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Brouckaert J, Vandendriessche K, Degezelle K, Van de Voorde K, De Burghgraeve F, Desmet L, Vlasselaers D, Ingels C, Dauwe D, De Troy E, Ceulemans LJ, Van Raemdonck D, Monbaliu D, Meyns B, Van den Eynde R, Rex S, Van Cleemput J, Rega F. Successful clinical transplantation of hearts donated after circulatory death using direct procurement followed by hypothermic oxygenated perfusion: A report of the first 3 cases. J Heart Lung Transplant 2024:S1053-2498(24)01751-0. [PMID: 39069162 DOI: 10.1016/j.healun.2024.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 07/02/2024] [Accepted: 07/23/2024] [Indexed: 07/30/2024] Open
Affiliation(s)
- Janne Brouckaert
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.
| | | | - Karlien Degezelle
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Francis De Burghgraeve
- LCGO Leuven Cooperating Group for Organ Donation, University Hospitals Leuven, Leuven, Belgium
| | - Lars Desmet
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Vlasselaers
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Catherine Ingels
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Dieter Dauwe
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Erwin De Troy
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Abdominal Transplantation Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Raf Van den Eynde
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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2
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Royo-Villanova M, Miñambres E, Coll E, Domínguez-Gil B. Normothermic Regional Perfusion in Controlled Donation After the Circulatory Determination of Death: Understanding Where the Benefit Lies. Transplantation 2024:00007890-990000000-00833. [PMID: 39049104 DOI: 10.1097/tp.0000000000005143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Controlled donation after the circulatory determination of death (cDCDD) has emerged as a strategy to increase the availability of organs for clinical use. Traditionally, organs from cDCDD donors have been subject to standard rapid recovery (SRR) with poor posttransplant outcomes of abdominal organs, particularly the liver, and limited organ utilization. Normothermic regional perfusion (NRP), based on the use of extracorporeal membrane oxygenation devices, consists of the in situ perfusion of organs that will be subject to transplantation with oxygenated blood under normothermic conditions after the declaration of death and before organ recovery. NRP is a potential solution to address the limitations of traditional recovery methods. It has become normal practice in several European countries and has been recently introduced in the United States. The increased use of NRP in cDCDD has occurred as a result of a growing body of evidence on its association with improved posttransplant outcomes and organ utilization compared with SRR. However, the expansion of NRP is precluded by obstacles of an organizational, legal, and ethical nature. This article details the technique of both abdominal and thoracoabdominal NRP. Based on the available evidence, it describes its benefits in terms of posttransplant outcomes of abdominal and thoracic organs and organ utilization. It addresses cost-effectiveness aspects of NRP, as well as logistical and ethical obstacles that limit the implementation of this innovative preservation strategy.
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Affiliation(s)
- Mario Royo-Villanova
- Transplant Coordination Unit and Service of Intensive Care, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Eduardo Miñambres
- Transplant Coordination Unit and Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, Universidad de Cantabria, Santander, Spain
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3
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Benkert AR, Keenan JE, Schroder JN, DeVore AD, Patel CB, Milano C, Jawitz OK. Early U.S. Heart Transplant Experience With Normothermic Regional Perfusion Following Donation After Circulatory Death. JACC. HEART FAILURE 2024:S2213-1779(24)00507-9. [PMID: 39093259 DOI: 10.1016/j.jchf.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 06/12/2024] [Accepted: 06/18/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Heart transplantation following donation after circulatory death (DCD HT) has short-term survival outcomes comparable to donation after brain death and has led to a significant increase in transplantation volume. The U.S. experience with the normothermic regional perfusion (NRP) DCD HT procurement method has not been evaluated. OBJECTIVES The aim of this study was to examine short-term outcomes associated with NRP vs direct procurement and perfusion (DPP) methods used during DCD HT in the United States. METHODS The UNOS (United Network for Organ Sharing) registry was queried for all adult (age ≥18 years) heart recipients and corresponding donors of controlled DCD HT from January 2019-December 2023. Transplantations were stratified by NRP or DPP reperfusion methods. The primary outcome was overall survival. RESULTS A total of 918 heart donors and recipients met inclusion criteria, including 622 (68%) DPP and 296 (32%) NRP transplantations. Unadjusted Kaplan-Meier survival analysis demonstrated improved short-term survival associated with NRP (log-rank P = 0.005). After adjustment, DCD HT with NRP was independently associated with improved survival (HR: 0.39 [95% CI: 0.22-0.70]; P = 0.002). A propensity-matched analysis similarly demonstrated a cumulative survival benefit to NRP (log-rank P = 0.006). CONCLUSIONS In this largest national series of DCD HT procurement perfusion strategies, NRP is associated with improved short-term survival as compared with DPP. This study evaluates the U.S. early experience with DCD HT, and longer-term follow-up data are needed to further assess the impact of DPP and NRP methods on post-heart transplantation outcomes.
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Affiliation(s)
- Abigail R Benkert
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
| | - Jeffrey E Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Adam D DeVore
- Duke Clinical Research Institute, Duke University Medical Center, Durham North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Chetan B Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Carmelo Milano
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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4
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Kharawala A, Nagraj S, Seo J, Pargaonkar S, Uehara M, Goldstein DJ, Patel SR, Sims DB, Jorde UP. Donation After Circulatory Death Heart Transplant: Current State and Future Directions. Circ Heart Fail 2024; 17:e011678. [PMID: 38899474 DOI: 10.1161/circheartfailure.124.011678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/16/2024] [Indexed: 06/21/2024]
Abstract
Orthotopic heart transplant is the gold standard therapeutic intervention for patients with end-stage heart failure. Conventionally, heart transplant has relied on donation after brain death for organ recovery. Donation after circulatory death (DCD) is the donation of the heart after confirming that circulatory function has irreversibly ceased. DCD-orthotopic heart transplant differs from donation after brain death-orthotopic heart transplant in ways that carry implications for widespread adoption, including differences in organ recovery, storage and ethical considerations surrounding normothermic regional perfusion with DCD. Despite these differences, DCD has shown promising early outcomes, augmenting the donor pool and allowing more individuals to benefit from orthotopic heart transplant. This review aims to present the current state and future trajectory of DCD-heart transplant, examine key differences between DCD and donation after brain death, including clinical experiences and innovations in methodologies, and address the ongoing ethical challenges surrounding the new frontier in heart transplant with DCD donors.
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Affiliation(s)
- Amrin Kharawala
- Jacobi Medical Center, New York City Health & Hospitals Corp, Bronx, NY (A.K., J.S., S.P.)
| | - Sanjana Nagraj
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (S.N., M.U., D.J.G., S.R.P., D.B.S., U.P.J.)
| | - Jiyoung Seo
- Jacobi Medical Center, New York City Health & Hospitals Corp, Bronx, NY (A.K., J.S., S.P.)
| | - Sumant Pargaonkar
- Jacobi Medical Center, New York City Health & Hospitals Corp, Bronx, NY (A.K., J.S., S.P.)
| | - Mayuko Uehara
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (S.N., M.U., D.J.G., S.R.P., D.B.S., U.P.J.)
| | - Daniel J Goldstein
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (S.N., M.U., D.J.G., S.R.P., D.B.S., U.P.J.)
| | - Snehal R Patel
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (S.N., M.U., D.J.G., S.R.P., D.B.S., U.P.J.)
| | - Daniel B Sims
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (S.N., M.U., D.J.G., S.R.P., D.B.S., U.P.J.)
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (S.N., M.U., D.J.G., S.R.P., D.B.S., U.P.J.)
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Sonnenberg EM, Abu-Gazala S, Bittermann T, Abt PL. Following the Flow: Changes in Organ Preservation Methods Require Changes in Our Data Collection. Transplantation 2024; 108:1265-1268. [PMID: 38291568 DOI: 10.1097/tp.0000000000004920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
| | - Samir Abu-Gazala
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
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Bommareddi S, Lima B, Shah AS, Trahanas JM. Thoraco-abdominal normothermic regional perfusion for thoracic transplantation in the United States: current state and future directions. Curr Opin Organ Transplant 2024; 29:180-185. [PMID: 38483139 DOI: 10.1097/mot.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2024]
Abstract
PURPOSE OF REVIEW To provide an update regarding the state of thoracoabdominal normothermic regional perfusion (taNRP) when used for thoracic organ recovery. RECENT FINDINGS taNRP is growing in its utilization for thoracic organ recovery from donation after circulatory death donors, partly because of its cost effectiveness. taNRP has been shown to yield cardiac allograft recipient outcomes similar to those of brain-dead donors. Regarding the use of taNRP to recover donor lungs, United Network for Organ Sharing (UNOS) analysis shows that taNRP recovered lungs are noninferior, and taNRP has been used to consistently recover excellent lungs at high volume centers. Despite its growth, ethical debate regarding taNRP continues, though clinical data now supports the notion that there is no meaningful brain perfusion after clamping the aortic arch vessels. SUMMARY taNRP is an excellent method for recovering both heart and lungs from donation after circulatory death donors and yields satisfactory recipient outcomes in a cost-effective manner. taNRP is now endorsed by the American Society of Transplant Surgeons, though ethical debate continues.
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Affiliation(s)
- Swaroop Bommareddi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Ott M, Murphy N, Lingard L, Slessarev M, Blackstock L, Basmaji J, Brahmania M, Healey A, Shemie S, Skaro A, Weijer C. Sowing "seeds of trust": How trust in normothermic regional perfusion is built in a continuum of care. Am J Transplant 2024:S1600-6135(24)00345-9. [PMID: 38825154 DOI: 10.1016/j.ajt.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 06/04/2024]
Abstract
Normothermic regional perfusion (NRP) is a promising technology to improve organ transplantation outcomes by reversing ischemic injury caused by controlled donation after circulatory determination of death. However, it has not yet been implemented in Canada due to ethical questions. These issues must be resolved to preserve public trust in organ donation and transplantation. This qualitative, constructivist grounded theory study sought to understand how those most impacted by NRP perceived the ethical implications. We interviewed 29 participants across stakeholder groups of donor families, organ recipients, donation and transplantation system leaders, and care providers. The interview protocol included a short presentation about the purpose of NRP and procedures in abdomen versus chest and abdomen NRP, followed by questions probing potential violations of the dead donor rule and concerns regarding brain reperfusion. The results present a grounded theory placing NRP within a trust-building continuum of care for the donor, their family, and organ recipients. Stakeholders consistently described both forms of NRP as an ethical intervention, but their rationales were predicated on assumptions that neurologic criteria for death had been met following circulatory death determination. Empirical validation of these assumptions will help ground the implementation of NRP in a trust-preserving way.
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Affiliation(s)
- Mary Ott
- Faculty of Education, York University, Toronto, Ontario, Canada; Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Nicholas Murphy
- Departments of Philsophy and Medicine, Western University, London, Ontario, Canada
| | - Lorelei Lingard
- Centre for Education Research and Innovation and Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Marat Slessarev
- Department of Medicine, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada; Trillium Gift of Life Network, Toronto, Ontario, Canada
| | - Laurie Blackstock
- Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada
| | - John Basmaji
- Departments of Medicine and Epidemiology & Biostatistics, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Mayur Brahmania
- Division of Gastroenterology, Department of Medicine, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Andrew Healey
- Trillium Gift of Life Network, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sam Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Canadian Blood Services, Ottawa, Ontario, Canada
| | - Anton Skaro
- Department of Surgery, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Charles Weijer
- Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada; Departments of Medicine, Epidemiology & Biostatistics, and Philosophy, Western University, London, Ontario, Canada
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Hess NR, Hong Y, Yoon P, Bonatti J, Sultan I, Serna-Gallegos D, Chu D, Hickey GW, Keebler ME, Kaczorowski DJ. Donation after circulatory death improves probability of heart transplantation in waitlisted candidates and results in post-transplant outcomes similar to those achieved with brain-dead donors. J Thorac Cardiovasc Surg 2024; 167:1845-1860.e12. [PMID: 37714368 DOI: 10.1016/j.jtcvs.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/14/2023] [Accepted: 09/04/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVE To quantitate the impact of heart donation after circulatory death (DCD) donor utilization on both waitlist and post-transplant outcomes in the United States. METHODS The United Network for Organ Sharing database was queried to identify all adult waitlisted and transplanted candidates between October 18, 2018, and December 31, 2022. Waitlisted candidates were stratified according to whether they had been approved for donation after brain death (DBD) offers only or also approved for DCD offers. The cumulative incidence of transplantation was compared between the 2 cohorts. In a post-transplant analysis, 1-year post-transplant survival was compared between unmatched and propensity-score-matched cohorts of DBD and DCD recipients. RESULTS A total of 14,803 candidates were waitlisted, including 12,287 approved for DBD donors only and 2516 approved for DCD donors. Overall, DCD approval was associated with an increased sub-hazard ratio (HR) for transplantation and a lower sub-HR for delisting owing to death/deterioration after risk adjustment. In a subgroup analysis, candidates with blood type B and status 4 designation received the greatest benefit from DCD approval. A total of 12,238 recipients underwent transplantation, 11,636 with DBD hearts and 602 with DCD hearts. Median waitlist times were significantly shorter for status 3 and status 4 recipients receiving DCD hearts. One-year post-transplant survival was comparable between unmatched and propensity score-matched cohorts of DBD and DCD recipients. CONCLUSIONS The use of DCD hearts confers a higher probability of transplantation and a lower incidence of death/deterioration while on the waitlist, particularly among certain subpopulations such as status 4 candidates. Importantly, the use of DCD donors results in similar post-transplant survival as DBD donors.
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Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Yeahwa Hong
- Department of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Pyongsoo Yoon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Johannes Bonatti
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Gavin W Hickey
- Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Mary E Keebler
- Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - David J Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Royo-Villanova M, Miñambres E, Sánchez JM, Torres E, Manso C, Ballesteros MÁ, Parrilla G, de Paco Tudela G, Coll E, Pérez-Blanco A, Domínguez-Gil B. Maintaining the permanence principle of death during normothermic regional perfusion in controlled donation after the circulatory determination of death: Results of a prospective clinical study. Am J Transplant 2024; 24:213-221. [PMID: 37739346 DOI: 10.1016/j.ajt.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Abstract
One concern about the use of normothermic regional perfusion (NRP) in controlled donation after the circulatory determination of death (cDCD) is that the brain may be perfused. We aimed to demonstrate that certain technical maneuvers preclude such brain perfusion. A nonrandomized trial was performed on cDCD donors. In abdominal normothermic regional perfusion (A-NRP), the thoracic aorta was blocked with an intra-aortic occlusion balloon. In thoracoabdominal normothermic regional perfusion (TA-NRP), the arch vessels were clamped and the cephalad ends vented to the atmosphere. The mean intracranial arterial blood pressure (ICBP) was invasively measured at the circle of Willis. Ten cDCD donors subject to A-NRP or TA-NRP were included. Mean ICBP and mean blood pressure at the thoracic and the abdominal aorta during the circulatory arrest were 17 (standard deviation [SD], 3), 17 (SD, 3), and 18 (SD, 4) mmHg, respectively. When A-NRP started, pressure at the abdominal aorta increased to 50 (SD, 13) mmHg, while the ICBP remained unchanged. When TA-NRP was initiated, thoracic aorta pressure increased to 71 (SD, 18) mmHg, but the ICBP remained unmodified. Recorded values of ICBP during NRP were 10 mmHg. In conclusion, appropriate technical measures applied during NRP preclude perfusion of the brain in cDCD. This study might help to expand NRP and increase the number of organs available for transplantation.
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Affiliation(s)
- Mario Royo-Villanova
- Donor Transplant Coordination Unit, Service of Intensive Care, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Eduardo Miñambres
- Donor Transplant Coordination Unit, Service of Intensive Care, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, Universidad de Cantabria, Santander, Spain.
| | - José Moya Sánchez
- Donor Transplant Coordination Unit, Service of Intensive Care, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Eduardo Torres
- Neuro-intervention Unit, Hospital Universitario de Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Clara Manso
- Service of Intensive Care, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - María Ángeles Ballesteros
- Donor Transplant Coordination Unit, Service of Intensive Care, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Guillermo Parrilla
- Interventional Neurovascular Unit, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Gonzalo de Paco Tudela
- Interventional Neurovascular Unit, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
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Ruch B, Kumm K, Arias S, Katariya NN, Mathur AK. Donation After Circulatory Death Liver Transplantation: Early Challenges, Clinical Improvement, and Future Directions. Surg Clin North Am 2024; 104:27-44. [PMID: 37953039 DOI: 10.1016/j.suc.2023.08.001] [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: 11/14/2023]
Abstract
Donation after circulatory death (DCD) liver allografts remain a widely underutilized source of donor organs for transplantation. Although initially linked with inferior outcomes, DCD liver transplant can achieve excellent patient and graft survival with suitable matching of donor and recipient characteristics, rapid donor recovery and precise donor assessment, and appropriate perioperative management. The advent of clinical liver perfusion modalities promises to redefine the viability parameters for DCD liver allografts and hopefully will encourage more widespread usage of this growing source of donor livers.
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Affiliation(s)
- Brianna Ruch
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA. https://twitter.com/BriannaCRuch
| | - Kayla Kumm
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA. https://twitter.com/Kayla_Kumm
| | - Sandra Arias
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Nitin N Katariya
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA. https://twitter.com/nnk_tx_hpb
| | - Amit K Mathur
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA.
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Wall AE, Adams BL, Brubaker A, Chang CWJ, Croome KP, Frontera J, Gordon E, Hoffman J, Kaplan LJ, Kumar D, Levisky J, Miñambres E, Parent B, Watson C, Zemmar A, Pomfret EA. The American Society of Transplant Surgeons Consensus Statement on Normothermic Regional Perfusion. Transplantation 2024; 108:312-318. [PMID: 38254280 DOI: 10.1097/tp.0000000000004894] [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: 01/24/2024]
Abstract
On June 3, 2023, the American Society of Transplant Surgeons convened a meeting in San Diego, California to (1) develop a consensus statement with supporting data on the ethical tenets of thoracoabdominal normothermic regional perfusion (NRP) and abdominal NRP; (2) provide guidelines for the standards of practice that should govern thoracoabdominal NRP and abdominal NRP; and (3) develop and implement a central database for the collection of NRP donor and recipient data in the United States. National and international leaders in the fields of neuroscience, transplantation, critical care, NRP, Organ Procurement Organizations, transplant centers, and donor families participated. The conference was designed to focus on the controversial issues of neurological flow and function in donation after circulatory death donors during NRP and propose technical standards necessary to ensure that this procedure is performed safely and effectively. This article discusses major topics and conclusions addressed at the meeting.
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Affiliation(s)
- Anji E Wall
- Division of Abdominal Transplantation, Baylor Simmons Transplant Institute, Dallas, TX
| | | | - Aleah Brubaker
- Department of Surgery, University of California San Diego, San Diego, CA
| | - Cherylee W J Chang
- Neurocritical Care Division, Department of Neurology, Duke University, Durham, NC
| | | | - Jennifer Frontera
- Department of Neurology, NYU Grossman School of Medicine, New York, NY
| | - Elisa Gordon
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Jordan Hoffman
- Heart and Lung Transplantation and CTEPH Program, University of Colorado School of Medicine, Anschutz Medical Campus, Denver, CO
| | - Lewis J Kaplan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Surgical Critical Care Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Deepali Kumar
- Transplant Infectious Diseases, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Josh Levisky
- Division of Hepatology, Department of Medicine, Northwestern Medicine, Chicago, IL
| | - Eduardo Miñambres
- Donor Transplant Coordination Unit and Intensive Care Service, Hospital Universitario de Marqués de Valdecilla-IDIVAL, Spain
| | - Brendan Parent
- Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY
| | - Christopher Watson
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom
| | - Ajmal Zemmar
- Department of Neurosurgery, University of Louisville, Louisville, KY
| | - Elizabeth A Pomfret
- Division of Transplant Surgery and Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado Anschutz Medical Campus, Denver, CO
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Secanella L, Alconchel F, López-Monclús J, Toledo-Martínez E, Barrios O, Ramírez P, Jiménez-Garrido MC, Rodríguez-Sanjuán JC, Royo-Villanova M, Moreno-González G, Lladó L. Outcomes of liver transplantation with thoracoabdominal normothermic regional perfusion: a matched-controlled initial experience in Spain. FRONTIERS IN TRANSPLANTATION 2023; 2:1280454. [PMID: 38993919 PMCID: PMC11235216 DOI: 10.3389/frtra.2023.1280454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 10/16/2023] [Indexed: 07/13/2024]
Abstract
Thoracoabdominal (TA) normothermic regional perfusion (NRP) should allow the safe recovery of heart and liver grafts simultaneously in the context of controlled donation after circulatory death (cDCD). We present the initial results of cDCD liver transplantation with simultaneous liver and heart procurement in Spain until October 2021. Outcomes were compared with a matched cohort of cDCD with abdominal NRP (A-NRP) from participating institutions. Primary endpoints comprised early allograft dysfunction (EAD) or primary non-function (PNF), and the development of ischemic-type biliary lesions (ITBL). Six transplants were performed using cDCD with TA-NRP during the study period. Donors were significantly younger in the TA-NRP group than in the A-NRP group (median 45.6 years and 62.9 years respectively, p = 0.011), with a median functional warm ischemia time of 12.5 min in the study group and 13 min in the control group. Patient characteristics, procurement times, and surgical baseline characteristics did not differ significantly between groups. No patient in the study group developed EAD or PNF, and over a median follow-up of 9.8 months, none developed ITBL or graft loss. Extending A-NRP to TA-NRP for cardiac procurement may be technically challenging, but it is both feasible and safe, showing comparable postoperative outcomes to A-NRP.
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Affiliation(s)
- Luis Secanella
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y Digestiva, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Felipe Alconchel
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Virgen de la Arrixaca), Murcia, Spain
| | - Javier López-Monclús
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Trasplante Hepático, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Enrique Toledo-Martínez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Oriana Barrios
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y Digestiva, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Pablo Ramírez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Virgen de la Arrixaca), Murcia, Spain
| | - Manuel Cecilio Jiménez-Garrido
- Servicio de Cirugía General y del Aparato Digestivo, Unidad de Trasplante Hepático, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Mario Royo-Villanova
- Servicio de Medicina Intensiva, Coordinación de Trasplantes, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Virgen de la Arrixaca), Murcia, Spain
| | - Gabriel Moreno-González
- Servicio de Medicina Intensiva, Coordinación de Trasplantes, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Laura Lladó
- Unidad HPB y Trasplante Hepático, Servicio de Cirugía General y Digestiva, Hospital Universitari de Bellvitge, Barcelona, Spain
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Mora-Cuesta VM, Tello-Mena S, Izquierdo-Cuervo S, Iturbe-Fernández D, Sánchez-Moreno L, Ballesteros MA, Alonso-Lecue P, Ortíz-Portal F, Ferrer-Pargada D, Miñambres-García E, Cifrián-Martínez JM, Naranjo-Gozalo S. Bronchial Stenosis After Lung Transplantation From cDCD Donors Using Simultaneous Abdominal Normothermic Regional Perfusion: A Single-center Experience. Transplantation 2023; 107:2415-2423. [PMID: 37389647 DOI: 10.1097/tp.0000000000004698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
BACKGROUND Controlled donation after circulatory death (cDCD) has increased the number of lung donors significantly. The use of abdominal normothermic regional perfusion (A-NRP) during organ procurement is a common practice in some centers due to its benefits on abdominal grafts. This study aimed to assess whether the use of A-NRP in cDCD increases the frequency of bronchial stenosis in lung transplant (LT) recipients. METHODS A single-center, retrospective study including all LTs was performed between January 1, 2015, and August 30, 2022. Airway stenosis was defined as a stricture that leads to clinical/functional worsening requiring the use of invasive monitoring and therapeutic procedures. RESULTS A total of 308 LT recipients were included in the study. Seventy-six LT recipients (24.7%) received lungs from cDCD donors using A-NRP during organ procurement. Forty-seven LT recipients (15.3%) developed airway stenosis, with no differences between lung recipients with grafts from cDCD (17.2%) and donation after brain death donors (13.3%; P = 0.278). A total of 48.9% of recipients showed signs of acute airway ischemia on control bronchoscopy at 2 to 3 wk posttransplant. Acute ischemia was an independent risk factor for airway stenosis development (odds ratio = 2.523 [1.311-4.855], P = 0.006). The median number of bronchoscopies per patient was 5 (2-9), and 25% of patients needed >8 dilatations. Twenty-three patients underwent endobronchial stenting (50.0%) and each patient needed a median of 1 (1-2) stent. CONCLUSIONS Incidence of airway stenosis is not increased in LT recipients with grafts obtained from cDCD donors using A-NRP.
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Affiliation(s)
- Víctor M Mora-Cuesta
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Sandra Tello-Mena
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Sheila Izquierdo-Cuervo
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - David Iturbe-Fernández
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Laura Sánchez-Moreno
- Thoracic Surgery, Lung Transplant Unit, Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Maria Angeles Ballesteros
- Transplant Coordination Unit and Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, Universidad de Cantabria, Santander, Cantabria, Spain
| | | | - Felix Ortíz-Portal
- Respiratory Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain
| | - Diego Ferrer-Pargada
- Respiratory Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain
| | - Eduardo Miñambres-García
- Transplant Coordination Unit and Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, Universidad de Cantabria, Santander, Cantabria, Spain
| | - José M Cifrián-Martínez
- Lung Transplant Unit, Respiratory Department Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
| | - Sara Naranjo-Gozalo
- Thoracic Surgery, Lung Transplant Unit, Marqués de Valdecilla University Hospital, ERN-LUNG (European Reference Network on Rare Respiratory Diseases), Santander, Cantabria, Spain
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14
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Stewart D, Hasz R, Lonze B. Beyond donation to organ utilization in the USA. Curr Opin Organ Transplant 2023; 28:197-206. [PMID: 36912063 DOI: 10.1097/mot.0000000000001060] [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: 03/14/2023]
Abstract
PURPOSE OF REVIEW The deceased donor organ pool has broadened beyond young, otherwise healthy head trauma victims. But an abundance of donated organs only benefits patients if they are accepted, expeditiously transported and actually transplanted. This review focuses on postdonation challenges and opportunities to increase the number of transplants through improved organ utilization. RECENT FINDINGS We build upon recently proposed changes in terminology for measuring organ utilization. Among organs recovered for transplant, the nonuse rate (NUR REC ) has risen above 25% for kidneys and pancreata. Among donors, the nonuse rate (NUR DON ) has risen to 40% for livers and exceeds 70% for thoracic organs. Programme-level variation in offer acceptance rates vastly exceeds variation in the traditional, 1-year survival benchmark. Key opportunities to boost utilization include donation after circulatory death and hepatitis C virus (HCV)+ organs; acute kidney injury and suboptimal biopsy kidneys; older and steatotic livers. SUMMARY Underutilization of less-than-ideal, yet transplant-worthy organs remains an obstacle to maximizing the impact of the U.S. transplant system. The increased risk of inferior posttransplant outcomes must always be weighed against the risks of remaining on the waitlist. Advanced perfusion technologies; tuning allocation systems for placement efficiency; and data-driven clinical decision support have the potential to increase utilization of medically complex organs.
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Affiliation(s)
- Darren Stewart
- Department of Surgery, NYU Langone Health, New York, New York
| | - Richard Hasz
- Gift of Life Donor Program, Philadelphia, Pennsylvania, USA
| | - Bonnie Lonze
- Department of Surgery, NYU Langone Health, New York, New York
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Groba Marco MDV, Galvan Ruiz M, Cabrera Santana M, Romero Lujan JL, Portela Torron F, Santana Ortega L, Fernandez de Sanmamed Giron M, Caballero Dorta EJ, Garcia Quintana A. Expanding Heart Donor Pool With a Broken Heart: Cardiac Transplant From Donor Following Circulatory Death With Takotsubo Syndrome. Transplantation 2023; 107:e152-e153. [PMID: 37097980 DOI: 10.1097/tp.0000000000004546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Affiliation(s)
- Maria Del Val Groba Marco
- Cardiology Department, Hospital Universitario de Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria, Spain
- Department of medical and surgical sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Mario Galvan Ruiz
- Department of medical and surgical sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Miriam Cabrera Santana
- Transplant Coordination Unit, Hospital Universitario de Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria, Spain
- Department of Critical Care, Hospital Universitario de Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Jose Luis Romero Lujan
- Department of Critical Care, Hospital Universitario de Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Francisco Portela Torron
- Department of medical and surgical sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
- Department of Cardiac Surgery, Hospital Universitario de Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Luis Santana Ortega
- Department of Anesthesiology, Hospital Universitario de Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | | | - Eduardo Jose Caballero Dorta
- Cardiology Department, Hospital Universitario de Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria, Spain
- Department of medical and surgical sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Antonio Garcia Quintana
- Department of medical and surgical sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
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16
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Campo-Cañaveral de la Cruz JL, Miñambres E, Coll E, Padilla M, Sánchez Antolín G, de la Rosa G, Rosado J, González García FJ, Crowley Carrasco S, Sales Badía G, María Fieria Costa E, Alberto García Salcedo J, Mora V, de la Torre C, Badenes R, Atutxa Bizkarguenaga L, Domínguez-Gil B. Outcomes Of Lung And Liver Transplantation After Simultaneous Recovery Using Abdominal Normothermic Regional Perfusion In Donors After The Circulatory Determination Of Death Versus Donors After Brain Death. Am J Transplant 2023:S1600-6135(23)00414-8. [PMID: 37100392 DOI: 10.1016/j.ajt.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 04/28/2023]
Abstract
Normothermic regional perfusion (NRP) in controlled donation after the circulatory determination of death (cDCD) is a growing preservation technique for abdominal organs that coexists with the rapid recovery of lungs. We aim at describing the outcomes of lung transplants (LuTx) and liver transplants (LiTx) when both grafts are simultaneously recovered from cDCD donors using NRP, and compare them to donation after brain death (DBD). All LuTx and LiTx meeting these criteria during January-2015 to December-2020 in Spain were included in the study. Simultaneous recovery of lungs and livers was undertaken in 227 (17%) cDCD with NRP and 1,879 (21%) DBD donors (p<0.001). Primary graft dysfunction grade-3 within the first 72hours was similar in both LuTx groups (14.7% cDCD vs. 10.5% DBD;p=0.139). LuTx survival at 1 and 3years was 79.9% and 66.4% in cDCD, vs. 81.9% and 69.7% in DBD (p=0.403). The incidence of primary non-function and ischemic cholangiopathy was similar in both LiTx groups. Graft survival at 1 and 3years was 89.7% and 80.8% in cDCD vs. 88.2% and 82.1% in DBD LiTx (p=0.669). In conclusion, the simultaneous rapid recovery of lungs and preservation of abdominal organs with NRP in cDCD donors is feasible, and offers similar outcomes in both LuTx and LiTx recipients to transplants using DBD grafts.
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Affiliation(s)
| | - Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL. School of Medicine, Universidad de Cantabria, Santander, Spain
| | | | | | | | | | - Joel Rosado
- Thoracic Surgery and Lung Transplantation. Vall d'Hebrón University Hospital. Barcelona, Spain
| | | | - Silvana Crowley Carrasco
- Thoracic Surgery and Lung Transplantation Department. Hospital Universitario Puerta de Hierro-Majadahonda. Madrid, Spain
| | - Gabriel Sales Badía
- Thoracic Surgery and Lung Transplantation. Hospital Universitari i Politècnic La Fe. Valencia, Spain
| | - Eva María Fieria Costa
- Thoracic Surgery and Lung Transplantation. Complejo Hospitalario Universitario A Coruña. A Coruña, Spain
| | | | - Victor Mora
- Pneumology Department, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Carlos de la Torre
- Pediatric Surgery and Lung Transplantation. La Paz University Hospital. Madrid, Spain
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain
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Pasrija C, Tipograf Y, Shah AS, Trahanas JM. Normothermic regional perfusion for donation after circulatory death donors. Curr Opin Organ Transplant 2023; 28:71-75. [PMID: 36409266 DOI: 10.1097/mot.0000000000001038] [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: 11/23/2022]
Abstract
PURPOSE OF REVIEW This review is intended to provide an update on the logistics, technique, and outcomes associated with normothermic regional perfusion (NRP), as well as provide a discussion of the associated ethical issues. RECENT FINDINGS There has been renewed interest in utilizing NRP to increase quality and availability of organs from donation after circulatory death (DCD) donors. Our institution has increasing experience with thoraco-abdominal NRP (TA-NRP) in controlled DCD donors (cDCD), whereas abdominal NRP (A-NRP) has been used with success in both cDCD and uncontrolled DCD (uDCD). There is increasing evidence that NRP can be conducted in a practical and cost-efficient manner, and that the organ yield may be of better quality than standard direct procurement and perfusion (DPP). SUMMARY NRP is increasingly successful and will likely prove to be a superior method for cDCD recovery. However, before TA-NRP can be widely accepted the ethical debate surrounding this technique must be settled. VIDEO ABSTRACT http://links.lww.com/COOT/A11.
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Affiliation(s)
- Chetan Pasrija
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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18
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Louca J, Öchsner M, Shah A, Hoffman J, Vilchez FG, Garrido I, Royo-Villanova M, Domínguez-Gil B, Smith D, James L, Moazami N, Rega F, Brouckaert J, Van Cleemput J, Vandendriessche K, Tchana-Sato V, Bandiougou D, Urban M, Manara A, Berman M, Messer S, Large S. The international experience of in-situ recovery of the DCD heart: a multicentre retrospective observational study. EClinicalMedicine 2023; 58:101887. [PMID: 36911270 PMCID: PMC9995283 DOI: 10.1016/j.eclinm.2023.101887] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Heart transplantation is an effective treatment offering the best recovery in both quality and quantity of life in those affected by refractory, severe heart failure. However, transplantation is limited by donor organ availability. The reintroduction of heart donation after the circulatory determination of death (DCD) in 2014 offered an uplift in transplant activity by 30%. Thoraco-abdominal normothermic regional perfusion (taNRP) enables in-situ reperfusion of the DCD heart. The objective of this paper is to assess the clinical outcomes of DCD donor hearts recovered and transplanted from donors undergoing taNRP. METHOD This was a multicentre retrospective observational study. Outcomes included functional warm ischaemic time, use of mechanical support immediately following transplantation, perioperative and long-term actuarial survival and incidence of acute rejection requiring treatment. 157 taNRP DCD heart transplants, performed between February 2, 2015, and July 29, 2022, have been included from 15 major transplant centres worldwide including the UK, Spain, the USA and Belgium. 673 donations after the neurological determination of death (DBD) heart transplantations from the same centres were used as a comparison group for survival. FINDINGS taNRP resulted in a 23% increase in heart transplantation activity. Survival was similar in the taNRP group when compared to DBD. 30-day survival was 96.8% ([92.5%-98.6%] 95% CI, n = 156), 1-year survival was 93.2% ([87.7%-96.3%] 95% CI, n = 72) and 5-year survival was 84.3% ([69.6%-92.2%] 95% CI, n = 13). INTERPRETATION Our study suggests that taNRP provides a significant boost to heart transplantation activity. The survival rates of taNRP are comparable to those obtained for DBD transplantation in this study. The similar survival may in part be related to a short warm ischaemic time or through a possible selection bias of younger donors, this being an uncontrolled observational study. Therefore, our study suggests that taNRP offers an effective method of organ preservation and procurement. This early success of the technique warrants further investigation and use. FUNDING None of the authors have a financial relationship with a commercial entity that has an interest in the subject.
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Affiliation(s)
- John Louca
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Rd, Cambridge CB2 0SP, UK
- Corresponding author.
| | - Marco Öchsner
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Rd, Cambridge CB2 0SP, UK
| | - Ashish Shah
- Vanderbilt Heart Transplant Unit 1215, 21st Ave, Nashville, Tennessee 37232, USA
| | - Jordan Hoffman
- Vanderbilt Heart Transplant Unit 1215, 21st Ave, Nashville, Tennessee 37232, USA
| | | | - Iris Garrido
- Hospital Universitario Virgen de La Arrixaca, Ctra. Madrid-Cartagena, s/n, El Palmar, Murcia 30120, Spain
| | - Mario Royo-Villanova
- Hospital Universitario Virgen de La Arrixaca, Ctra. Madrid-Cartagena, s/n, El Palmar, Murcia 30120, Spain
| | | | - Deane Smith
- Department of Cardiothoracic Surgery, Langone, 1300 Franklin Avenue, Suite ML-2, Garden City, NY, USA
| | - Leslie James
- Department of Cardiothoracic Surgery, Langone, 1300 Franklin Avenue, Suite ML-2, Garden City, NY, USA
| | - Nader Moazami
- Department of Cardiothoracic Surgery, Langone, 1300 Franklin Avenue, Suite ML-2, Garden City, NY, USA
| | - Filip Rega
- Departments of Cardiac Surgery and Cardiology, The University Hospital Leuven, Leuven, Belgium
| | - Janne Brouckaert
- Departments of Cardiac Surgery and Cardiology, The University Hospital Leuven, Leuven, Belgium
| | - Johan Van Cleemput
- Departments of Cardiac Surgery and Cardiology, The University Hospital Leuven, Leuven, Belgium
| | - Katrien Vandendriessche
- Departments of Cardiac Surgery and Cardiology, The University Hospital Leuven, Leuven, Belgium
| | | | | | - Marian Urban
- Department of Cardiothoracic Surgery, University of Nebraska Medical Centre, 2410 Atherholt Road, Omaha, NE, USA
| | - Alex Manara
- The Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol BS 10 5NB, UK
| | - Marius Berman
- Royal Papworth Hospital Biomedical Campus, Cambridge, CB2 0AY, UK
| | - Simon Messer
- Golden Jubilee Hospital, Agamermnon Street, Glasgow G81 4DY, UK
| | - Stephen Large
- Royal Papworth Hospital Biomedical Campus, Cambridge, CB2 0AY, UK
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Miñambres E, Estébanez B, Ballesteros MÁ, Coll E, Flores-Cabeza EM, Mosteiro F, Lara R, Domínguez-Gil B. Normothermic Regional Perfusion in Pediatric Controlled Donation After Circulatory Death Can Lead to Optimal Organ Utilization and Posttransplant Outcomes. Transplantation 2023; 107:703-708. [PMID: 36226852 DOI: 10.1097/tp.0000000000004326] [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: 10/17/2022]
Abstract
BACKGROUND The benefits of normothermic regional perfusion (NRP) in posttransplant outcomes after controlled donation after the determination of death by circulatory criteria (cDCD) has been shown in different international adult experiences. However, there is no information on the use of NRP in pediatric cDCD donors. METHODS This is a multicenter, retrospective, observational cohort study describing the pediatric (<18 y) cDCD procedures performed in Spain, using either abdominal NRP or thoracoabdominal NRP and the outcomes of recipients of the obtained organs. RESULTS Thirteen pediatric cDCD donors (age range, 2-17 y) subject to abdominal NRP or thoracoabdominal NRP were included. A total of 46 grafts (24 kidneys, 11 livers, 8 lungs, 2 hearts, and 1 pancreas) were finally transplanted (3.5 grafts per donor). The mean functional warm ischemic time was 15 min (SD 6 min)' and the median duration of NRP was 87 min (interquartile range, 69-101 min). One-year noncensored for death kidney graft survival was 91.3%. The incidence of delayed graft function was 13%. One-year' noncensored-for-death liver graft survival was 90.9%. All lung and pancreas recipients had an excellent evolution. One heart recipient died due to a septic shock. CONCLUSIONS This is the largest experience of pediatric cDCD using NRP as graft preservation method. Although our study has several limitations, such as its retrospective nature and the small sample size, its reveals that NRP may increase the utilization of cDCD pediatric organs and offer optimal recipients' outcomes.
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Affiliation(s)
- Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
- School of Medicine, Universidad de Cantabria, Santander, Spain
| | - Belen Estébanez
- Transplant Coordination Unit & Service of Intensive Care, University Hospital La Paz, Madrid, Spain
| | - Maria Ángeles Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | | | - Fernando Mosteiro
- Transplant Coordination Unit & Service of Intensive Care, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Ramón Lara
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Virgen De Las Nieves, Granada, Spain
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20
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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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21
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James L, LaSala VR, Hill F, Ngai JY, Reyentovich A, Hussain ST, Gidea C, Piper GL, Galloway AC, Smith DE, Moazami N. Donation after circulatory death heart transplantation using normothermic regional perfusion:The NYU Protocol. JTCVS Tech 2022; 17:111-120. [PMID: 36820336 PMCID: PMC9938390 DOI: 10.1016/j.xjtc.2022.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/25/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022] Open
Abstract
Objective This study aimed to evaluate the impact of cardiopulmonary bypass for thoraco-abdominal normothermic regional perfusion on the metabolic milieu of donation after cardiac death organ donors before transplantation. Methods Local donation after cardiac death donor offers are assessed for suitability and willingness to participate. Withdrawal of life-sustaining therapy is performed in the operating room. After declaration of circulatory death and a 5-minute observation period, the cardiac team performs a median sternotomy, ligation of the aortic arch vessels, and initiation of thoraco-abdominal normothermic regional perfusion via central cardiopulmonary bypass at 37 °C. Three sodium chloride zero balance ultrafiltration bags containing 50 mEq sodium bicarbonate and 0.5 g calcium carbonate are infused. Arterial blood gas measurements are obtained every 15 minutes after every zero balance ultrafiltration bag is infused, and blood is transfused as needed to maintain hemoglobin greater than 8 mg/dL. Cardiopulmonary bypass is weaned with concurrent hemodynamic and transesophageal echocardiogram evaluation of the donor heart. The remainder of the procurement, including the abdominal organs, proceeds in a similar controlled fashion as is performed for a standard donation after brain death donor. Results Between January 2020 and May 2022, 18 donation after cardiac death transplants using the thoraco-abdominal normothermic regional perfusion protocol were performed at our institution. The median donor age was 42.5 years (range, 20-51 years), and 88.9% (16/18) were male. The mean total donor cardiopulmonary bypass time was 88.8 ± 51.8 minutes. At the beginning of cardiopulmonary bypass, the average donor lactate was 9.4 ± 1.5 mmol/L compared with an average final lactate of 5.3 ± 2.7 mmol/L (P<.0001). The average beginning potassium was 6.5 ± 1.8 mmol/L compared with an average end potassium of 4.2 ± 0.4 mmol/L (P<.0001) . The average beginning hemoglobin was 6.8 ± 0.7 g/dL, and the average end hemoglobin was 8.2 ± 1.3 g/dL (P<.001) . On average, donation after cardiac death donors received transfusions of 2.3 ± 1.5 units of packed red blood cells. Of the 18 donors who underwent normothermic regional perfusion, all hearts were deemed suitable for recovery and successfully transplanted, a yield of 100%. Other organs successfully recovered and transplanted include kidneys (80.6% yield), livers (66.7% yield), and bilateral lungs (27.8% yield). Conclusions The use of cardiopulmonary bypass for thoraco-abdominal normothermic regional perfusion is a burgeoning option for improving the quality of organs from donation after cardiac death donors. Meticulous intraoperative management of donation after cardiac death donors with a specific focus on improving their metabolic milieu may lead to improved graft function in transplant recipients.
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Key Words
- CIT, cold ischemic time
- CPB, cardiopulmonary bypass
- DBD, donation after brain death
- DCD, donation after circulatory death
- DWIT, donor warm ischemic time
- ICU, intensive care unit
- NRP, normothermic regional perfusion
- OPO, Organ Procurement Organization
- TEE, transesophageal echocardiography
- UF, ultrafiltration
- WLST, withdrawal of life-sustaining therapy
- Z-BUF, zero-balance ultrafiltration
- donation after circulatory death
- heart transplantation
- normothermic regional perfusion
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Affiliation(s)
- Les James
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY
| | - V. Reed LaSala
- Department of General Surgery, SUNY Downstate Health Sciences University, Brooklyn, NY
| | - Fredrick Hill
- Perfusion Services, NYU Langone Health, New York, NY
| | - Jennie Y. Ngai
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Health, New York, NY
| | - Alex Reyentovich
- Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY
| | - Syed T. Hussain
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY
| | - Claudia Gidea
- Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY
| | | | | | - Deane E. Smith
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY,Address for reprints: Nader Moazami, MD, Division of Heart and Lung Transplantation and Mechanical Circulatory Support, Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, 530 1st Ave, Suite 9V, New York, NY 10016.
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22
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Barreda P, Miñambres E, Ballesteros MÁ, Mazón J, Gómez-Román J, Gómez Ortega JM, Belmar L, Valero R, Ruiz JC, Rodrigo E. Controlled Donation After Circulatory Death Using Normothermic Regional Perfusion Does Not Increase Graft Fibrosis in the First Year Posttransplant Surveillance Biopsy. EXP CLIN TRANSPLANT 2022; 20:1069-1075. [PMID: 36718005 DOI: 10.6002/ect.2022.0171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The number of kidney transplants obtained from controlled donations after circulatory death is increasing, with long-term outcomes similar to those obtained with donations after brain death. Extraction using normothermic regional perfusion can improve results with controlled donors after circulatory death; however, information on the histological impact and extraction procedure is scarce. MATERIALS AND METHODS We retrospectively investigated all kidney transplants performed from October 2014 to December 2019, in which a follow-up kidney biopsy had been performed at 1-year follow-up, comparing controlled procedures with donors after circulatory death and normothermic regional perfusion versus donors after brain death. Interstitial fibrosis/tubular atrophy was assessed by adding the values of interstitial fibrosis and tubular atrophy, according to the Banff classification of renal allograft pathology. RESULTS When we compared histological data from 66 transplants with donations after brain death versus 24 transplants with donations after circulatory death and normothermic regional perfusion, no differences were found in the degree of fibrosis in the 1-year follow-up biopsy (1.7 ± 1.3 vs 1.7 ± 1.1; P = .971) or in the ratio of patients with increased fibrosis calculated as interstitial fibrosis/tubular atrophy >2 (18% vs 13%; P = .522). In our multivariate analysis, which included acute rejection, expanded criteria donation, and the type of donation, no variable was independently related to an increased risk of interstitial fibrosis/tubular atrophy >2. CONCLUSIONS The outcomes of kidney grafts procured in our center using controlled procedures with donors after circulatory death and normothermic regional perfusion were indistinguishable from those obtained from donors after brain death, showing the same degree of fibrosis in the 1-year posttransplant surveillance biopsy. Our data support the conclusion that normothermic regional perfusion should be the method of choice for extraction in donors after circulatory death.
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Affiliation(s)
- Paloma Barreda
- From the Nephrology Department/Transplantation and Autoimmunity Groupt, University Hospital Marqués de Valdecilla/IDIVAL, University of Cantabria, Cantabria, Spain
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23
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Ruiz MG, Marco MDVG, Castellano MT, Torrón FP, Luján JLR, Girón MFDS, Dorta EC, Quintana AG. Breaking barriers in cardiac donation after circulatory death. J Card Surg 2022; 37:5496-5498. [PMID: 36335606 DOI: 10.1111/jocs.17112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/17/2022] [Accepted: 09/28/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Heart transplant (HT) from controlled donation after circulatory death (cDCD) is an emerging strategy that is rapidly expanding and may help increase the heart donor pool. MATERIALS AND METHODS The use of thoracoabdominal normothermic regional perfusion with extracorporeal membrane oxygenation device has allowed to perform HT after cDCD in our country. We present a successful case of heart transplantation using a graft from cDCD with 201 min cold ischemia time. DISCUSSION AND CONCLUSION HT from cDCD could be a good alternative to brain dead donation. This experience suggests than nonlocal cardiac from cDCD could tolerate long periods of cold ischemia time and break the main barriers with this technique.
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Affiliation(s)
- Mario Galván Ruiz
- Department of Cardiology, University Hospital of Gran Canaria Doctor Negrín, Las Palmas, Spain
| | | | - Michelle Tout Castellano
- Department for Transplant Coordination, University Hospital of Gran Canaria Doctor Negrín, Las Palmas, Spain.,Department for Critical Care Medicine, University Hospital of Gran Canaria Doctor Negrín, Las Palmas, Spain
| | - Francisco Portela Torrón
- Department for Cardiothoracic Surgery, University Hospital of Gran Canaria Doctor Negrín, Las Palmas, Spain
| | - José Luis Romero Luján
- Department for Critical Care Medicine, University Hospital of Gran Canaria Doctor Negrín, Las Palmas, Spain
| | | | - Eduardo Caballero Dorta
- Department of Cardiology, University Hospital of Gran Canaria Doctor Negrín, Las Palmas, Spain
| | - Antonio García Quintana
- Department of Cardiology, University Hospital of Gran Canaria Doctor Negrín, Las Palmas, Spain
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24
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Normothermic Regional Perfusion Provides a Great Opportunity to Maximize Organ Procurement in Donation After the Circulatory Determination of Death. Crit Care Med 2022; 50:1649-1653. [PMID: 36227033 DOI: 10.1097/ccm.0000000000005645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Expanding Donor Heart Utilization Through Machine Perfusion Technologies. CURRENT TRANSPLANTATION REPORTS 2022. [DOI: 10.1007/s40472-022-00375-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Abstract
Purpose of Review
Recent advances in donor heart preservation have allowed the utilization of hearts that would typically be discarded due to prolonged ischemic times or donation via the circulatory death pathway. This review will discuss recent advances in donor heart preservation including optimization of machine perfusion technologies and future strategies of potential benefit for the donor heart and transplant outcomes.
Recent Findings
Improvements in organ preservation strategies have enabled retrieval of donor hearts that were not ideal for static cold storage. Machine perfusion (normothermic and hypothermic) and normothermic regional perfusion have ultimately expanded the donor pool for adult heart transplantation. Xenotransplantation has also incorporated machine perfusion for porcine donor heart preservation.
Summary
Traditional static cold storage is feasible for non-complex donors and transplants. Machine perfusion has enabled increased donor heart utilization however optimal preservation strategies are dependent on the donor criteria, predicted ischemic times and surgical complexity.
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26
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Mora V, Ballesteros MA, Naranjo S, Sánchez L, Suberviola B, Iturbe D, Cimadevilla B, Tello S, Alvarez C, Miñambres E. Lung transplantation from controlled donation after circulatory death using simultaneous abdominal normothermic regional perfusion: A single center experience. Am J Transplant 2022; 22:1852-1860. [PMID: 35390225 DOI: 10.1111/ajt.17057] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/04/2022] [Accepted: 04/04/2022] [Indexed: 01/25/2023]
Abstract
Despite the benefits of abdominal normothermic regional perfusion (A-NRP) for abdominal grafts in controlled donation after circulatory death (cDCD), there is limited information on the effect of A-NRP on the quality of the cDCD lungs. We aimed to study the effect of A-NRP in lungs obtained from cDCD and its impact on recipients´ outcomes. This is a study comparing outcomes of lung transplants (LT) from cDCD donors (September 2014 to December 2021) obtained using A-NRP as the abdominal preservation method. As controls, all lung recipients transplanted from donors after brain death (DBD) were considered. The primary outcomes were lung recipient 3-month, 1-year, and 5-year survival. A total of 269 LT were performed (60 cDCD and 209 DBD). There was no difference in survival at 3 months (98.3% cDCD vs. 93.7% DBD), 1 year (90.9% vs. 87.2%), and 5 years (68.7% vs. 69%). LT from the cDCD group had a higher rate of primary graft dysfunction grade 3 at 72 h (10% vs. 3.4%; p < .001). This is the largest experience ever reported with the use of A-NRP combined with lung retrieval in cDCD donors. This combined method is safe for lung grafts presenting short-term survival outcomes equivalent to those transplanted through DBD.
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Affiliation(s)
- Victor Mora
- Service of Neumology, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Maria Angeles Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Sara Naranjo
- Service of Thoracic Surgery, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Laura Sánchez
- Service of Thoracic Surgery, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Borja Suberviola
- Transplant Coordination Unit & Service of Intensive Care, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - David Iturbe
- Service of Neumology, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Bonifacio Cimadevilla
- Service of Anesthesia, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Sandra Tello
- Service of Neumology, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Carlos Alvarez
- Service of Thoracic Surgery, Lung Transplantation Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain.,School of Medicine, University of Cantabria, Santander, Spain
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27
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Alamouti-fard E, Garg P, Wadiwala IJ, Yazji JH, Alomari M, Hussain MWA, Elawady MS, Jacob S. Normothermic Regional Perfusion is an Emerging Cost-Effective Alternative in Donation After Circulatory Death (DCD) in Heart Transplantation. Cureus 2022; 14:e26437. [PMID: 35800191 PMCID: PMC9246458 DOI: 10.7759/cureus.26437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 11/24/2022] Open
Abstract
In donation after circulatory death (DCD) organ transplantation, normothermic regional perfusion (NRP) restores oxygenated blood flow following cardiac arrest and reverses warm ischemia. Recently, NRP has also been used to help recover DCD hearts in addition to the abdominal organs. While DCD donation has increased the number of abdominal organs and lungs pool, it has not been able to increase the number of heart transplants, despite the fact that it has the potential to increase the number of heart transplants by 15-30%. Thoracoabdominal normothermic regional perfusion makes heart transplantation feasible and permits assessing heart function before an organ procurement without affecting the preservation of abdominal organs. NRP can be used in two ways for DCD donor heart transplants: normothermic regional perfusion followed by machine perfusion (NRP-MP) and normothermic regional perfusion followed by static cold storage (NRP-SCS). Normothermic regional perfusion is an emerging technology, a cost-effective alternative in donation after circulatory death (DCD), and will increase the pool of donors in heart transplantation.
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28
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Melandro F, Basta G, Torri F, Biancofiore G, Del Turco S, Orlando F, Guarracino F, Maremmani P, Lazzeri C, Peris A, De Simone P, Ghinolfi D. Normothermic regional perfusion in liver transplantation from donation after cardiocirculatory death: Technical, biochemical, and regulatory aspects and review of literature. Artif Organs 2022; 46:1727-1740. [PMID: 35733227 DOI: 10.1111/aor.14330] [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: 01/07/2022] [Revised: 03/21/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Organs from donation after circulatory death (DCD) are increasingly used for liver transplantation, due to the persisting organ shortage and waiting list mortality. However, the use of DCD grafts is still limited by the inferior graft survival rate and the increased risk of primary non-function and biliary complications when compared to brain death donors' grafts. METHODS Abdominal normothermic regional perfusion with extracorporeal membrane oxygenation (ECMO) is an in situ preservation strategy. which may mitigate ischemia-reperfusion injuries. and has been proposed to restore blood perfusion after the determination of death thus optimizing liver function before implantation. RESULTS In this systematic review, we highlighted the clinical evidence supporting the use of normothermic regional perfusion in DCD liver underlying the pathophysiological mechanisms, and technical, logistic, and regulatory aspects. CONCLUSIONS Despite the lack of properly designed, prospective, randomized trials, the current available data suggest beneficial effects of normothermic regional perfusion on clinical outcomes after liver transplantation.
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Affiliation(s)
- Fabio Melandro
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Giuseppina Basta
- Institute of Clinical Physiology, CNR San Cataldo Research Area, Pisa, Italy
| | - Francesco Torri
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Giandomenico Biancofiore
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy.,Department of Surgical, Medical, Biochemical Pathology and Intensive Care, University of Pisa, Pisa, Italy
| | - Serena Del Turco
- Institute of Clinical Physiology, CNR San Cataldo Research Area, Pisa, Italy
| | - Francesco Orlando
- Hepatobiliary Surgery and Liver Transplant Center Hospital A. Cardarelli, Naples, Italy
| | - Fabio Guarracino
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paolo Maremmani
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Chiara Lazzeri
- Tuscany Regional Transplant Authority, Centro Regionale Allocazione Organi e Tessuti (CRAOT), Florence, Italy
| | - Adriano Peris
- Tuscany Regional Transplant Authority, Centro Regionale Allocazione Organi e Tessuti (CRAOT), Florence, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy.,Department of Surgical, Medical, Biochemical Pathology and Intensive Care, University of Pisa, Pisa, Italy
| | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
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29
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The Future of Heart Procurement with Donation after Circulatory Death: Current Practice and Opportunities for Advancement. J Heart Lung Transplant 2022; 41:1385-1390. [DOI: 10.1016/j.healun.2022.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/16/2022] [Accepted: 06/20/2022] [Indexed: 12/12/2022] Open
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30
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Casanova D, Castillo F, Miñambres E. Multiorgan retrieval and preservation of the thoracic and abdominal organs in Maastricht III donors. World J Transplant 2022; 12:83-87. [PMID: 35663542 PMCID: PMC9136717 DOI: 10.5500/wjt.v12.i5.83] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 10/10/2021] [Accepted: 04/26/2022] [Indexed: 02/06/2023] Open
Abstract
This editorial describes the indications and technical aspects of the simultaneous retrieval of thoracic and abdominal organs in Maastricht III donors as well as the preservation of such organs until their implantation.
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Affiliation(s)
- Daniel Casanova
- Department of Surgery, University Hospital Marqués de Valdecilla University Cantabria, Santander 39008, Cantabria, Spain
| | - Federico Castillo
- Department of Surgery, University Hospital Marqués de Valdecilla University Cantabria, Santander 39008, Cantabria, Spain
| | - Eduardo Miñambres
- Intensive Care Unit, Transplant Office, University Hospital Marques de Valdecilla University of Cantabria Medical School, Santander 39008, Cantabria, Spain
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31
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High Oxygenation During Normothermic Regional Perfusion After Circulatory Death Is Beneficial on Donor Cardiac Function in a Porcine Model. Transplantation 2022; 106:e326-e335. [PMID: 35546529 DOI: 10.1097/tp.0000000000004164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Thoracoabdominal normothermic regional perfusion (NRP) is a new method for in situ reperfusion and reanimation of potential donor organs in donation after circulatory death by reperfusion of the thoracic and abdominal organs with oxygenated blood. We investigated effects of high oxygenation (HOX) versus low oxygenation (LOX) during NRP on donor heart function in a porcine model. METHODS Pigs (80 kg) underwent a 15-min anoxic cardiac arrest followed by cardiac reanimation on NRP using a heart-lung bypass machine with subsequent assessment 180 minutes post-NRP. The animals were randomized to HOX (FiO2 1.0) or LOX (FiO2 0.21 increased to 0.40 during NRP). Hemodynamic data were obtained by invasive blood pressure and biventricular pressure-volume measurements. Blood gases, biomarkers of inflammation, and oxidative stress were measured. RESULTS Eight of 9 animals in the HOX group and 7 of 10 in the LOX group were successfully weaned from NRP. Right ventricular end-systole elastance was significantly improved in the HOX group compared with the LOX group, whereas left ventricular end-systole elastance was preserved at baseline levels. Post-NRP cardiac output, mean arterial, central venous, and pulmonary capillary wedge pressure were all comparable to baseline. Creatinine kinase-MB increased more in the LOX group than the HOX group, whereas proinflammatory cytokines increased more in the HOX group than the LOX group. No difference was found in oxidative stress between groups. CONCLUSIONS All hearts weaned from NRP showed acceptable hemodynamic function for transplantation. Hearts exposed to LOX showed more myocardial damage and showed poorer contractile performance than hearts reperfused with high oxygen.
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32
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Koscik R, Ngai J. Donation after Circulatory Death: Expanding Heart Transplants. J Cardiothorac Vasc Anesth 2022; 36:3867-3876. [DOI: 10.1053/j.jvca.2022.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 11/11/2022]
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33
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Sánchez‐Cámara S, Asensio‐López MC, Royo‐Villanova M, Soler F, Jara‐Rubio R, Garrido‐Peñalver JF, Pinar E, Hernández‐Vicente Á, Hurtado JA, Lax A, Pascual‐Figal DA. Critical warm ischemia time point for cardiac donation after circulatory death. Am J Transplant 2022; 22:1321-1328. [PMID: 35114047 PMCID: PMC9303247 DOI: 10.1111/ajt.16987] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/21/2022] [Accepted: 01/21/2022] [Indexed: 01/25/2023]
Abstract
Donation after circulatory death (DCD) represents a promising opportunity to overcome the relative shortage of donors for heart transplantation. However, the necessary period of warm ischemia is a concern. This study aims to determine the critical warm ischemia time based on in vivo biochemical changes. Sixteen DCD non-cardiac donors, without cardiovascular disease, underwent serial endomyocardial biopsies immediately before withdrawal of life-sustaining therapy (WLST), at circulatory arrest (CA) and every 2 min thereafter. Samples were processed into representative pools to assess calcium homeostasis, mitochondrial function and cellular viability. Compared to baseline, no significant deterioration was observed in any studied parameter at the time of CA (median: 9 min; IQR: 7-13 min; range: 4-19 min). Ten min after CA, phosphorylation of cAMP-dependent protein kinase-A on Thr197 and SERCA2 decreased markedly; and parallelly, mitochondrial complex II and IV activities decreased, and caspase 3/7 activity raised significantly. These results did not differ when donors with higher WLST to CA times (≥9 min) were analyzed separately. In human cardiomyocytes, the period from WLST to CA and the first 10 min after CA were not associated with a significant compromise in cellular function or viability. These findings may help to incorporate DCD into heart transplant programs.
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Affiliation(s)
- Silvia Sánchez‐Cámara
- Biomedical Research Institute Virgen de la Arrixaca (IMIB‐Arrixaca)MurciaSpain,Intensive Medicine ServiceHospital Virgen de la ArrixacaMurciaSpain
| | - Mari C. Asensio‐López
- Biomedical Research Institute Virgen de la Arrixaca (IMIB‐Arrixaca)MurciaSpain,Medicine DepartmentUniversity of MurciaMurciaSpain
| | - Mario Royo‐Villanova
- Biomedical Research Institute Virgen de la Arrixaca (IMIB‐Arrixaca)MurciaSpain,Intensive Medicine ServiceHospital Virgen de la ArrixacaMurciaSpain,Transplant Coordination UnitHospital Virgen de la ArrixacaMurciaSpain
| | - Fernando Soler
- Biochemistry and Molecular Biology DepartmentUniversity of MurciaMurciaSpain
| | - Rubén Jara‐Rubio
- Biomedical Research Institute Virgen de la Arrixaca (IMIB‐Arrixaca)MurciaSpain,Intensive Medicine ServiceHospital Virgen de la ArrixacaMurciaSpain
| | | | - Eduardo Pinar
- Biomedical Research Institute Virgen de la Arrixaca (IMIB‐Arrixaca)MurciaSpain,Medicine DepartmentUniversity of MurciaMurciaSpain
| | - Álvaro Hernández‐Vicente
- Biomedical Research Institute Virgen de la Arrixaca (IMIB‐Arrixaca)MurciaSpain,Medicine DepartmentUniversity of MurciaMurciaSpain
| | | | - Antonio Lax
- Biomedical Research Institute Virgen de la Arrixaca (IMIB‐Arrixaca)MurciaSpain,Medicine DepartmentUniversity of MurciaMurciaSpain
| | - Domingo A. Pascual‐Figal
- Biomedical Research Institute Virgen de la Arrixaca (IMIB‐Arrixaca)MurciaSpain,Medicine DepartmentUniversity of MurciaMurciaSpain,Centro Nacional de Investigaciones Cardiovasculares (CNIC)MadridSpain,CIBERCVMadridSpain
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34
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Wall AE, Fiedler A, Karp S, Shah A, Testa G. Applying the ethical framework for donation after circulatory death to thoracic normothermic regional perfusion procedures. Am J Transplant 2022; 22:1311-1315. [PMID: 35040263 DOI: 10.1111/ajt.16959] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 01/25/2023]
Abstract
The novel approach of thoracic normothermic regional perfusion (TA-NRP) for in-situ preservation of organs prior to removal presents a new series of ethical questions about donation after circulatory determination of death (DCD) procedures. This manuscript describes the framework used for the analysis of ethical acceptability of DCD donation and analyzes the specific practice of TA-NRP DCD within that framework to demonstrate that TA-NRP DCD can be performed within the ethical boundaries of DCD donation. We argue that TA-NRP DCD organ procurements meet the ethical standards of informed consent, non-maleficence, adherence to the dead donor rule, and irreversibility, and as such, are ethically acceptable. We also describe the potential benefits of TA-NRP DCD procedures that result from higher organ yields and better recipient outcomes. Finally, we call for open and transparent support of TA-NRP DCD by professional organizations as a necessary cornerstone for the advancement of TA-NRP DCD procedures.
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Affiliation(s)
- Anji E Wall
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Amy Fiedler
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Seth Karp
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish Shah
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Giuliano Testa
- Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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35
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Villar-García S, Martín-López CE, Pérez-Redondo M, Hernández-Pérez FJ, Martínez-López D, de Villarreal-Soto JE, Ríos-Rosado EC, Vera-Puente B, Ospina-Mosquera VM, Serrano-Fiz S, Forteza-Gil A. Donación en asistolia controlada: cómo iniciar un programa. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Clamping of the Aortic Arch Vessels During Normothermic Regional Perfusion After Circulatory Death Prevents the Return of Brain Activity in a Porcine Model. Transplantation 2022; 106:1763-1769. [PMID: 35066546 DOI: 10.1097/tp.0000000000004047] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The cerebral effect of clamping following normothermic regional perfusion (NRP) in donation after circulatory death (DCD) remains unknown. We investigated the effect of cerebral reperfusion during NRP and the preventive effect of clamping on brain function in a porcine model. METHODS In 16 pigs, intracranial physiological parameters were recorded, including pressure, cerebral blood perfusion (CBF), temperature, and oxygen. Additionally, electroencephalography (EEG) and somatosensory evoked potentials (SSEPs) were used to assess brain function. The animals were cannulated for the heart-lung machine, and baseline measurements were performed before withdrawal from life support. After 8 min of mechanical asystole, the animals were randomly allocated to clamp (n = 8) or nonclamp (n = 8) of the aortic arch vessels. After 30 min of NRP, the animals were monitored for 3 h after weaning (AW). RESULTS Intracranial measurements of CBF, oxygen, and temperature indicated successful occlusion of the arch vessels following NRP and AW in the clamp group versus the nonclamp group. In the clamp group, EEG was isoelectric and SSEPs were absent AW in all pigs. In the nonclamp group, EEG activity was observed in all 8 pigs, whereas SSEPs were observed in 6 of 8 pigs. Additionally, agonal respiratory movements in the form of gasping were observed in 6 of 8 pigs in the nonclamp group. CONCLUSIONS Reperfusion of the brain during NRP led to a return of brain activity. Conversely, clamping of the arch vessels halted cerebral circulation, ensuring the permanent cessation of brain function and maintaining the determination of death in DCD.
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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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38
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Abstract
PURPOSE OF REVIEW To highlight the current global experience with DCD heart transplantation and explore the evolution of, and compare preservation strategies; examine early clinical outcomes, and discuss the growing use of DCD donors as a new frontier in heart transplantation. RECENT FINDINGS The two strategies of DCD heart preservation include NMP using the OCS Heart and TA-NRP followed by either: NMP or CSS. Better understanding the limits of cold ischaemia following TA-NRP will aid in distant procurement. Asystolic warm ischaemia plays an important role in determining immediate post-operative graft function and potential need for mechanical support. Large volume DCD heart transplant units show no difference in survival between DCD and DBD donor heart transplants. In a previously non-utilised source of donor hearts, often viewed as an "unknown frontier" in heart transplantation, DCD hearts are a suitable alternative to brain-dead donor hearts and are likely to remain a permanent part of the heart transplantation landscape. Global uptake is currently increasing, and as understanding of preservation strategies and tolerable ischaemic times improve, utilisation of DCD hearts will continue to grow.
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39
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Padilla M, Coll E, Fernández-Pérez C, Pont T, Ruiz Á, Pérez-Redondo M, Oliver E, Atutxa L, Manciño JM, Daga D, Miñambres E, Moya J, Vidal B, Dueñas-Jurado JM, Mosteiro F, Rodríguez-Salgado A, Fernández-García E, Lara R, Hernández-Marrero D, Estébanez B, Rodríguez-Ferrero ML, Barber M, García-López F, Andrés A, Santiago C, Zapatero A, Badenes R, Carrizosa F, Blanco JJ, Bernal JL, Elola FJ, Vidal C, Terrón C, Castro P, Comas J, Domínguez-Gil B. Improved short-term outcomes of kidney transplants in controlled donation after the circulatory determination of death with the use of normothermic regional perfusion. Am J Transplant 2021; 21:3618-3628. [PMID: 33891793 DOI: 10.1111/ajt.16622] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/26/2021] [Accepted: 04/16/2021] [Indexed: 01/25/2023]
Abstract
Normothermic regional perfusion (NRP) allows the in situ perfusion of organs with oxygenated blood in donation after the circulatory determination of death (DCDD). We aimed at evaluating the impact of NRP on the short-term outcomes of kidney transplants in controlled DCDD (cDCDD). This is a multicenter, nationwide, retrospective study comparing cDCDD kidneys obtained with NRP versus the standard rapid recovery (RR) technique. During 2012-2018, 2302 cDCDD adult kidney transplants were performed in Spain using NRP (n = 865) or RR (n = 1437). The study groups differed in donor and recipient age, warm, and cold ischemic time and use of ex situ machine perfusion. Transplants in the NRP group were more frequently performed in high-volume centers (≥90 transplants/year). Through matching by propensity score, two cohorts with a total of 770 patients were obtained. After the matching, no statistically significant differences were observed between the groups in terms of primary nonfunction (p = .261) and mortality at 1 year (p = .111). However, the RR of kidneys was associated with a significantly increased odds of delayed graft function (OR 1.97 [95% CI 1.43-2.72]; p < .001) and 1-year graft loss (OR 1.77 [95% CI 1.01-3.17]; p = .034). In conclusion, compared with RR, NRP appears to improve the short-term outcomes of cDCDD kidney transplants.
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Affiliation(s)
| | | | - Cristina Fernández-Pérez
- Preventive Medicine and Public Health Department, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain.,Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
| | - Teresa Pont
- Donation and Transplantation Coordination Unit, Hospital Universitario Vall d'Hebrón, Barcelona, Spain.,Vall d'Hebron Barcelona Hospital Campus, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Ángel Ruiz
- Donation and Transplantation Coordination Unit, Hospital Clinic, Barcelona, Spain
| | - Marina Pérez-Redondo
- Donation and Transplantation Coordination Unit, Hospital Universitario Puerta de Hierro- Majadahona, Madrid, Spain
| | - Eva Oliver
- Donation and Transplantation Coordination Unit, Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Lander Atutxa
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital Universitario de Donostia, San Sebastián, Spain
| | - José M Manciño
- Intensive Care Department, Hospital Universitario Germans Trias i Pujol, Badalona, Spain
| | - Domingo Daga
- Intensive Care Department, Regional Donor Transplant Coordination, Hospital Universitario Virgen de la Victoria de Málaga, Málaga, Spain
| | - Eduardo Miñambres
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain.,School of Medicine, University of Cantabria, Santander, Spain
| | - José Moya
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Bárbara Vidal
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | | | - Fernando Mosteiro
- Donation and Transplantion Coordination Unit, Complejo Hospitalario Universitario de A Coruña, La Coruña, Spain
| | - Alberto Rodríguez-Salgado
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | | | - Ramón Lara
- Intensive Care Department, Hospital Universitario Virgen de las Nieves, Regional Donor Transplant Coordination in Granada, Granada, Spain
| | - Domingo Hernández-Marrero
- Nephrology Department, Instituto de Investigación Biomédica de Málaga (IBIMA) REDINREN RD16/0009/0006, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Belén Estébanez
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital Universitario La Paz, Madrid, Spain
| | | | - María Barber
- Intensive Care Department, Donation and Transplantation Coordination Unit, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Fernando García-López
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital General Universitario de Albacete, Albacete, Spain
| | - Amado Andrés
- Nephrology Department, Donation and Transplantation Coordination Unit, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Carlos Santiago
- Nephrology Department, Donation and Transplantation Coordination Unit, Hospital General Universitario de Alicante, Alicante, Spain
| | - Ana Zapatero
- Donation and Transplantation Coordination Unit, Hospital del Mar, Barcelona, Spain
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Department of Surgery, University of Valencia, Valencia, Spain.,INCLIVA, Research Health Institute, Valencia, Spain
| | - Francisco Carrizosa
- Intensive Care Department, Donation and Transplantation Coordination Unit, Hospital Universitario de Jerez de la Frontera, Jerez de la Frontera, Spain
| | - José J Blanco
- Intensive Care Department, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - José L Bernal
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain.,Management Control Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Francisco J Elola
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
| | | | | | - Pablo Castro
- Coordinación Autonómica de Trasplantes de Andalucía, Sevilla, Spain
| | - Jordi Comas
- Organització Catalana de Trasplantaments, Barcelona, Spain
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40
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Domínguez-Gil B, Ascher N, Capron AM, Gardiner D, Manara AR, Bernat JL, Miñambres E, Singh JM, Porte RJ, Markmann JF, Dhital K, Ledoux D, Fondevila C, Hosgood S, Van Raemdonck D, Keshavjee S, Dubois J, McGee A, Henderson GV, Glazier AK, Tullius SG, Shemie SD, Delmonico FL. Expanding controlled donation after the circulatory determination of death: statement from an international collaborative. Intensive Care Med 2021; 47:265-281. [PMID: 33635355 PMCID: PMC7907666 DOI: 10.1007/s00134-020-06341-7] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/21/2020] [Indexed: 12/14/2022]
Abstract
A decision to withdraw life-sustaining treatment (WLST) is derived by a conclusion that further treatment will not enable a patient to survive or will not produce a functional outcome with acceptable quality of life that the patient and the treating team regard as beneficial. Although many hospitalized patients die under such circumstances, controlled donation after the circulatory determination of death (cDCDD) programs have been developed only in a reduced number of countries. This International Collaborative Statement aims at expanding cDCDD in the world to help countries progress towards self-sufficiency in transplantation and offer more patients the opportunity of organ donation. The Statement addresses three fundamental aspects of the cDCDD pathway. First, it describes the process of determining a prognosis that justifies the WLST, a decision that should be prior to and independent of any consideration of organ donation and in which transplant professionals must not participate. Second, the Statement establishes the permanent cessation of circulation to the brain as the standard to determine death by circulatory criteria. Death may be declared after an elapsed observation period of 5 min without circulation to the brain, which confirms that the absence of circulation to the brain is permanent. Finally, the Statement highlights the value of perfusion repair for increasing the success of cDCDD organ transplantation. cDCDD protocols may utilize either in situ or ex situ perfusion consistent with the practice of each country. Methods to accomplish the in situ normothermic reperfusion of organs must preclude the restoration of brain perfusion to not invalidate the determination of death.
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Affiliation(s)
| | - Nancy Ascher
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Alexander M Capron
- Scott H. Bice Chair in Healthcare Law, Policy and Ethics, Department of Medicine and Law, University of Southern California, Los Angeles, CA, USA
| | - Dale Gardiner
- Intensive Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alexander R Manara
- Consultant in Intensive Care Medicine, The Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - James L Bernat
- Department of Neurology and Medicine, Active Emeritus, Dartmouth Geisel School of Medicine, Hanover, NH, USA
| | - Eduardo Miñambres
- Transplant Coordination Unit and Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - Jeffrey M Singh
- University of Toronto, and Trillium Gift of Life Network, Toronto, Canada
| | - Robert J Porte
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - James F Markmann
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kumud Dhital
- Department of Cardiothoracic Surgery, Sant Vincent'S Hospital, Sidney, Australia
| | - Didier Ledoux
- Department of Anesthesia and Intensive Care, University of Liège, Liège, Belgium
| | - Constantino Fondevila
- General and Digestive Surgery, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Sarah Hosgood
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Dirk Van Raemdonck
- University Hospitals Leuven and Catholic University Leuven, Leuven, Belgium
| | - Shaf Keshavjee
- Toronto General Hospital, University of Toronto, Toronto, Canada
| | - James Dubois
- Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Andrew McGee
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane City, Australia
| | - Galen V Henderson
- Director of Neurocritical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Stefan G Tullius
- Division of Transplant Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sam D Shemie
- Pediatric Intensive Care, Montreal Children's Hospital, McGill University, Medical Advisor, Deceased Donation, Canadian Blood Services, Montreal, Canada
| | - Francis L Delmonico
- Chief Medical Officer, New England Donor Services, 60 1st Ave, Waltham, MA, 02451, USA.
- Department of Surgery, Harvard Medical School at Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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