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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; 38:2047-2058. [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] [MESH Headings] [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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Kharawala A, Nagraj S, Seo J, Pargaonkar S, Uehara M, Goldstein DJ, Patel SR, Sims DB, Jorde UP. Donation After Circulatory Death Heart Transplant: Current State and Future Directions. Circ Heart Fail 2024; 17:e011678. [PMID: 38899474 DOI: 10.1161/circheartfailure.124.011678] [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: 02/06/2024] [Accepted: 05/16/2024] [Indexed: 06/21/2024]
Abstract
Orthotopic heart transplant is the gold standard therapeutic intervention for patients with end-stage heart failure. Conventionally, heart transplant has relied on donation after brain death for organ recovery. Donation after circulatory death (DCD) is the donation of the heart after confirming that circulatory function has irreversibly ceased. DCD-orthotopic heart transplant differs from donation after brain death-orthotopic heart transplant in ways that carry implications for widespread adoption, including differences in organ recovery, storage and ethical considerations surrounding normothermic regional perfusion with DCD. Despite these differences, DCD has shown promising early outcomes, augmenting the donor pool and allowing more individuals to benefit from orthotopic heart transplant. This review aims to present the current state and future trajectory of DCD-heart transplant, examine key differences between DCD and donation after brain death, including clinical experiences and innovations in methodologies, and address the ongoing ethical challenges surrounding the new frontier in heart transplant with DCD donors.
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Affiliation(s)
- Amrin Kharawala
- Jacobi Medical Center, New York City Health & Hospitals Corp, Bronx, NY (A.K., J.S., S.P.)
| | - Sanjana Nagraj
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (S.N., M.U., D.J.G., S.R.P., D.B.S., U.P.J.)
| | - Jiyoung Seo
- Jacobi Medical Center, New York City Health & Hospitals Corp, Bronx, NY (A.K., J.S., S.P.)
| | - Sumant Pargaonkar
- Jacobi Medical Center, New York City Health & Hospitals Corp, Bronx, NY (A.K., J.S., S.P.)
| | - Mayuko Uehara
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (S.N., M.U., D.J.G., S.R.P., D.B.S., U.P.J.)
| | - Daniel J Goldstein
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (S.N., M.U., D.J.G., S.R.P., D.B.S., U.P.J.)
| | - Snehal R Patel
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (S.N., M.U., D.J.G., S.R.P., D.B.S., U.P.J.)
| | - Daniel B Sims
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (S.N., M.U., D.J.G., S.R.P., D.B.S., U.P.J.)
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (S.N., M.U., D.J.G., S.R.P., D.B.S., U.P.J.)
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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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DiChiacchio L, Goodwin ML, Kagawa H, Griffiths E, Nickel IC, Stehlik J, Selzman CH. Heart Transplant and Donors After Circulatory Death: A Clinical-Preclinical Systematic Review. J Surg Res 2023; 292:222-233. [PMID: 37657140 DOI: 10.1016/j.jss.2023.07.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 09/03/2023]
Abstract
INTRODUCTION Heart transplantation is the treatment of choice for end-stage heart failure. There is a mismatch between the number of donor hearts available and the number of patients awaiting transplantation. Expanding the donor pool is critically important. The use of hearts donated following circulatory death is one approach to increasing the number of available donor hearts. MATERIALS AND METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines utilizing Pubmed/MEDLINE and Embase. Articles including adult human studies and preclinical animal studies of heart transplantation following donation after circulatory death were included. Studies of pediatric populations or including organs other than heart were excluded. RESULTS Clinical experience and preclinical studies are reviewed. Clinical experience with direct procurement, normothermic regional perfusion, and machine perfusion are included. Preclinical studies addressing organ function assessment and enhancement of performance of marginal organs through preischemic, procurement, preservation, and reperfusion maneuvers are included. Articles addressing the ethical considerations of thoracic transplantation following circulatory death are also reviewed. CONCLUSIONS Heart transplantation utilizing organs procured following circulatory death is a promising method to increase the donor pool and offer life-saving transplantation to patients on the waitlist living with end-stage heart failure. There is robust ongoing preclinical and clinical research to optimize this technique and improve organ yield. There are also ongoing ethical considerations that must be addressed by consensus before wide adoption of this approach.
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Affiliation(s)
- Laura DiChiacchio
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Matthew L Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Hiroshi Kagawa
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Eric Griffiths
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Ian C Nickel
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Josef Stehlik
- Division of Cardiology, University of Utah, Salt Lake City, Utah
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah.
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James L, LaSala VR, Hill F, Ngai JY, Reyentovich A, Hussain ST, Gidea C, Piper GL, Galloway AC, Smith DE, Moazami N. Donation after circulatory death heart transplantation using normothermic regional perfusion:The NYU Protocol. JTCVS Tech 2022; 17:111-120. [PMID: 36820336 PMCID: PMC9938390 DOI: 10.1016/j.xjtc.2022.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/25/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022] Open
Abstract
Objective This study aimed to evaluate the impact of cardiopulmonary bypass for thoraco-abdominal normothermic regional perfusion on the metabolic milieu of donation after cardiac death organ donors before transplantation. Methods Local donation after cardiac death donor offers are assessed for suitability and willingness to participate. Withdrawal of life-sustaining therapy is performed in the operating room. After declaration of circulatory death and a 5-minute observation period, the cardiac team performs a median sternotomy, ligation of the aortic arch vessels, and initiation of thoraco-abdominal normothermic regional perfusion via central cardiopulmonary bypass at 37 °C. Three sodium chloride zero balance ultrafiltration bags containing 50 mEq sodium bicarbonate and 0.5 g calcium carbonate are infused. Arterial blood gas measurements are obtained every 15 minutes after every zero balance ultrafiltration bag is infused, and blood is transfused as needed to maintain hemoglobin greater than 8 mg/dL. Cardiopulmonary bypass is weaned with concurrent hemodynamic and transesophageal echocardiogram evaluation of the donor heart. The remainder of the procurement, including the abdominal organs, proceeds in a similar controlled fashion as is performed for a standard donation after brain death donor. Results Between January 2020 and May 2022, 18 donation after cardiac death transplants using the thoraco-abdominal normothermic regional perfusion protocol were performed at our institution. The median donor age was 42.5 years (range, 20-51 years), and 88.9% (16/18) were male. The mean total donor cardiopulmonary bypass time was 88.8 ± 51.8 minutes. At the beginning of cardiopulmonary bypass, the average donor lactate was 9.4 ± 1.5 mmol/L compared with an average final lactate of 5.3 ± 2.7 mmol/L (P<.0001). The average beginning potassium was 6.5 ± 1.8 mmol/L compared with an average end potassium of 4.2 ± 0.4 mmol/L (P<.0001) . The average beginning hemoglobin was 6.8 ± 0.7 g/dL, and the average end hemoglobin was 8.2 ± 1.3 g/dL (P<.001) . On average, donation after cardiac death donors received transfusions of 2.3 ± 1.5 units of packed red blood cells. Of the 18 donors who underwent normothermic regional perfusion, all hearts were deemed suitable for recovery and successfully transplanted, a yield of 100%. Other organs successfully recovered and transplanted include kidneys (80.6% yield), livers (66.7% yield), and bilateral lungs (27.8% yield). Conclusions The use of cardiopulmonary bypass for thoraco-abdominal normothermic regional perfusion is a burgeoning option for improving the quality of organs from donation after cardiac death donors. Meticulous intraoperative management of donation after cardiac death donors with a specific focus on improving their metabolic milieu may lead to improved graft function in transplant recipients.
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Key Words
- CIT, cold ischemic time
- CPB, cardiopulmonary bypass
- DBD, donation after brain death
- DCD, donation after circulatory death
- DWIT, donor warm ischemic time
- ICU, intensive care unit
- NRP, normothermic regional perfusion
- OPO, Organ Procurement Organization
- TEE, transesophageal echocardiography
- UF, ultrafiltration
- WLST, withdrawal of life-sustaining therapy
- Z-BUF, zero-balance ultrafiltration
- donation after circulatory death
- heart transplantation
- normothermic regional perfusion
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Affiliation(s)
- Les James
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY
| | - V. Reed LaSala
- Department of General Surgery, SUNY Downstate Health Sciences University, Brooklyn, NY
| | - Fredrick Hill
- Perfusion Services, NYU Langone Health, New York, NY
| | - Jennie Y. Ngai
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Health, New York, NY
| | - Alex Reyentovich
- Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY
| | - Syed T. Hussain
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY
| | - Claudia Gidea
- Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY
| | | | | | - Deane E. Smith
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY,Address for reprints: Nader Moazami, MD, Division of Heart and Lung Transplantation and Mechanical Circulatory Support, Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, 530 1st Ave, Suite 9V, New York, NY 10016.
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6
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Peled H, Mathews S, Rhodes D, Bernat JL. Normothermic Regional Perfusion Requires Careful Ethical Analysis Before Adoption Into Donation After Circulatory Determination of Death. Crit Care Med 2022; 50:1644-1648. [PMID: 36227032 DOI: 10.1097/ccm.0000000000005632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Harry Peled
- Providence St Jude Medical Center, Fullerton, CA
| | | | - David Rhodes
- Providence St Jude Medical Center, Fullerton, CA
| | - James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, NH
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Koscik R, Ngai J. Donation after Circulatory Death: Expanding Heart Transplants. J Cardiothorac Vasc Anesth 2022; 36:3867-3876. [DOI: 10.1053/j.jvca.2022.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 11/11/2022]
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Truby LK, Casalinova S, Patel CB, Agarwal R, Holley CL, Mentz RJ, Milano C, Bryner B, Schroder JN, Devore AD. Donation After Circulatory Death in Heart Transplantation: History, Outcomes, Clinical Challenges, and Opportunities to Expand the Donor Pool. J Card Fail 2022; 28:1456-1463. [PMID: 35447338 DOI: 10.1016/j.cardfail.2022.03.353] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 11/15/2022]
Abstract
Heart transplantation remains the gold-standard therapy for end-stage heart failure; the expected median survival range is 12-13 years. More than 30,000 heart transplants have been performed globally in the past decade alone. With advances in medical and surgical therapies for heart failure, including durable left ventricular assist devices, an increasing number of patients are living with end-stage disease. Last year alone, more than 2500 patients were added to the heart-transplant waitlist in the United States. Despite recent efforts to expand the donor pool, including an increase in transplantation of hepatitis C-positive and extended-criteria donors, supply continues to fall short of demand. Donation after circulatory death (DCD), defined by irreversible cardiopulmonary arrest rather than donor brain death, is widely used in other solid-organ transplants, including kidney and liver, but has not been widely adopted in heart transplantation. However, resurging interest in DCD donation and the introduction of ex vivo perfusion technology has catalyzed recent clinical trials and the development of DCD heart-transplantation programs. Herein, we review the history of DCD heart transplantation, describe the currently used procurement protocols for it and examine clinical challenges and outcomes of such a procedure.
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Affiliation(s)
- Lauren K Truby
- From the Duke Molecular Physiology Institute, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Sarah Casalinova
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Chetan B Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Richa Agarwal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Christopher L Holley
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Carmelo Milano
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Benjamin Bryner
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Adam D Devore
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
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Cardounel A, Julliard W. Donation after cardiac death in heart transplantation: is there an ethical dilemma? Curr Opin Anaesthesiol 2022; 35:48-52. [PMID: 34878419 DOI: 10.1097/aco.0000000000001088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW In an attempt to address the organ shortages in heart transplantation, USA centres have begun utilizing donation after cardiac death (DCD) as an alternative to traditional donation after brain death (DBD). As this paradigm continues to expand, there is a need to address the medico-legal and ethical aspects of DCD donation, which is the focus of the current review. RECENT FINDINGS Current protocols use criteria established by the Uniform Determination of Death Act (UDDA), which is explicit in defining the irreversibility of circulation and brain function in determining death. By the nature of DCD, the patient may not meet death criteria from a biological systems perspective of irreversibility, and thus, the moral dilemma ensues on whether removing vital organs violates our legal and moral obligations to the patient. SUMMARY In the current article, we review the ethical issues raised with DCD and define DCD protocols and their ability to comply with established regulatory guidelines while respecting the wishes of patients and their surrogates through informed decisions making about organ donation and end-of-life care.
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Affiliation(s)
- Arturo Cardounel
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
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10
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Abstract
PURPOSE OF REVIEW To highlight the current global experience with DCD heart transplantation and explore the evolution of, and compare preservation strategies; examine early clinical outcomes, and discuss the growing use of DCD donors as a new frontier in heart transplantation. RECENT FINDINGS The two strategies of DCD heart preservation include NMP using the OCS Heart and TA-NRP followed by either: NMP or CSS. Better understanding the limits of cold ischaemia following TA-NRP will aid in distant procurement. Asystolic warm ischaemia plays an important role in determining immediate post-operative graft function and potential need for mechanical support. Large volume DCD heart transplant units show no difference in survival between DCD and DBD donor heart transplants. In a previously non-utilised source of donor hearts, often viewed as an "unknown frontier" in heart transplantation, DCD hearts are a suitable alternative to brain-dead donor hearts and are likely to remain a permanent part of the heart transplantation landscape. Global uptake is currently increasing, and as understanding of preservation strategies and tolerable ischaemic times improve, utilisation of DCD hearts will continue to grow.
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Peled Y, Messer S, Large SR, Kittleson MM. Donation after Circulatory Death: Extending the Boundaries of this New Frontier. J Heart Lung Transplant 2021; 40:1419-1421. [PMID: 34429239 DOI: 10.1016/j.healun.2021.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Yael Peled
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Simon Messer
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge
| | - Stephen R Large
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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Hoffman JRH, McMaster WG, Rali AS, Rahaman Z, Balsara K, Absi T, Levack M, Brinkley M, Menachem J, Punnoose L, Sacks S, Wigger M, Zalawadiya S, Stevenson L, Schlendorf K, Lindenfeld J, Shah AS. Early US experience with cardiac donation after circulatory death (DCD) using normothermic regional perfusion. J Heart Lung Transplant 2021; 40:1408-1418. [PMID: 34334301 DOI: 10.1016/j.healun.2021.06.022] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Given the shortage of suitable donor hearts for cardiac transplantation and the growing interest in donation after circulatory death (DCD), our institution recently began procuring cardiac allografts from DCD donors. METHODS Between October 2020 and March 2021, 15 patients with heart failure underwent cardiac transplantation using DCD allografts. Allografts were procured using a modified extracorporeal membrane oxygenation circuit for thoracic normothermic regional perfusion (TA-NRP) and were subsequently transported using cold static storage. Data collection and analysis were performed with institutional review board approval. RESULTS The mean age of the DCD donors was 23 ± 7 years and average time on TA-NRP was 56 ± 8 minutes. Total ischemic time was 183 ± 31 minutes and distance from transplant center was 373 ± 203 nautical miles. Recipient age was 55 ± 14 years, with 8 (55.3%) recipients on durable left ventricular assist device support. Post-transplant, 6 (40%) recipients experienced mild left ventricle primary graft dysfunction (PGD-LV), 3 (20%) recipients experienced moderate PGD-LV, and no recipients experienced severe PGD-LV. Postoperative transthoracic echocardiogram demonstrated left ventricular ejection fraction >55% in all recipients. One recipient (6.6%) developed International Society for Heart and Lung Transplantation 2R acute cellular rejection on first biopsy. At last follow-up, all 15 recipients were alive past 30-days. CONCLUSIONS Cardiac DCD provides an opportunity to increase the availability of donor hearts for transplantation. Utilizing TA-NRP with cold static storage, we have extended the cold ischemic time of DCD allografts to almost 3 hours, allowing for inter-hospital organ transport.
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Affiliation(s)
- Jordan R H Hoffman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - William G McMaster
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aniket S Rali
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Zakiur Rahaman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Keki Balsara
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tarek Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melissa Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marshall Brinkley
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Menachem
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lynn Punnoose
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Suzanne Sacks
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark Wigger
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandip Zalawadiya
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lynne Stevenson
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly Schlendorf
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - JoAnn Lindenfeld
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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13
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Anguela-Calvet L, Moreno-Gonzalez G, Sbraga F, Gonzalez-Costello J, Tsui S, Oliver-Juan E. Heart Donation From Donors After Controlled Circulatory Death. Transplantation 2021; 105:1482-1491. [PMID: 33208694 DOI: 10.1097/tp.0000000000003545] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The gold-standard therapy for advanced-stage heart failure is cardiac transplantation. Since the first heart transplant in 1967, the majority of hearts transplanted came from brain death donors. Nevertheless, in recent years, the option of donation after circulatory death (DCD) is gaining importance to increase donor pool. Currently, heart-transplant programs using controlled donation after circulatory death (cDCD) have been implemented in the United Kingdom, Belgium, Australia, United States of America, and, recently, in Spain. In this article, we performed a concise review of the literature in heart cDCD; we summarize the pathophysiology involved in ischemia and reperfusion injury during this process, the different techniques of heart retrieval in cDCD donors, and the strategies that can be used to minimize the damage during retrieval and until transplantation. Heart transplant using DCD hearts is in continuous improvement and must be implemented in experienced cardiac transplant centers.
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Affiliation(s)
- Laura Anguela-Calvet
- Intensive Care Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Transplant Procurement Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Gabriel Moreno-Gonzalez
- Intensive Care Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Transplant Procurement Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Fabrizio Sbraga
- Cardiac Surgery Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Jose Gonzalez-Costello
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Advance Heart Failure and Cardiac Transplantation Unit, Cardiology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Steven Tsui
- Cardiothoracic Surgery Department, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Eva Oliver-Juan
- Intensive Care Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Transplant Procurement Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
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Gilliland S, Tran T, Alber S, Krause M, Weitzel N. Year in Review 2020: Noteworthy Literature in Cardiothoracic Critical Care. Semin Cardiothorac Vasc Anesth 2021; 25:128-137. [PMID: 33988043 DOI: 10.1177/10892532211016167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This year will be forever marked by the drastic changes COVID-19 wrought on our personal and professional lives. New roles and challenges in critical care have forced us to be constantly nimble and flexible in how we approach medicine. The strain of these challenges is apparent throughout the health care community and our society as a whole. Despite this adversity, 2020 will also be remembered for fantastic advances in research. This article is a collection of influential and exciting studies published in 2020 encompassing a broad swath of critical care with a focus on cardiothoracic critical care. Themes include examinations of early extracorporeal membrane oxygenation support for out-of-hospital cardiac arrest patients, the impact of sedation and other risk factors on perioperative mortality, a novel fluid resuscitation strategy following cardiac surgery, and advances in the fields of heart and lung transplantation as well as how they were affected by COVID-19. Given that many cardiothoracic intensivists were redeployed to the care of SARS-CoV-2 patients, we also discuss important advances in therapeutics for the virus.
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15
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Abrams BA, Wilkey B. The Year 2020 in Review: Noteworthy Literature for Thoracic Transplant Anesthesiologists. Semin Cardiothorac Vasc Anesth 2021; 25:120-127. [PMID: 33853464 DOI: 10.1177/10892532211007636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The year 2020 was a monumental year in medicine, and this review focuses on selected articles for cardiothoracic anesthesiologists and perioperative physicians involved in the care of heart and lung transplant patients. In the field of lung transplantation, significant strides were made in our knowledge of risk stratification during the preoperative assessment of potential recipients, perioperative transfusion medicine, and the administration of coagulation factor concentrates. In addition, variations in perioperative management and outcomes between institutions were studied across an assortment of metrics regarding lung transplantation, including case volumes and anesthetic practices. Transitioning to topics in the field of heart transplantation, consideration was given to recipients with adult congenital heart disease, and separately, approaches to expanding the donor pool through donation after circulatory death. With regard to preoperative support, outcomes for the total artificial heart as well as the MitraClip as bridges to transplantation were published.
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Affiliation(s)
| | - Barbara Wilkey
- University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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16
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Scheuer SE, Jansz PC, Macdonald PS. Heart transplantation following donation after circulatory death: Expanding the donor pool. J Heart Lung Transplant 2021; 40:882-889. [PMID: 33994229 DOI: 10.1016/j.healun.2021.03.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022] Open
Abstract
Heart transplantation from donation after circulatory death (DCD) donors is a rapidly expanding practice. In this review, we describe the history and challenges of DCD heart transplantation and overview the procurement protocols and methods of limiting ischemic injury, current outcomes, and future directions. There are now at least three protocols that permit resuscitation and viability assessment of the DCD heart either in situ or ex situ. While the retrieval protocol for hearts from DCD donors will depend on local regulations, the outcomes of DCD heart transplant recipients reported to date are excellent regardless of the retrieval protocol and are comparable to the outcomes of heart transplant recipients from donation after brain death (DBD) donors. In the two centers with the largest published experience, DCD heart transplantation now accounts for one third of their heart transplant activity. With international trends indicating that there is an increasing utilisation of the DCD pathway, it is expected that DCD donors will become a major source of heart donation worldwide.
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Affiliation(s)
- Sarah E Scheuer
- Cardiac Physiology & Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; Heart & Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Randwick, Australia
| | - Paul C Jansz
- Cardiac Physiology & Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; Heart & Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Randwick, Australia
| | - Peter S Macdonald
- Cardiac Physiology & Transplantation, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; Heart & Lung Transplant Unit, St Vincent's Hospital, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Randwick, Australia.
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17
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Potter KF, Cocchiola B, Quader MA. Donation after circulatory death: opportunities on the horizon. Curr Opin Anaesthesiol 2021; 34:168-172. [PMID: 33560667 DOI: 10.1097/aco.0000000000000960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Organ transplantation remains the gold standard therapy for many end-organ diseases. The demand for donor organs continues to grow to far exceed supply. This review summarizes recent protocols, procedures, and ethics surrounding the increased utilization of donors after circulatory death for transplantation. RECENT FINDINGS An increasing number of centers are utilizing donation after circulatory death, and outcomes are improving. Although outcomes from donors after brain death continue to be the primary source of donation, circulatory death outcomes continue to improve approaching the level of brain death donors. SUMMARY Donation after circulatory death offers a real opportunity to narrow the supply and demand issue with organ donation. Outcomes are improving, and protocols continue to evolve.
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Affiliation(s)
- Kenneth F Potter
- Division of Critical Care Medicine
- Department of Anesthesiology, Virginia Commonwealth University Health System
| | - Brian Cocchiola
- Department of Anesthesiology, Virginia Commonwealth University Health System
| | - Mohammed A Quader
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
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18
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Vandendriessche K, Tchana-Sato V, Ledoux D, Degezelle K, Rex S, Neyrinck A, Jochmans I, Monbaliu D, Vandenbriele C, Cleemput JV, Meyns B, Rega F. Transplantation of donor hearts after circulatory death using normothermic regional perfusion and cold storage preservation. Eur J Cardiothorac Surg 2021; 60:813-819. [PMID: 33783513 DOI: 10.1093/ejcts/ezab139] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/01/2021] [Accepted: 02/08/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Hearts donated after circulatory determination of death are usually preserved with normothermic machine perfusion prior to transplantation. This type of preservation is costly, requires bench time adding to warm ischaemia, and does not provide a reliable evaluation of the unloaded donor heart. We report on 4 successful donation after circulatory death (category III) hearts transplanted after thoraco-abdominal normothermic regional perfusion (NRP) and static cold storage. METHODS After life sustaining therapy was withdrawn and death was declared, perfusion to thoraco-abdominal organs was restored using extracorporeal circulation via cannulas in the femoral artery and vein and clamping of supra-aortic vessels. After weaning from extracorporeal circulation, cardiac function was assessed. Once approved, the heart was retrieved and stored using classic static cold storage. Data are expressed as median [min-max]. RESULTS Donor and recipient ages were 44 years [12-60] (n = 4) and 53 years [14-64] (n = 4), respectively. Time from the withdrawal of life sustaining therapy to start of NRP was 22 min [18-31]. Cold storage time was 72 min [35-129]. Thirty-day survival was 100% with a left ventricle ejection fraction of 60% [50-60]. CONCLUSIONS Donation after circulatory death heart transplantation using thoraco-abdominal NRP and subsequent cold storage preservation for up to 129 min was safe for 4 procedures and could be a way to expand the donor heart pool while avoiding costs of machine preservation.
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Affiliation(s)
- Katrien Vandendriessche
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Vincent Tchana-Sato
- Department of Cardiothoracic Surgery, University Hospital Liège, Liege, Belgium
| | - Didier Ledoux
- Department of Anesthesiology and Intensive Care, University Hospital Liège, Liege, Belgium
| | - Karlien Degezelle
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Ina Jochmans
- Department of Abdominal Transplantation, University Hospitals Leuven, Leuven, Belgium.,Transplant Research Group, Department of Microbiology, Immunology, and Transplantation, Catholic University Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Abdominal Transplantation, University Hospitals Leuven, Leuven, Belgium.,Transplant Research Group, Department of Microbiology, Immunology, and Transplantation, Catholic University Leuven, Leuven, Belgium
| | - Christophe Vandenbriele
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Van Cleemput
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
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