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Hoffman JRH, Hartwig MG, Cain MT, Rove JY, Siddique A, Urban M, Mulligan MS, Bush EL, Balsara K, Demarest CT, Silvestry SC, Wilkey B, Trahanas JM, Pretorius VG, Shah AS, Moazami N, Pomfret EA, Catarino PA. Consensus Statement: Technical Standards for Thoracoabdominal Normothermic Regional Perfusion. Ann Thorac Surg 2024; 118:778-791. [PMID: 39023462 DOI: 10.1016/j.athoracsur.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Thoracoabdominal normothermic regional perfusion (TA-NRP) has emerged as a powerful technique for optimizing organ procurement from donation after circulatory death donors. Despite its rapid adoption, standardized guidelines for TA-NRP implementation are lacking, prompting the need for consensus recommendations to ensure safe and effective utilization of this technique. METHODS A working group composed of members from The American Society of Transplant Surgeons, The International Society of Heart and Lung Transplantation, The Society of Thoracic Surgeons, and The American Association for Thoracic Surgery was convened to develop technical guidelines for TA-NRP. The group systematically reviewed existing literature, consensus statements, and expert opinions to identify key areas requiring standardization, including predonation evaluation, intraoperative management, postdonation procedures, and future research directions. RESULTS The working group formulated recommendations encompassing donor evaluation and selection criteria, premortem testing and therapeutic interventions, communication protocols, and procedural guidelines for TA-NRP implementation. These recommendations aim to facilitate coordination among transplant teams, minimize variability in practice, and promote transparency and accountability throughout the TA-NRP process. CONCLUSIONS The consensus guidelines presented herein serve as a comprehensive framework for the successful and ethical implementation of TA-NRP programs in organ procurement from donation after circulatory death donors. By providing standardized recommendations and addressing areas of uncertainty, these guidelines aim to enhance the quality, safety, and efficiency of TA-NRP procedures, ultimately contributing to improved outcomes for transplant recipients.
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Affiliation(s)
- Jordan R H Hoffman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Matthew G Hartwig
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael T Cain
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Jessica Y Rove
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Aleem Siddique
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Marian Urban
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Michael S Mulligan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - Errol L Bush
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Medicine, Baltimore, Maryland
| | - Keki Balsara
- Department of Cardiothoracic Surgery, MedStar Washington Hospital Center, Washington, DC
| | - Caitlin T Demarest
- Section of Surgical Sciences, Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Barbara Wilkey
- Department of Anesthesia, Section of Cardiothoracic Anesthesia, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - John M Trahanas
- Section of Surgical Sciences, Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Victor G Pretorius
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of California, San Diego, California
| | - Ashish S Shah
- Section of Surgical Sciences, Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, New York
| | - Elizabeth A Pomfret
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado.
| | - Pedro A Catarino
- Department of Cardiac Surgery, Cedars Sinai Medical Center, Los Angeles, California
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2
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Hoffman JRH, Hartwig MG, Cain MT, Rove JY, Siddique A, Urban M, Mulligan MS, Bush EL, Balsara K, Demarest CT, Silvestry SC, Wilkey B, Trahanas JM, Pretorius VG, Shah AS, Moazami N, Pomfret EA, Catarino PA. Consensus Statement: Technical Standards for Thoracoabdominal Normothermic Regional Perfusion. Transplantation 2024; 108:1669-1680. [PMID: 39012953 DOI: 10.1097/tp.0000000000005101] [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: 07/18/2024]
Abstract
BACKGROUND Thoracoabdominal normothermic regional perfusion (TA-NRP) has emerged as a powerful technique for optimizing organ procurement from donation after circulatory death donors. Despite its rapid adoption, standardized guidelines for TA-NRP implementation are lacking, prompting the need for consensus recommendations to ensure safe and effective utilization of this technique. METHODS A working group composed of members from The American Society of Transplant Surgeons, The International Society of Heart and Lung Transplantation, The Society of Thoracic Surgeons, and The American Association for Thoracic Surgery was convened to develop technical guidelines for TA-NRP. The group systematically reviewed existing literature, consensus statements, and expert opinions to identify key areas requiring standardization, including predonation evaluation, intraoperative management, postdonation procedures, and future research directions. RESULTS The working group formulated recommendations encompassing donor evaluation and selection criteria, premortem testing and therapeutic interventions, communication protocols, and procedural guidelines for TA-NRP implementation. These recommendations aim to facilitate coordination among transplant teams, minimize variability in practice, and promote transparency and accountability throughout the TA-NRP process. CONCLUSIONS The consensus guidelines presented herein serve as a comprehensive framework for the successful and ethical implementation of TA-NRP programs in organ procurement from donation after circulatory death donors. By providing standardized recommendations and addressing areas of uncertainty, these guidelines aim to enhance the quality, safety, and efficiency of TA-NRP procedures, ultimately contributing to improved outcomes for transplant recipients.
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Affiliation(s)
- Jordan R H Hoffman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Matthew G Hartwig
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Michael T Cain
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Jessica Y Rove
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Aleem Siddique
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Marian Urban
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Michael S Mulligan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA
| | - Errol L Bush
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Medicine, Baltimore, MD
| | - Keki Balsara
- Department of Cardiothoracic Surgery, MedStar Washington Hospital Center, Washington, DC
| | - Caitlin T Demarest
- Section of Surgical Sciences, Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Barbara Wilkey
- Department of Anesthesia, Section of Cardiothoracic Anesthesia, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - John M Trahanas
- Section of Surgical Sciences, Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Victor G Pretorius
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of California, San Diego, CA
| | - Ashish S Shah
- Section of Surgical Sciences, Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, NY
| | - Elizabeth A Pomfret
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Pedro A Catarino
- Department of Cardiac Surgery, Cedars Sinai Medical Center, Los Angeles, CA
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Nicolson C, Burke A, Gardiner D, Harvey D, Munshi L, Shaw M, Tsanas A, Lone N, Puxty K. Predicting time to asystole following withdrawal of life-sustaining treatment: a systematic review. Anaesthesia 2024; 79:638-649. [PMID: 38301032 DOI: 10.1111/anae.16222] [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] [Accepted: 12/04/2023] [Indexed: 02/03/2024]
Abstract
The planned withdrawal of life-sustaining treatment is a common practice in the intensive care unit for patients where ongoing organ support is recognised to be futile. Predicting the time to asystole following withdrawal of life-sustaining treatment is crucial for setting expectations, resource utilisation and identifying patients suitable for organ donation after circulatory death. This systematic review evaluates the literature for variables associated with, and predictive models for, time to asystole in patients managed on intensive care units. We conducted a comprehensive structured search of the MEDLINE and Embase databases. Studies evaluating patients managed on adult intensive care units undergoing withdrawal of life-sustaining treatment with recorded time to asystole were included. Data extraction and PROBAST quality assessment were performed and a narrative summary of the literature was provided. Twenty-three studies (7387 patients) met the inclusion criteria. Variables associated with imminent asystole (<60 min) included: deteriorating oxygenation; absence of corneal reflexes; absence of a cough reflex; blood pressure; use of vasopressors; and use of comfort medications. We identified a total of 20 unique predictive models using a wide range of variables and techniques. Many of these models also underwent secondary validation in further studies or were adapted to develop new models. This review identifies variables associated with time to asystole following withdrawal of life-sustaining treatment and summarises existing predictive models. Although several predictive models have been developed, their generalisability and performance varied. Further research and validation are needed to improve the accuracy and widespread adoption of predictive models for patients managed in intensive care units who may be eligible to donate organs following their diagnosis of death by circulatory criteria.
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Affiliation(s)
- C Nicolson
- Department of Critical Care, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, Glasgow, UK
- School of Informatics, University of Edinburgh, Edinburgh, UK
| | - A Burke
- Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - D Gardiner
- Critical Care, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NHS Blood and Transplant, Watford, UK
| | - D Harvey
- Critical Care, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NHS Blood and Transplant, Watford, UK
| | - L Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - M Shaw
- Department of Clinical Physics & Bioengineering, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, Glasgow, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - A Tsanas
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - N Lone
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Department of Critical Care, NHS Lothian, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - K Puxty
- Department of Critical Care, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, Glasgow, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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Lyle MA, English SW, Goswami RM, Leoni Moreno JC, Nativi-Nicolau J, Yip DS, Patel PC. Donation after circulatory death: A transplant cardiologist's take on neuroprognostication. J Heart Lung Transplant 2023; 42:1481-1483. [PMID: 37268053 DOI: 10.1016/j.healun.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/08/2023] [Accepted: 05/22/2023] [Indexed: 06/04/2023] Open
Abstract
Donation after circulatory death (DCD) is becoming increasingly utilized in heart transplantation and has the potential to further expand the donor pool. As transplant cardiologists gain more familiarity with DCD donor selection, there are many issues that lack consensus including how we incorporate the neurologic examination, how we measure functional warm ischemic time (fWIT), and what fWIT thresholds are acceptable. DCD donor selection calls for prognostication tools to help determine how quickly a donor may expire, and in current practice there is no standardization in how we make these predictions. Current scoring systems help to determine which donor may expire within a specified time window either require the temporary disconnection of ventilatory support or do not incorporate any neurologic examination or imaging. Moreover, the specified time windows differ from other DCD solid organ transplantation without standardization or strong scientific justification for these thresholds. In this perspective, we highlight the challenges faced by transplant cardiologists as they navigate the muddy waters of neuroprognostication in DCD cardiac donation. Given these difficulties, this is also a call to action for the creation of a more standardized approach to improve the DCD donor selection process for appropriate resource allocation and organ utilization.
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Affiliation(s)
- Melissa A Lyle
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, Florida.
| | | | - Rohan M Goswami
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, Florida
| | - Juan C Leoni Moreno
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, Florida
| | - Jose Nativi-Nicolau
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, Florida
| | - Daniel S Yip
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, Florida
| | - Parag C Patel
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, Florida
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Martínez-Castro S, Navarro R, García-Pérez ML, Segura JM, Carbonell JA, Hornero F, Guijarro J, Zaplana M, Bruño MÁ, Tur A, Martínez-León JB, Zaragoza R, Núñez J, Domínguez-Gil B, Badenes R. Evaluation of functional warm ischemia time during controlled donation after circulatory determination of death using normothermic regional perfusion (ECMO-TT): A prospective multicenter cohort study. Artif Organs 2023; 47:1371-1385. [PMID: 37042612 DOI: 10.1111/aor.14539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/29/2023] [Accepted: 04/06/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Controlled donation after circulatory determination of death (cDCD) seems an effective way to mitigate the critical shortage of available organs for transplant worldwide. As a recently developed procedure for organ retrieval, some questions remain unsolved such as the uncertainty regarding the effect of functional warm ischemia time (FWIT) on organs´ viability. METHODS We developed a multicenter prospective cohort study collecting all data from evaluated organs during cDCD from 2017 to 2020. All the procedures related to cDCD were performed with normothermic regional perfusion. The analysis included organ retrieval as endpoint and FWIT as exposure of interest. The effect of FWIT on the likelihood for organ retrieval was evaluated with Relative distribution analysis. RESULTS A total amount of 507 organs´ related information was analyzed from 95 organ donors. Median donor age was 62 years, and 63% of donors were male. Stroke was the most common diagnosis before withdrawal of life-sustaining therapy (61%), followed by anoxic encephalopathy (21%). This analysis showed that length of FWIT was inversely associated with organ retrieval rates for liver, kidneys, and pancreas. No statistically significant association was found for lungs. CONCLUSIONS Results showed an inverse association between functional warm ischemia time (FWIT) and retrieval rate. We also have postulated optimal FWIT's thresholds for organ retrieval. FWIT for liver retrieval remained between 6 and less than 11 min and in case of kidneys and pancreas, the optimal FWIT for retrieval was 6 to 12 min. These results could be valuable to improve organ utilization and for future analysis.
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Affiliation(s)
- Sara Martínez-Castro
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Rosalía Navarro
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
| | - María Luisa García-Pérez
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
| | - José Manuel Segura
- Department of Medical Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- Transplant Coordination Unit, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - José A Carbonell
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
| | - Fernando Hornero
- Department of Cardiac Surgery, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - Jorge Guijarro
- Department of Interventional Radiology, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - Marta Zaplana
- Department of Vascular Surgery, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - María Ángeles Bruño
- Cardiovascular Perfussion Unit, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - Ana Tur
- Transplant Coordination Unit, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Juan Bautista Martínez-León
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
- Department of Cardiac Surgery, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Rafael Zaragoza
- Department of Intensive Care Medicine, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Julio Núñez
- INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Cardiology, Hospital Clínic Universitari de Valencia, Valencia, Spain
- Department of Medicine. School of Medicine, University of Valencia, Valencia, Spain
| | | | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
- Transplant Coordination Unit, Hospital Clínic Universitari de Valencia, Valencia, Spain
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Predicting Time to Death After Withdrawal of Life-Sustaining Measures Using Vital Sign Variability: Derivation and Validation. Crit Care Explor 2022; 4:e0675. [PMID: 35415612 PMCID: PMC8994079 DOI: 10.1097/cce.0000000000000675] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
To develop a predictive model using vital sign (heart rate and arterial blood pressure) variability to predict time to death after withdrawal of life-supporting measures.
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Prospective Multicenter Observational Cohort Study on Time to Death in Potential Controlled Donation after Circulatory Death Donors-Development and External Validation of Prediction Models: The DCD III Study. Transplantation 2022; 106:1844-1851. [PMID: 35266926 DOI: 10.1097/tp.0000000000004106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acceptance of organs from controlled donation after circulatory death (cDCD) donors depends on the time to circulatory death. Here we aimed to develop and externally validate prediction models for circulatory death within 1 or 2 h after withdrawal of life-sustaining treatment. METHODS In a multicenter, observational, prospective cohort study, we enrolled 409 potential cDCD donors. For model development, we applied the least absolute shrinkage and selection operator (LASSO) regression and machine learning-artificial intelligence analyses. Our LASSO models were validated using a previously published cDCD cohort. Additionally, we validated 3 existing prediction models using our data set. RESULTS For death within 1 and 2 h, the area under the curves (AUCs) of the LASSO models were 0.77 and 0.79, respectively, whereas for the artificial intelligence models, these were 0.79 and 0.81, respectively. We were able to identify 4% to 16% of the patients who would not die within these time frames with 100% accuracy. External validation showed that the discrimination of our models was good (AUCs 0.80 and 0.82, respectively), but they were not able to identify a subgroup with certain death after 1 to 2 h. Using our cohort to validate 3 previously published models showed AUCs ranging between 0.63 and 0.74. Calibration demonstrated that the models over- and underestimated the predicted probability of death. CONCLUSIONS Our models showed a reasonable ability to predict circulatory death. External validation of our and 3 existing models illustrated that their predictive ability remained relatively stable. We accurately predicted a subset of patients who died after 1 to 2 h, preventing starting unnecessary donation preparations, which, however, need external validation in a prospective cohort.
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