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Derse AR. An Ethics Committee's Evaluation of Normothermic Regional Perfusion (NRP) in 2018-Unsatisfactory Answers Then-and Now. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:34-37. [PMID: 38829600 DOI: 10.1080/15265161.2024.2336800] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
An adult university hospital ethics committee evaluated a proposed TA-NRP protocol in the fall of 2018. The protocol raised ethical concerns about violation of the Uniform Determination of Death Act and the prohibition known as the Dead Donor Rule, with potential resultant legal consequences. An additional concern was the potential for increased mistrust by the community of organ donation and transplantation. The ethics committee evaluated the responses to these concerns as unable to surmount the ethical and legal boundaries and the ethics committee declined to endorse the procedure. These concerns endure.
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2
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da Graca B, Borries T, Polk H, Ramakrishnan S, Testa G, Wall A. Ethical Issues in Donation following Circulatory Death: A Scoping Review Examining Changes over Time from 1993 to 2022. AJOB Empir Bioeth 2023; 14:237-277. [PMID: 37343208 DOI: 10.1080/23294515.2023.2224590] [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] [Indexed: 06/23/2023]
Abstract
Background: Ethical frameworks for organ donation following circulatory death (DCD) were established >20 years ago. However, considerable variation exists among these, indicating consensus has not been reached on all issues. Additionally, advances such as cardiac DCD transplants and normothermic regional perfusion (NRP) may have reignited old debates.Methods: We reviewed the English-language literature addressing ethical issues in DCD from 1993 to 2022, examining changes in frequency with which ethical principles and their sub-themes identified within each, were addressed.Results: Non-maleficence was the most frequently addressed principle (192 of 199 articles), as well as the most varied, with 9 subthemes (versus 2-4 within each of the other bioethical principles).Conclusions: There were several changes in the terminology used to refer to DCD over time, and substantial interest in cardiac DCD and NRP in recent publications, arising in 11 and 19 of the 30 publications from 2018 to 2022.
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Affiliation(s)
| | - Trevor Borries
- Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Heather Polk
- Baylor Scott & White Research Institute, Dallas, TX, USA
| | | | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Anji Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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3
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Thiessen C, Wisel SA, Roll GR. Simultaneous thoracic and abdominal donation after circulatory death organ recovery: the abdominal surgeon's perspective. Curr Opin Organ Transplant 2023; 28:139-144. [PMID: 36603197 PMCID: PMC9994842 DOI: 10.1097/mot.0000000000001045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF THE REVIEW To summarize the international experience with heart-liver (joint) donation after circulatory death (DCD) procurements and to explore the technical challenges in joint abdominal and thoracic DCD procurement. RECENT FINDINGS Following completion of the Donors After Circulatory Death Heart Trial in the US, combined thoracic and abdominal DCD is poised to become the standard of care, expanding access to life-saving heart and lung allografts. DCD heart procurement relies on collection of donor blood for priming of the normothermic perfusion pump, which delays cooling of abdominal organs and increases risk of ischemic injury. We review the effect of donor ischemia time on abdominal organs, with several proposed technical solutions to optimize transplant outcomes for all organs. SUMMARY The strategies reviewed in this manuscript may inform clinical decision-making, preoperative coordination between thoracic and abdominal procurement teams, and surgical technique for joint DCD procurements. Several approaches to organ procurement organization (OPO) and national policy, as well as future areas of focus for research are proposed.
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Affiliation(s)
- Carrie Thiessen
- Division of Transplantation, University of Wisconsin, Madison, Wisconsin
| | - Steven A. Wisel
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles
| | - Garrett R. Roll
- Division of Transplantation, University of California, San Francisco, San Francisco, California, USA
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4
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Circelli A, Antonini MV, Nanni A, Prugnoli M, Gamberini E, Maitan S, Gecele C, Viola L, Bissoni L, Scognamiglio G, Mezzatesta L, Bergamini C, Gobbi L, Meca MCC, Sangiorgi G, Bisulli M, Spiga M, Pransani V, Liuzzi D, Fantini V, Catena F, Russo E, Agnoletti V. cDCD organ donation pathway of Romagna Local Health Authority: strategic planning, organizational management, and results. DISCOVER HEALTH SYSTEMS 2023; 2:12. [PMID: 37520516 PMCID: PMC10062274 DOI: 10.1007/s44250-023-00022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 02/03/2023] [Indexed: 04/03/2023]
Abstract
The introduction of pathways to enrol deceased donors after cardio-circulatory confirmation of death (donation after circulatory death, DCD) is expanding in many countries to face the shortage of organs for transplantation. The implementation of normothermic regional reperfusion (NRP) with warm oxygenated blood is a strategy to manage in-situ the organs of DCD donors. This approach, an alternative to in-situ cold preservation, and followed by prompt retrieval and cold static storage and/or ex-vivo machine perfusion (EVMP), could be limited to abdominal organs (A-NRP) or extended to the thorax (thoraco-abdominal, TA-NRP. NRP is also referred to as extracorporeal interval support for organ retrieval (EISOR). The use of EISOR is increasing in Europe, even if variably regulated. A-NRP has been demonstrated to be effective in decreasing the risk associated with transplantation of abdominal organs from DCD donors, and was recommended by the European Society for Organ Transplantation (ESOT) in a recent consensus document. We aim to explain how we select the candidates for DCD, to describe our regionalized model for implementing EISOR provision, and to introduce the health care professionals involved in this complex process, with their strictly defined roles, responsibilities, and boundaries. Finally, we report the results of our program, recruiting cDCD donors over a large network of hospitals, all pertaining to a Local Health Authority (Azienda Unità Sanitaria Locale, AUSL) in Romagna, Italy.
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Affiliation(s)
- Alessandro Circelli
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Emilia-Romagna, Italy
| | - Andrea Nanni
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
- Transplant Procurement Management-AUSL della Romagna, Cesena, Italy
| | - Manila Prugnoli
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
- Transplant Procurement Management-AUSL della Romagna, Cesena, Italy
| | - Emiliano Gamberini
- Anesthesia and Intensive Care Unit, Infermi Hospital, AUSL della Romagna, Rimini, Italy
| | - Stefano Maitan
- Intensive Care Unit, Morgagni-Pierantoni Hospital-AUSL della Romagna, Forlì, Italy
| | - Claudio Gecele
- Anesthesia and Intensive Care Unit, Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Lorenzo Viola
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Luca Bissoni
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Giovanni Scognamiglio
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Luca Mezzatesta
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Carlo Bergamini
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Luca Gobbi
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | | | | | - Marcello Bisulli
- Interventional Radiology Department, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Martina Spiga
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Veruska Pransani
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Daria Liuzzi
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Valentina Fantini
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Fausto Catena
- General and Emergency Surgery, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Emanuele Russo
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, Bufalini Hospital-AUSL della Romagna, Cesena, Italy
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5
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Hatami S, Conway J, Freed DH, Urschel S. Thoracic organ donation after circulatory determination of death. TRANSPLANTATION REPORTS 2023. [DOI: 10.1016/j.tpr.2022.100125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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6
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Moeslund N, Zhang ZL, Dalsgaard FF, Glenting SB, Ilkjaer LB, Ryhammer P, Palmfeldt J, Pedersen M, Erasmus M, Eiskjaer H. Clamping of the Aortic Arch Vessels During Normothermic Regional Perfusion Does Not Negatively Affect Donor Cardiac Function in Donation After Circulatory Death. Transplantation 2023; 107:e3-e10. [PMID: 36042552 DOI: 10.1097/tp.0000000000004298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The hemodynamic effects of aortic arch vessel (AAV) clamping during normothermic regional perfusion (NRP) in donation after circulatory death is unknown. We investigated effects of AAV clamping during NRP compared with no clamping in a porcine model. METHODS In 16 pigs, hemodynamic parameters were recorded including biventricular pressure-volume measurements and invasive blood pressure. Additionally, blood gas parameters and inflammatory cytokines were used to assess the effect of AAV clamping. The animals were centrally cannulated for NRP, and baseline measurements were obtained before hypoxic circulatory arrest was induced by halting mechanical ventilation. During an 8-min asystole period, the animals were randomized to clamp (n = 8) or no-clamp (n = 8) of the AAV before commencement of NRP. During NRP, circulation was supported with norepinephrine (NE) and dobutamine. After 30 min of NRP, animals were weaned and observed for 180 min post-NRP. RESULTS All hearts were successfully reanimated and weaned from NRP. The nonclamp groups received significantly more NE to maintain a mean arterial pressure >60 mm Hg during and after NRP compared with the clamp group. There were no between group differences in blood pressure or cardiac output. Pressure-volume measurements demonstrated preserved cardiac function' including ejection fraction and diastolic and systolic function. No between group differences in inflammatory markers were observed. CONCLUSIONS AAV clamping did not negatively affect donor cardiac function or inflammation after circulatory death and NRP. Significantly less NE was used to support in the clamp group than in the nonclamp group.
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Affiliation(s)
- Niels Moeslund
- Department of Cardiology, Aarhus University Hospital, Denmark
- Department for Clinical Medicine-Comparative Medicine Laboratory, Aarhus University, Denmark
| | - Zhang Long Zhang
- Department for Cardiothoracic Surgery, University Medical Centre Groningen, The Netherlands
| | - Frederik Flyvholm Dalsgaard
- Department of Cardiology, Aarhus University Hospital, Denmark
- Department for Clinical Medicine-Comparative Medicine Laboratory, Aarhus University, Denmark
| | - Sif Bay Glenting
- Department for Clinical Medicine-Comparative Medicine Laboratory, Aarhus University, Denmark
| | - Lars Bo Ilkjaer
- Department for Cardiothoracic Surgery, Aarhus University Hospital, Denmark
| | - Pia Ryhammer
- Department for Anesthesiology, Region Hospital Silkeborg, Denmark
| | - Johan Palmfeldt
- Research Unit for Molecular Medicine, Institute for Clinical Medicine, Aarhus University, Denmark
| | - Michael Pedersen
- Department for Clinical Medicine-Comparative Medicine Laboratory, Aarhus University, Denmark
| | - Michiel Erasmus
- Department for Cardiothoracic Surgery, University Medical Centre Groningen, The Netherlands
| | - Hans Eiskjaer
- Department of Cardiology, Aarhus University Hospital, Denmark
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7
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Lung transplantation following donation after circulatory death. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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8
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Siddiqui F, Al-Adwan Y, Subramanian J, Henry ML. Contemporary Considerations in Solid Organ Transplantation Utilizing DCD Donors. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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9
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Abstract
In donation after circulatory death donors, warm ischemia time is a significant threat to successful cardiac transplantation. The ability to perfuse these organs during the minutes after death, until cardiac evaluation is completed to satisfaction, is crucial in limiting total warm ischemic time. Thoracoabdominal normothermic regional perfusion (TANRP) has emerged as a promising strategy for recovering and monitoring these hearts. We propose a series of clinical practice pearls that we follow for all donation after circulatory death procurements to streamline the process of setting up a TANRP circuit and ensuring all team members present at time procurement are familiar with the procedure. Bicaval cannulation is achieved via the abdomen for aortic cannulation, and via the chest for right atrial cannulation, avoiding deairing maneuvers and providing the shortest possible duration from incision to initiation of cardiopulmonary bypass. Here, we describe a series of practice techniques which we have utilized in our early experience with TANRP.
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10
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Controlled DCD Lung Transplantation: Circumventing Imagined and Real Barriers- Time for an International Taskforce? J Heart Lung Transplant 2022; 41:1198-1203. [DOI: 10.1016/j.healun.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/03/2022] [Accepted: 06/08/2022] [Indexed: 11/22/2022] Open
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11
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Van Raemdonck D, Ceulemans LJ, Neyrinck A, Levvey B, Snell GI. Donation After Circulatory Death in lung transplantation. Thorac Surg Clin 2022; 32:153-165. [PMID: 35512934 DOI: 10.1016/j.thorsurg.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The continuing shortage of pulmonary grafts from donors after brain death has led to a resurgence of interest in lung transplantation from donors after circulatory death (DCD). Most lungs from donors after withdrawal from life-sustaining therapy can be recovered rapidly and transplanted directly without ex-vivo assessment in case functional warm ischemic time is limited to 30 to 60 min. The potential of the DCD lung pool is still underutilized and should be maximized in countries with existing legislation. Countries lacking a DCD pathway should be encouraged to develop national ethical, professional, and legal frameworks to address public and professional concerns.
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Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, UZ Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium; Department of Chronic Diseases and Metabolism, KU Leuven University, Leuven, Belgium.
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, UZ Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium; Department of Chronic Diseases and Metabolism, KU Leuven University, Leuven, Belgium
| | - Arne Neyrinck
- Department of Anesthesiology, University Hospitals Leuven, UZ Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium; Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium
| | - Bronwyn Levvey
- Lung Transplant Service, The Alfred Hospital and Monash University, 55 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Gregory I Snell
- Lung Transplant Service, The Alfred Hospital and Monash University, 55 Commercial Road, Melbourne, Victoria 3004, Australia
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12
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Parent B, Caplan A, Moazami N, Montgomery RA. Response to American College of Physician's statement on the ethics of transplant after normothermic regional perfusion. Am J Transplant 2022; 22:1307-1310. [PMID: 35072337 DOI: 10.1111/ajt.16947] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/27/2021] [Accepted: 12/28/2021] [Indexed: 01/25/2023]
Abstract
This paper responds to the position statement released by the American College of Physicians (ACP) entitled "Ethics, Determination of Death, and Organ Transplantation in Normothermic Regional Perfusion (NRP) with Controlled Donation after Circulatory Determination of Death (cDCD): American College of Physicians Statement of Concern." The ACP's statement engages with critical ethical issues surrounding cDCD NRP, but several of their conclusions are flawed. Contrary to the statement, the practice respects the dead donor rule and the legal definition of death while honoring the wishes of the deceased and their loved ones to help save the lives of those in need of organ transplants. cDCD NRP is well established in many countries, it can enhance trust in medical practice and organ donation, and will increase the availability of optimal organs for life-saving transplants.
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Affiliation(s)
- Brendan Parent
- Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York
| | - Arthur Caplan
- Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York
| | - Nader Moazami
- NYU Langone Medical Center, Transplant Institute, New York, New York
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13
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HOLM AM, COURTWRIGHT A, OLLAND A, ZUCKERMANN A, RAEMDONCK DVAN. ISHLT Position Paper on Thoracic Organ Transplantation in Controlled Donation after Circulatory Determination of Death (cDCD). J Heart Lung Transplant 2022; 41:671-677. [DOI: 10.1016/j.healun.2022.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/28/2022] [Accepted: 03/08/2022] [Indexed: 01/12/2023] Open
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14
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Feo M, Miñambres E, Suberviola B, Campos-Fernández S, Sánchez-Arguiano J, Kislikova M, Ballesteros MA. Controlled Donation After Circulatory Death Program: Analysis and Results at a Tertiary Care Hospital. Transplant Proc 2022; 54:70-72. [PMID: 34974895 DOI: 10.1016/j.transproceed.2021.09.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/13/2021] [Accepted: 09/28/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The objective of the study was to evaluate the impact in organs obtained and transplanted from controlled donation after circulatory death (cDCD). METHODS Transplants from cDCD donors performed at the Hospital Universitario Marqués de Valdecilla from the beginning of the program (December 2013) to December 2020 were evaluated. All procedures were performed with normothermic regional perfusion. Donors after brain death (DBDs) during the same period were used as a control group. RESULTS A total of 95 donors after cardiac death and 152 DBDs were included. Age was similar in both groups (60 years [IQR, 53-68 years vs 62 years {IQR, 51-79 years]; P = .390). The number of organs recovered per donor was higher in the DBD group (4 [IQR, 3-5] vs 3 [IQR, 2-4], P < .001], as well as the number of transplanted organs (4 [IQR, 2-4] vs 2 [IQR, 2-4]; P = .002]. However, the number of noneffective donors was similar. DBDs presented a higher rate of liver donation (30.5% vs 46.7%; P = .012), lung donation (25.3% vs 38.2%; P = .036), and cardiac donation (1.1% vs 21.7%; P < .001) with respect to the donors after cardiac death group, but kidney and pancreatic donation were similar. CONCLUSIONS The cDCD with normothermic regional perfusion program is fully established in our center. The age of the cDCD donor has increased with experience and it is currently identical to the control group (DBD). After overcoming the learning curve, cDCD is a multiorgan donation that presents an excellent profitability in the number of organs extracted and transplanted.
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Affiliation(s)
- Marlene Feo
- Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Eduardo Miñambres
- Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain; Transplant Coordination Unit, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain; School of Medicine, University of Cantabria, Santander, Spain
| | - Borja Suberviola
- Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain; Transplant Coordination Unit, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Sandra Campos-Fernández
- Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Juncal Sánchez-Arguiano
- Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Maria Kislikova
- Service of Nephrology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - María A Ballesteros
- Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain; Transplant Coordination Unit, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain.
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15
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Urban M, Castleberry AW, Markin NW, Chacon MM, Strah HM, Um JY, Berkheim D, Merani S, Siddique A. Successful lung transplantation with graft recovered after thoracoabdominal normothermic perfusion from donor after circulatory death. Am J Transplant 2022; 22:294-298. [PMID: 34403207 DOI: 10.1111/ajt.16806] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/14/2021] [Accepted: 07/30/2021] [Indexed: 01/25/2023]
Abstract
Lung transplantation with lungs procured from donors after circulatory death (DCD) has been established as an alternative technique to traditional donation after brain death (DBD) with comparable outcomes. Recently, in situ thoracoabdominal normothermic regional perfusion (TA-NRP) has emerged as a novel technique employed in the procurement of cardiac allografts after circulatory death. TA-NRP, in contrast to ex situ machine perfusion, has the advantage of allowing in situ assessment of donor organs prior to final acceptance. However, there are some concerns that this technique may adversely impact the quality of lung allografts. Here, we present a case of a successful bilateral sequential lung transplantation in a patient with postinflammatory pulmonary fibrosis due to acute respiratory distress syndrome (ARDS), with lungs procured after normothermic in situ lung perfusion. Apart from the lungs, heart, liver, and kidneys were also successfully transplanted from this donor.
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Affiliation(s)
- Marian Urban
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Anthony W Castleberry
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Nicholas W Markin
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Megan M Chacon
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Heather M Strah
- Division of Pulmonary, Critical Care and Sleep, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - John Y Um
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - David Berkheim
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Shaheed Merani
- Division of Transplant Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Aleem Siddique
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
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16
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De Beule J, Vandendriessche K, Pengel LHM, Bellini MI, Dark JH, Hessheimer AJ, Kimenai HJAN, Knight SR, Neyrinck AP, Paredes D, Watson CJE, Rega F, Jochmans I. A systematic review and meta-analyses of regional perfusion in donation after circulatory death solid organ transplantation. Transpl Int 2021; 34:2046-2060. [PMID: 34570380 DOI: 10.1111/tri.14121] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 12/29/2022]
Abstract
In donation after circulatory death (DCD), (thoraco)abdominal regional perfusion (RP) restores circulation to a region of the body following death declaration. We systematically reviewed outcomes of solid organ transplantation after RP by searching PubMed, Embase, and Cochrane libraries. Eighty-eight articles reporting on outcomes of liver, kidney, pancreas, heart, and lung transplants or donor/organ utilization were identified. Meta-analyses were conducted when possible. Methodological quality was assessed using National Institutes of Health (NIH)-scoring tools. Case reports (13/88), case series (44/88), retrospective cohort studies (35/88), retrospective matched cohort studies (5/88), and case-control studies (2/88) were identified, with overall fair quality. As blood viscosity and rheology change below 20 °C, studies were grouped as hypothermic (HRP, ≤20 °C) or normothermic (NRP, >20 °C) regional perfusion. Data demonstrate that RP is a safe alternative to in situ cold preservation (ISP) in uncontrolled and controlled DCDs. The scarce HRP data are from before 2005. NRP appears to reduce post-transplant complications, especially biliary complications in controlled DCD livers, compared with ISP. Comparisons for kidney and pancreas with ISP are needed but there is no evidence that NRP is detrimental. Additional data on NRP in thoracic organs are needed. Whether RP increases donor or organ utilization needs further research.
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Affiliation(s)
- Julie De Beule
- Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | | | - Liset H M Pengel
- Nuffield Department of Surgical Sciences, Centre for Evidence in Transplantation, University of Oxford, Oxford, UK
| | - Maria Irene Bellini
- Department of Emergency Medicine and Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - John H Dark
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Amelia J Hessheimer
- Department of General & Digestive Surgery, Institut Clínic de Malalties Digestives i Metabòliques (ICMDM), Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Hendrikus J A N Kimenai
- Division of Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Simon R Knight
- Nuffield Department of Surgical Sciences, Centre for Evidence in Transplantation, University of Oxford, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Arne P Neyrinck
- Department of Cardiovascular Sciences, Anesthesiology and Algology, KU Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - David Paredes
- Donation and Transplant Coordination Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Christopher J E Watson
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,The NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Filip Rega
- Department of Cardiovascular Sciences, Cardiac Surgery, KU Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
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17
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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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18
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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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19
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Ehrsam JP, Benden C, Immer FF, Inci I. Current status and further potential of lung donation after circulatory death. Clin Transplant 2021; 35:e14335. [PMID: 33948997 DOI: 10.1111/ctr.14335] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 12/13/2022]
Abstract
Chronic organ shortage remains the most limiting factor in lung transplantation. To overcome this shortage, a minority of centers have started with efforts to reintroduce donation after circulatory death (DCD). This review aims to evaluate the experimental background, the current international clinical experience, and the further potential and challenges of the different DCD categories. Successful strategies have been implemented to reduce the problems of warm ischemic time, thrombosis after circulatory arrest, and difficulties in organ assessment, which come with DCD donation. From the currently reported results, controlled-DCD lungs are an effective and safe method with good mid-term and even long-term survival outcomes comparable to donation after brain death (DBD). Primary graft dysfunction and onset of chronic allograft dysfunction seem also comparable. Thus, controlled-DCD lungs should be ceased to be treated as marginal and instead be promoted as an equivalent alternative to DBD. A wide implementation of controlled-DCD-lung donation would significantly decrease the mortality on the waiting list. Therefore, further efforts in establishment of legislation and logistics are crucial. With regard to uncontrolled DCD, more data are needed analyzing long-term outcomes. To help with the detailed assessment and improvement of uncontrolled or otherwise questionable grafts after retrieval, ex-vivo lung perfusion is promising.
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Affiliation(s)
- Jonas P Ehrsam
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland.,Department of Thoracic Surgery, Cantonal Hospital Aarau, Zurich, Switzerland
| | | | | | - Ilhan Inci
- Department of Thoracic Surgery, Cantonal Hospital Aarau, Zurich, Switzerland.,University of Zurich Faculty of Medicine, Zurich, Switzerland
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20
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Cullen PP, Tsui SS, Caplice NM, Hinchion JA. A state-of-the-art review of the current role of cardioprotective techniques in cardiac transplantation. Interact Cardiovasc Thorac Surg 2021; 32:683-694. [PMID: 33971665 DOI: 10.1093/icvts/ivaa333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/24/2020] [Accepted: 12/06/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The use of 'extended criteria' donor hearts and reconditioned hearts from donation after circulatory death has corresponded with an increase in primary graft dysfunction, with ischaemia-reperfusion injury being a major contributing factor in its pathogenesis. Limiting ischaemia-reperfusion injury through optimising donor heart preservation may significantly improve outcomes. We sought to review the literature to evaluate the evidence for this. METHODS A review of the published literature was performed to assess the potential impact of organ preservation optimisation on cardiac transplantation outcomes. RESULTS Ischaemia-reperfusion injury is a major factor in myocardial injury during transplantation with multiple potential therapeutic targets. Innate survival pathways have been identified, which can be mimicked with pharmacological conditioning. Although incompletely understood, discoveries in this domain have yielded extremely encouraging results with one of the most exciting prospects being the synergistic effect of selected agents. Ex situ heart perfusion is an additional promising adjunct. CONCLUSIONS Cardiac transplantation presents a unique opportunity to perfuse the whole heart before, or immediately after, the onset of ischaemia, thus maximising the potential for global cardioprotection while limiting possible systemic side effects. While clinical translation in the setting of myocardial infarction has often been disappointing, cardiac transplantation may afford the opportunity for cardioprotection to finally deliver on its preclinical promise.
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Affiliation(s)
- Paul P Cullen
- Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
| | - Steven S Tsui
- Department of Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Noel M Caplice
- Centre for Research in Vascular Biology, Biosciences Institute, University College Cork, Cork, Ireland
| | - John A Hinchion
- Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
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21
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Keshavamurthy S, Rodgers-Fischl P. Donation after circulatory death (DCD)-lung procurement. Indian J Thorac Cardiovasc Surg 2021; 37:425-432. [PMID: 33821109 PMCID: PMC8012413 DOI: 10.1007/s12055-021-01156-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 12/01/2022] Open
Abstract
The number of lungs available for lung transplantation is far lower than the number of patients awaiting them. Consequently, there is a significant attrition rate while awaiting transplantation. Lung procurement rates are lower than those of other solid organs. Lungs are procured from only 15–20% of donors compared with 30% of decreased donors for hearts. The reason for this low retrieval rate is related to a number of factors. Brain death is associated with neurogenic pulmonary edema. Additionally, injury to the lung itself may occur before or after brain death. Aspiration of gastric contents, pneumonia, previous thoracic trauma, ventilator-associated injury, atelectasis, and pulmonary thrombosis/embolism may all contribute to lung injury before consideration for harvest. Donation after circulatory death (DCD) is one category of nontraditional organ donation now being performed in increasing numbers as a way to increase the number of lungs available for transplantation. In some studies, estimates show that utilization of DCD lung procurement could increase the number of lungs available by up to 50%.
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Affiliation(s)
- Suresh Keshavamurthy
- Department of Surgery, Division of Cardiothoracic Surgery, Surgical Director,Lung Transplantation, University of Kentucky College of Medicine, 740 S. Limestone, A-301, Lexington, KY 40536 USA
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22
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Tanaka S, Luis Campo-Cañaveral de la Cruz J, Crowley Carrasco S, Romero Román A, Hoyos Mejía L, Manuel NaranjoGómez J, Córdoba Peláez M, Sánchez Calle Á, Gil Barturen M, Pérez Redondo M, García Fadul C, Varela de Ugarte A, Gómez-de-Antonio D. Effect on the donor lungs of using abdominal normothermic regional perfusion in controlled donation after circulatory death. Eur J Cardiothorac Surg 2020; 59:ezaa398. [PMID: 33225359 DOI: 10.1093/ejcts/ezaa398] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/21/2020] [Accepted: 08/22/2020] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVES Controlled donation after circulatory death (cDCD) donors are becoming a common source of organs for transplantation globally. However, the graft survival rate of cDCD abdominal organs is inferior to that of organs from brain-dead donors. The rapid retrieval (RR) technique is used by most donor organ procurement teams. The abdominal normothermic regional perfusion (A-NRP) technique has been implemented to minimize warm ischaemic damage to the abdominal organs. However, there is limited information on the effect of A-NRP on the quality of the donor lungs. This study aimed to compare lung transplantation outcomes using lungs procured from cDCD donors using the A-NRP and abdominal RR techniques. METHODS A single-centre retrospective analysis of consecutive transplant recipients of cDCD lungs from June 2013 to December 2019 was performed. The recipients were divided into 2 cohorts according to the abdominal procurement technique used. The recipient and donor characteristics (age, sex, cause of brain injury, warm ischaemic time, diagnosis, lung allocation score and other factors), incidence of primary graft dysfunction and early survival were monitored. RESULTS Twenty-eight consecutive lung transplantation recipients were identified (median age 59 years; 61% male); 14 recipients received lungs using the A-NRP and 14 using abdominal RR for abdominal organ retrieval. There were no significant differences in the baseline characteristics, primary graft dysfunction (P = 0.70), hospital mortality (P = 1.0) and 1-year survival rate (P = 1.0) between the 2 groups. CONCLUSIONS No difference was observed in lung transplantation outcomes irrespective of the abdominal organ procurement technique used (A-NRP or abdominal RR).
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Affiliation(s)
- Shin Tanaka
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | | | - Silvana Crowley Carrasco
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Alejandra Romero Román
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Lucas Hoyos Mejía
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Jose Manuel NaranjoGómez
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Mar Córdoba Peláez
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Álvaro Sánchez Calle
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Mariana Gil Barturen
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Marina Pérez Redondo
- Intensive Care Unit, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Christian García Fadul
- Department of Pneumology, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Andrés Varela de Ugarte
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - David Gómez-de-Antonio
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
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23
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Van Raemdonck D, Ceulemans LJ, Jochmans I, Neyrinck A. Cooling the chest while keeping the abdomen warm: the best of both worlds in multi-organ preservation from controlled donation after circulatory death donors? Eur J Cardiothorac Surg 2020; 59:ezaa401. [PMID: 33230556 DOI: 10.1093/ejcts/ezaa401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Ina Jochmans
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology, and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
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24
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Tchana-Sato V, Ledoux D, Detry O, Hans G, Ancion A, D'Orio V, Massion PB, Amabili P, Bruls S, Lavigne JP, Monard J, Delbouille MH, Sakalihasan N, Defraigne JO. Successful clinical transplantation of hearts donated after circulatory death using normothermic regional perfusion. J Heart Lung Transplant 2020; 38:593-598. [PMID: 31128600 DOI: 10.1016/j.healun.2019.02.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Heart transplantation (HT) from donation after circulatory death (DCD) has yet to achieve wide clinical application despite the encouraging resultsreported recently. In this study we describe 2 cases of successful adult DCD HT performed at our institution using an original protocol. METHODS Our local abdominal DCD protocol was updated to allow DCD heart procurement, and was accepted by the institutional ethics committee. The main features of the protocol include: pre-mortem insertion of peripheral venoarterial extracorporeal membrane oxygenation cannulas; thoracoabdominal normothermic regional perfusion (NRP) by clamping the 3 aortic arch vessels to exclude cerebral circulation; and in-situ heart resuscitation. The retrieved hearts were directly transplanted into recipients located in an adjoining operating room. RESULTS The procurement warm ischemic time was 25 minutes for the first donor, and 26 minutes for the second donor. The cold ischemic time was 16 minutes for the first recipient and 17 minutes for the second recipient. The suture time was 30 minutes for the first recipient, and 53 minutes for the second recipient. Both recipients were easily weaned off cardiopulmonary bypass in sinus rhythm and inotropic support. Post-operative evaluation of cardiac function was excellent and the patients were subsequently discharged home. CONCLUSIONS Transplantation of hearts from DCD donors is now a clinical reality.NRP is a useful tool for resuscitation, reperfusion, and preservation of transplanted hearts. It also offers the opportunity to assess the function and viability of organs before transplantation. However,due to ethical issues, some may object to ante-mortem intervention.
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Affiliation(s)
| | | | - Olivier Detry
- Abdominal Surgery and Transplantation, Liege, Belgium
| | - Gregory Hans
- Anesthesiology and Intensive Care, Liege, Belgium
| | | | | | | | | | - Samuel Bruls
- Departments ofCardiothoracic Surgery, Liege, Belgium
| | | | - Josée Monard
- Abdominal Surgery and Transplantation, Liege, Belgium
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25
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Van Raemdonck D, Ceulemans LJ, Jochmans I, Neyrinck A. Commentary: Stay calm amid the agonal storm in controlled lung donation after circulatory determination of death. J Thorac Cardiovasc Surg 2020; 161:1556-1558. [PMID: 32713640 DOI: 10.1016/j.jtcvs.2020.05.080] [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: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Chronic Diseases and Metabolism, Katholieke Universiteit Leuven, Leuven, Belgium.
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Chronic Diseases and Metabolism, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Ina Jochmans
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
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26
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Copeland H, Hayanga JA, Neyrinck A, MacDonald P, Dellgren G, Bertolotti A, Khuu T, Burrows F, Copeland JG, Gooch D, Hackmann A, Hormuth D, Kirk C, Linacre V, Lyster H, Marasco S, McGiffin D, Nair P, Rahmel A, Sasevich M, Schweiger M, Siddique A, Snyder TJ, Stansfield W, Tsui S, Orr Y, Uber P, Venkateswaran R, Kukreja J, Mulligan M. Donor heart and lung procurement: A consensus statement. J Heart Lung Transplant 2020; 39:501-517. [DOI: 10.1016/j.healun.2020.03.020] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 03/25/2020] [Indexed: 01/02/2023] Open
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27
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Palleschi A, Tosi D, Rosso L, Zanella A, De Carlis R, Zanierato M, Benazzi E, Tarsia P, Colledan M, Nosotti M. Successful preservation and transplant of warm ischaemic lungs from controlled donors after circulatory death by prolonged in situ ventilation during normothermic regional perfusion of abdominal organs. Interact Cardiovasc Thorac Surg 2020; 29:699-705. [PMID: 31243436 DOI: 10.1093/icvts/ivz160] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/17/2019] [Accepted: 05/23/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Donation after circulatory death (DCD) potentially provides transplantable lungs suitable for a transplant, but in Italy, the need for 20 min of a no-touch period after cardiac arrest for legal declaration of death poses real challenges to organ preservation. METHODS This is a single-institution, retrospective study using data collected prospectively between October and December 2017. After the approval of the multidisciplinary DCD study group of Regione Lombardia, Maastricht category III DCD donors became eligible for combined procurement of lungs and abdominal organs. Our group subsequently established a dedicated technical protocol. Our protocol consists of a non-rapid normothermic open-lung procurement process that takes place during abdominal normothermic regional perfusion, namely without pleural topical cooling before the start of pneumoplegia. After the lung is procured according to the technique described in the article, lung function is evaluated by ex vivo lung perfusion, which is run with the low-flow, open atrium, low haematocrit technique. RESULTS During the study, we managed 5 controlled DCDs. In 3 cases, the lungs were successfully transplanted. All 3 patients are alive after 1 year, with good respiratory function. CONCLUSIONS Our approach resulted in adequate lung preservation and successful transplants without detrimental effects on abdominal organ procurement, confirming the possibility of overcoming the obstacle of a long no-touch period in a DCD setting.
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Affiliation(s)
- Alessandro Palleschi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Tosi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Rosso
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Marinella Zanierato
- Department of Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Elena Benazzi
- Coordinamento trapianti North Italy Transplantation program (NITp), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Tarsia
- Department of Pathophysiology and Transplantation, Respiratory Unit and Regional Adult Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michele Colledan
- Division of Liver and Small Bowel Transplantation, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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28
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Donation after circulatory death in lung transplantation—five-year follow-up from ISHLT Registry. J Heart Lung Transplant 2019; 38:1235-1245. [DOI: 10.1016/j.healun.2019.09.007] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 09/08/2019] [Accepted: 09/09/2019] [Indexed: 12/12/2022] Open
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29
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Palomo-López N, Martín-Sastre S, Martín-Villén L, Ruiz de Azúa-López Z, Solis-Clavijo D, Caballero-Gálvez S, Carballo-Caro JM, Egea-Guerrero JJ. Normothermic Regional Perfusion and Donation After Circulatory Death (Controlled and Uncontrolled): Metabolic Differences and Kidney Transplantation Evolution. Transplant Proc 2019; 51:3044-3046. [PMID: 31627924 DOI: 10.1016/j.transproceed.2019.08.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze metabolic differences during normothermic regional perfusion (NRP) between the dissimilar types of donation after circulatory death, uncontrolled (uDCD) and controlled (cDCD), and the evolution of the transplanted kidneys. METHODS Observational, prospective, cohort study. We included patients from uDCD and cDCD maintained with NRP in 2017. Six consecutive blood gases were collected with determination of pH and lactic acid. Creatinine levels were monitored at 24 hours, 3 months, and 6 months after transplant and the need for renal replacement therapy was evaluated. Descriptive statistical analysis was performed, presenting the qualitative variables as frequencies and percentages, and quantitative as mean ± SD or median (interquartile range [IQR]). We used χ2 testing for bivariate analysis of qualitative variables. RESULTS We collected 18 donors. Fifteen out of 18 (83.3%) were men with a median of 51 years (IQR, 46-60). Eleven out of 18 (61.1%) were cDCD and 7 out of 18 (38.9%) were uDCD. The blood gas results are illustrated in Table 1. A total of 28 renal transplants were obtained with a median age of 47 years (IQR, 45-57); 83% were male. Ten out of 28 (35.7%) came from uDCD and 18 out of 28 (64.7%) from cDCD. Table 2 shows the monitoring of the creatinine values of the recipients after the transplantation. CONCLUSIONS There are more metabolic disorders in our series in uDCD organ donation compared with cDCD. The recovery of the renal function of organs from uDCD is slower than that of cDCD, however; the tendency is toward normality.
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Affiliation(s)
- Nora Palomo-López
- Intensive Care Unit, University Hospital Virgen del Rocío, Sevilla, Spain.
| | - Sara Martín-Sastre
- Intensive Care Unit, University Hospital Virgen del Rocío, Sevilla, Spain
| | - Luis Martín-Villén
- Division of Transplantation, University Hospital Virgen del Rocío, Sevilla, Spain
| | | | - Diego Solis-Clavijo
- Division of Transplantation, University Hospital Virgen del Rocío, Sevilla, Spain
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30
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Tchana-Sato V, Ledoux D, Vandendriessche K, Van Cleemput J, Hans G, Ancion A, Cools B, Amabili P, Detry O, Massion PB, Monard J, Delbouille MH, Meyns B, Defraigne JO, Rega F. First report of a successful pediatric heart transplantation from donation after circulatory death with distant procurement using normothermic regional perfusion and cold storage. J Heart Lung Transplant 2019; 38:1112-1115. [PMID: 31548033 DOI: 10.1016/j.healun.2019.08.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 07/07/2019] [Accepted: 08/07/2019] [Indexed: 12/16/2022] Open
Abstract
Heart transplantation (HT) from donation after circulatory death (DCD) is a promising alternative to expand the heart donor pool. Cold storage can be used in a strategy to successfully retrieve and transplant DCD hearts after reconditioning using normothermic regional perfusion for distant procurement. Herein, we present the first report of a pediatric DCD heart reconditioned with normothermic regional perfusion, preserved using only cold storage while being transported to a neighboring center, and then successfully transplanted after nearly 2 hours of cold static storage. If supported by an appropriate trial, this finding could obviate the need to use expensive perfusion devices for short interhospital distances for DCD heart transportation and stimulate more centers across the world to embrace DCD HT.
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Affiliation(s)
| | - Didier Ledoux
- Department of Anesthesiology and Intensive Care, CHU Liege, Liege, Belgium
| | | | | | - Gregory Hans
- Department of Anesthesiology and Intensive Care, CHU Liege, Liege, Belgium
| | | | - Bjorn Cools
- Department of Cardiology, The University Hospitals, Leuven, Belgium
| | - Philippe Amabili
- Department of Anesthesiology and Intensive Care, CHU Liege, Liege, Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, Liege, Belgium
| | | | - Josee Monard
- Department of Abdominal Surgery and Transplantation, CHU Liege, Liege, Belgium
| | | | - Bart Meyns
- Department of Cardiac Surgery, The University Hospitals, Leuven, Belgium
| | | | - Filip Rega
- Department of Cardiac Surgery, The University Hospitals, Leuven, Belgium
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Impact of Donor Hepatectomy Time During Organ Procurement in Donation After Circulatory Death Liver Transplantation: The United Kingdom Experience. Transplantation 2019; 103:e79-e88. [DOI: 10.1097/tp.0000000000002518] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Mohite PN, García Sáez D, Butler AJ, Watson CJE, Simon A. Direct Procurement of Donor Heart With Normothermic Regional Perfusion of Abdominal Organs. Ann Thorac Surg 2019; 108:597-600. [PMID: 30910654 DOI: 10.1016/j.athoracsur.2019.01.087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/19/2018] [Accepted: 01/23/2019] [Indexed: 11/15/2022]
Abstract
PURPOSE We wanted to evaluate if direct procurement of the heart is possible in combination with normothermic regional perfusion of abdominal organs in donors after circulatory death. DESCRIPTION A donation after circulatory death pathway was used for a 41-year-old woman after an irreversible brain injury. After meeting criteria for the organ donation, the heart was retrieved and re-animated on ex situ perfusion system, and abdominal organs were perfused with normothermic regional perfusion. EVALUATION All the donated organs and their recipients had excellent short-term outcome. CONCLUSIONS We demonstrated a successful combination of direct procurement of the heart and normothermic regional perfusion of the abdominal organs.
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Affiliation(s)
- Prashant N Mohite
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom.
| | - Diana García Sáez
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom
| | - Andrew J Butler
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Christopher J E Watson
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Andre Simon
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom
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Abstract
PURPOSE OF REVIEW Donation after circulatory death (DCD) is still performed in a limited number of countries. This article summarizes the development of DCD in Spain and presents recent Spanish contributions to gain knowledge on the potential benefits and the practical use of normothermic regional perfusion (nRP). RECENT FINDINGS DCD now contributes to 24% of deceased donors in Spain. The development of DCD has been based on an assessment of practices in the treatment of cardiac arrest and end-of-life care to accommodate the option of DCD; the creation of an adequate regulatory framework; and institutional support, professional training and public education. Appropriate posttransplant outcomes have been obtained with organs from both uncontrolled and controlled DCD donors. nRP is increasingly used, with preliminary data supporting improved results compared with other in-situ preservation/recovery approaches. Mobile teams with portable extracorporeal membrane oxygenation devices are making nRP possible in hospitals without these resources. To avoid the possibility of reestablishing brain circulation after the determination of death, a specific methodology has been validated. SUMMARY DCD has been successfully developed in Spain following a streamlined process. nRP may become a standard in DCD, although further evidence on the benefits of this technology is eagerly awaited.
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Organ donation after circulatory death: current status and future potential. Intensive Care Med 2019; 45:310-321. [DOI: 10.1007/s00134-019-05533-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/14/2019] [Indexed: 01/26/2023]
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Fernández-Mondéjar E, Fuset-Cabanes MP, Grau-Carmona T, López-Sánchez M, Peñuelas Ó, Pérez-Vela JL, Pérez-Villares JM, Rubio-Muñoz JJ, Solla-Buceta M. The use of ECMO in ICU. Recommendations of the Spanish Society of Critical Care Medicine and Coronary Units. Med Intensiva 2018; 43:108-120. [PMID: 30482406 DOI: 10.1016/j.medin.2018.09.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/26/2018] [Accepted: 09/30/2018] [Indexed: 02/07/2023]
Abstract
The use of extracorporeal membrane oxygenation systems has increased significantly in recent years; given this reality, the Spanish Society of Critical Intensive Care Medicine and Coronary Units (SEMICYUC) has decided to draw up a series of recommendations that serve as a framework for the use of this technique in intensive care units. The three most frequent areas of extracorporeal membrane oxygenation systems use in our setting are: as a cardiocirculatory support, as a respiratory support and for the maintenance of the abdominal organs in donors. The SEMICYUC appointed a series of experts belonging to the three working groups involved (Cardiological Intensive Care and CPR, Acute Respiratory Failure and Transplant work group) that, after reviewing the existing literature until March 2018, developed a series of recommendations. These recommendations were posted on the SEMICYUC website to receive suggestions from the intensivists and finally approved by the Scientific Committee of the Society. The recommendations, based on current knowledge, are about which patients may be candidates for the technique, when to start it and the necessary infrastructure conditions of the hospital centers or, the conditions for transfer to centers with experience. Although from a physiopathological point of view, there are clear arguments for the use of extracorporeal membrane oxygenation systems, the current scientific evidence is weak, so studies are needed that define more precisely which patients benefit most from the technique and when they should start.
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Affiliation(s)
- E Fernández-Mondéjar
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, España; Instituto de Investigación Biosanitaria IBS, Granada, España.
| | - M P Fuset-Cabanes
- Servicio de Medicina Intensiva, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - T Grau-Carmona
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - M López-Sánchez
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Ó Peñuelas
- Servicio de Medicina Intensiva, Hospital Universitario de Getafe, Getafe, Madrid, España; CIBER de Enfermedades Respiratorias, CIBERES, Madrid, España
| | - J L Pérez-Vela
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - J M Pérez-Villares
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, España; Instituto de Investigación Biosanitaria IBS, Granada, España
| | - J J Rubio-Muñoz
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro, Madrid, España
| | - M Solla-Buceta
- Servicio de Medicina Intensiva, Complejo Hospitalario Universitario, La Coruña, España
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Schlegel A, Dutkowski P. Impact of Machine Perfusion on Biliary Complications after Liver Transplantation. Int J Mol Sci 2018; 19:ijms19113567. [PMID: 30424553 PMCID: PMC6274934 DOI: 10.3390/ijms19113567] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/01/2018] [Accepted: 11/05/2018] [Indexed: 12/13/2022] Open
Abstract
We describe in this review the different types of injuries caused to the biliary tree after liver transplantation. Furthermore, we explain underlying mechanisms and why oxygenated perfusion concepts could not only protect livers, but also repair high-risk grafts to prevent severe biliary complications and graft loss. Accordingly, we summarize experimental studies and clinical applications of machine liver perfusion with a focus on biliary complications after liver transplantation. Key points: (1) Acute inflammation with subsequent chronic ongoing liver inflammation and injury are the main triggers for cholangiocyte injury and biliary tree transformation, including non-anastomotic strictures; (2) Hypothermic oxygenated perfusion (HOPE) protects livers from initial oxidative injury at normothermic reperfusion after liver transplantation. This is a unique feature of a cold oxygenation approach, which is effective also end-ischemically, e.g., after cold storage, due to mitochondrial repair mechanisms. In contrast, normothermic oxygenated perfusion concepts protect by reducing cold ischemia, and are therefore most beneficial when applied instead of cold storage; (3) Due to less downstream activation of cholangiocytes, hypothermic oxygenated perfusion also significantly reduces the development of biliary strictures after liver transplantation.
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Affiliation(s)
- Andrea Schlegel
- Department of Surgery & Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland.
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham B15 2TH, UK.
- NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham B15 2TH, UK.
| | - Philipp Dutkowski
- Department of Surgery & Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland.
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Schlegel A, Kalisvaart M, Isaac J, Dutkowski P, Muiesan P. Reply to: "Redefining futility in DCD liver transplantation in the era of novel perfusion technologies". J Hepatol 2018; 68:1328-1330. [PMID: 29550341 DOI: 10.1016/j.jhep.2018.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 03/05/2018] [Indexed: 12/04/2022]
Affiliation(s)
- A Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom; The NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, UK
| | - M Kalisvaart
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom
| | - J Isaac
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom
| | - P Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - P Muiesan
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom.
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Abstract
This article summarizes recent knowledge and clinical advances in machine perfusion (MP) of thoracic organs. MP of thoracic organs has gained much attention during the last decade. Clinical studies are investigating the role of MP to preserve, resuscitate, and assess heart and lungs prior to transplantation. Currently, MP of the cardiac allograft is essential in all type DCD heart transplantation while MP of the pulmonary allograft is mandatory in uncontrolled DCD lung transplantation. MP of thoracic organs also offers an exciting platform to further investigate downregulation of the innate and adaptive immunity prior to reperfusion of the allograft in recipients. MP provides a promising technology that allows pre-transplant preservation, resuscitation, assessment, repair, and conditioning of cardiac and pulmonary allografts outside the body in a near physiologic state prior to planned transplantation. Results of ongoing clinical trials are awaited to estimate the true clinical value of this new technology in advancing the field of heart and lung transplantation by increasing the total number and the quality of available organs and by further improving recipient early and long-term outcome.
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Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, KU Leuven University, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium
| | - Steffen Rex
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
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