentation, response to pharmacotherapy, and outcomes in heart failure have been well described. Yet, less is known about sex differences in heart transplant candidate selection, waitlist management, donor selection, perioperative considerations, and post-transplant management and outcomes. The purpose of this review was to summarize the existing published reports related to sex differences in heart transplantation, highlighting areas in which sex-based considerations are well described and supported by available evidence, and emphasizing topics that require further study.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Andriana Nikolova
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Luise Holzhauser
- Division of Cardiovascular Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California, USA.
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50
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Quader M, Akande O, Cholyway R, Lesnefsky EJ, Toldo S, Chen Q. Infarct Size With Incremental Global Myocardial Ischemia Times: Cyclosporine A in Donation After Circulatory Death Rat Hearts. Transplant Proc 2023; 55:1495-1503. [PMID: 37422374 DOI: 10.1016/j.transproceed.2023.03.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/03/2023] [Accepted: 03/30/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND We quantified the myocardial infarct size with varying global ischemia durations and studied the benefits of Cyclosporine A (CyA) in reducing cardiac injury in ex vivo and transplanted rat hearts. METHODS Infarct size was measured after 15, 20, 25, 30, and 35 minutes of in vivo global ischemia (n = 34) and compared with control beating-heart donor (CBD) hearts (n = 10). For heart function assessment, donation after circulatory death (DCD) rat hearts (n = 20) were procured after 25 minutes of in vivo ischemia and reanimated ex vivo for 90 minutes. Half of the DCD hearts received CyA (0.5 mM) at reanimation. The CBD hearts (n = 10) served as controls. A separate group of CBD and DCD (with or without CyA treatment) hearts underwent heterotopic heart transplantation; heart function was measured at 48 hours. RESULTS Infarct size was 25% with 25 minutes of ischemia and increased significantly with 30 and 35 minutes to 32% and 41%, respectively. CyA treatment decreased infarct size in DCD hearts (15% vs 25%). Heart function in the transplanted DCD hearts was significantly better with CyA treatment and was comparable to CBD hearts. CONCLUSIONS CyA administered at reperfusion limited infarct size in DCD hearts and improved their function in transplanted hearts.
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Affiliation(s)
- Mohammed Quader
- Division of Cardio-Thoracic Surgery, Virginia Commonwealth University, Richmond, Virginia; Department of Surgery, McGuire Veterans Administration Medical Center and Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia.
| | - Oluwatoyin Akande
- Division of Cardio-Thoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Renee Cholyway
- Division of Cardio-Thoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Edward J Lesnefsky
- Department of Surgery, McGuire Veterans Administration Medical Center and Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia; Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Stefano Toldo
- Department of Surgery, McGuire Veterans Administration Medical Center and Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia; Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Qun Chen
- Department of Surgery, McGuire Veterans Administration Medical Center and Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia; Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
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