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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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2
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Derse AR. An Ethics Committee's Evaluation of Normothermic Regional Perfusion (NRP) in 2018-Unsatisfactory Answers Then-and Now. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:34-37. [PMID: 38829600 DOI: 10.1080/15265161.2024.2336800] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
An adult university hospital ethics committee evaluated a proposed TA-NRP protocol in the fall of 2018. The protocol raised ethical concerns about violation of the Uniform Determination of Death Act and the prohibition known as the Dead Donor Rule, with potential resultant legal consequences. An additional concern was the potential for increased mistrust by the community of organ donation and transplantation. The ethics committee evaluated the responses to these concerns as unable to surmount the ethical and legal boundaries and the ethics committee declined to endorse the procedure. These concerns endure.
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3
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Ahmed HF, Kulshrestha K, Kennedy JT, Gomez-Guzman A, Greenberg JW, Hossain MM, Zhang Y, D'Alessandro DA, John R, Moazami N, Chin C, Ashfaq A, Zafar F, Morales DLS. Donation after circulatory death significantly reduces waitlist times while not changing post-heart transplant outcomes: A United Network for Organ Sharing Analysis. J Heart Lung Transplant 2024; 43:461-470. [PMID: 37863451 PMCID: PMC10922468 DOI: 10.1016/j.healun.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/02/2023] [Accepted: 10/10/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Recently, several centers in the United States have begun performing donation after circulatory death (DCD) heart transplants (HTs) in adults. We sought to characterize the recent use of DCD HT, waitlist time, and outcomes compared to donation after brain death (DBD). METHODS Using the United Network for Organ Sharing database, 10,402 adult (aged >18 years) HT recipients from January 2019 to June 2022 were identified: 425 (4%) were DCD and 9,977 (96%) were DBD recipients. Posttransplant outcomes in matched and unmatched cohorts and waitlist times were compared between groups. RESULTS DCD and DBD recipients had similar age (57 years for both, p = 0.791). DCD recipients were more likely White (67% vs 60%, p = 0.002), on left ventricular assist device (LVAD; 40% vs 32%, p < 0.001), and listed as status 4 to 6 (60% vs 24%, p < 0.001); however, less likely to require inotropes (22% vs 40%, p < 0.001) and preoperative extracorporeal membrane oxygenation (0.9% vs 6%, p < 0.001). DCD donors were younger (29 vs 32 years, p < 0.001) and had less renal dysfunction (15% vs 39%, p < 0.001), diabetes (1.9% vs 3.8%, p = 0.050), or hypertension (9.9% vs 16%, p = 0.001). In matched and unmatched cohorts, early survival was similar (p = 0.22). Adjusted waitlist time was shorter in DCD group (21 vs 31 days, p < 0.001) compared to DBD cohort and 5-fold shorter (DCD: 22 days vs DBD: 115 days, p < 0.001) for candidates in status 4 to 6, which was 60% of DCD cohort. CONCLUSIONS The community is using DCD mostly for those recipients who are expected to have extended waitlist times (e.g., durable LVADs, status >4). DCD recipients had similar posttransplant early survival and shorter adjusted waitlist time compared to DBD group. Given this early success, efforts should be made to expand the donor pool using DCD, especially for traditionally disadvantaged recipients on the waitlist.
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Affiliation(s)
- Hosam F Ahmed
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kevin Kulshrestha
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John T Kennedy
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Amalia Gomez-Guzman
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jason W Greenberg
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Md Monir Hossain
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David A D'Alessandro
- Division of Cardiothoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ranjit John
- Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Nader Moazami
- Department of Cardiothoracic Surgery, New York University (NYU) Langone Health, New York, New York
| | - Clifford Chin
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Awais Ashfaq
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Farhan Zafar
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David L S Morales
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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4
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Jou S, Mendez SR, Feinman J, Mitrani LR, Fuster V, Mangiola M, Moazami N, Gidea C. Heart transplantation: advances in expanding the donor pool and xenotransplantation. Nat Rev Cardiol 2024; 21:25-36. [PMID: 37452122 DOI: 10.1038/s41569-023-00902-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023]
Abstract
Approximately 65 million adults globally have heart failure, and the prevalence is expected to increase substantially with ageing populations. Despite advances in pharmacological and device therapy of heart failure, long-term morbidity and mortality remain high. Many patients progress to advanced heart failure and develop persistently severe symptoms. Heart transplantation remains the gold-standard therapy to improve the quality of life, functional status and survival of these patients. However, there is a large imbalance between the supply of organs and the demand for heart transplants. Therefore, expanding the donor pool is essential to reduce mortality while on the waiting list and improve clinical outcomes in this patient population. A shift has occurred to consider the use of organs from donors with hepatitis C virus, HIV or SARS-CoV-2 infection. Other advances in this field have also expanded the donor pool, including opt-out donation policies, organ donation after circulatory death and xenotransplantation. We provide a comprehensive overview of these various novel strategies, provide objective data on their safety and efficacy, and discuss some of the unresolved issues and controversies of each approach.
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Affiliation(s)
- Stephanie Jou
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA.
| | - Sean R Mendez
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
| | - Jason Feinman
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
| | - Lindsey R Mitrani
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
| | - Valentin Fuster
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
| | - Massimo Mangiola
- Transplant Institute, New York University Langone Health, New York, NY, USA
| | - Nader Moazami
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA
| | - Claudia Gidea
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA
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5
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Schroeder SE. Mechanical Circulatory Support Therapy in the Cardiac Intensive Care Unit. Nurs Clin North Am 2023; 58:421-437. [PMID: 37536790 DOI: 10.1016/j.cnur.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Mechanical circulatory support (MCS) includes temporary and durable mechanical devices used for two sets of indications: 1. acute heart failure (HF) secondary sepsis, a myocardial infarction, or pulmonary emboli, and 2. for chronic end-stage HF secondary to worsening cardiomyopathy despite guideline driven medical treatment. This article is to aide cardiac intensive care unit (ICU) nurses in understanding the history of MCS therapy, the care of the MCS patient in the cardiac ICU, the critical and collaborative role of transplant teams with MCS therapy, educational needs for a successful discharge, and implications for education and shared decision-making when placing these devices.
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Affiliation(s)
- Sarah E Schroeder
- Mechanical Circulatory Support Nurse Practitioner and Program Manager, Bryan Heart, 1600 South 48th Street, Suite 600, Lincoln, NE 68506, USA.
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6
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Hosseini M, Stawiarski KM, Ramakrishna H. Donation After Circulatory Death (DCD) Heart Transplantation- Analysis of Recent Data. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00374-9. [PMID: 37438181 DOI: 10.1053/j.jvca.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/03/2023] [Indexed: 07/14/2023]
Affiliation(s)
| | | | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Brown MB, Abramowicz AE, Panzica PJ, Weber G. Anesthetic Considerations of Organ Procurement After Brain and Cardiac Death: A Narrative Review. Cureus 2023; 15:e40629. [PMID: 37476138 PMCID: PMC10355135 DOI: 10.7759/cureus.40629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 07/22/2023] Open
Abstract
Organ donation procedures have become more frequent in the US as the need for transplants is increasing. Defining the anesthesiologist's role in organ donations after brain and cardiac death is important, as is understanding its ethics and practical physiologic and perioperative implications. Despite this, there are few papers specifically addressing the anesthetic management of organ donors. This review summarizes the preoperative, intraoperative, and postmortem considerations for the anesthesiologist involved in organ donation after either brain or cardiac death. A search of the published literature was performed using PubMed, Excerpta Medica dataBASE (EMBASE), and Google Scholar in March of 2022 for articles addressing anesthetic considerations of organ procurement surgeries after brain and cardiac death. This review demonstrates that anesthesiologists play a significant role in the organ procurement process. Their role in the perioperative management of the donor may affect the outcomes of organ transplantation. The gap between the number of organs harvested and the number of patients awaiting organ transplantation remains high despite continued efforts to increase the number of available organs. Perioperative management of organ donors aims at counteracting the associated unique physiologic derangements and targets optimization of oxygenation of the organs intended for procurement. Optimizing care after death can help ensure the viability of organs and the best outcomes for recipients. As organ donation after cardiac death (DCD) becomes more frequent in the US, anesthesiologists should be aware of the DCD classifications of donors and emerging novel perfusion techniques.
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Affiliation(s)
| | - Apolonia E Abramowicz
- Department of Anesthesiology, Westchester Medical Center, Valhalla, USA
- School of Medicine, New York Medical College, Valhalla, USA
| | - Peter J Panzica
- Department of Anesthesiology, Westchester Medical Center, Valhalla, USA
- School of Medicine, New York Medical College, Valhalla, USA
| | - Garret Weber
- Department of Anesthesiology, Westchester Medical Center, Valhalla, USA
- School of Medicine, New York Medical College, Valhalla, USA
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8
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Andersen ND, Bryner BS, Aughtman SL, Kang L, Carboni MP, Casalinova S, Turek JW, Schroder JN. A report of the first pediatric heart transplant following donation after circulatory death in the United States using ex-vivo perfusion. J Heart Lung Transplant 2023; 42:287-288. [PMID: 36280565 DOI: 10.1016/j.healun.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/28/2022] [Accepted: 09/22/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
- Nicholas D Andersen
- Duke Children's Pediatric & Congenital Heart Center, Duke University Medical Center, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Benjamin S Bryner
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Lillian Kang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael P Carboni
- Duke Children's Pediatric & Congenital Heart Center, Duke University Medical Center, Durham, North Carolina; Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Sarah Casalinova
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Joseph W Turek
- Duke Children's Pediatric & Congenital Heart Center, Duke University Medical Center, Durham, North Carolina; Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob N Schroder
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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9
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Hatami S, Conway J, Freed DH, Urschel S. Thoracic organ donation after circulatory determination of death. TRANSPLANTATION REPORTS 2023. [DOI: 10.1016/j.tpr.2022.100125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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10
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Roesel MJ, Wiegmann B, Ius F, Knosalla C, Iske J. The role of ex-situ perfusion for thoracic organs. Curr Opin Organ Transplant 2022; 27:466-473. [PMID: 35950888 DOI: 10.1097/mot.0000000000001008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Ex-situ machine perfusion for both heart (HTx) and lung transplantation (LuTx) reduces ischemia-reperfusion injury (IRI), allows for greater flexibility in geographical donor management, continuous monitoring, organ assessment for extended evaluation, and potential reconditioning of marginal organs. In this review, we will delineate the impact of machine perfusion, characterize novel opportunities, and outline potential challenges lying ahead to improve further implementation. RECENT FINDINGS Due to the success of several randomized controlled trials (RCT), comparing cold storage to machine perfusion in HTx and LuTx, implementation and innovation continues. Indeed, it represents a promising interface for organ-specific therapies targeting IRI, allo-immune responses, and graft reconditioning. These mostly experimental efforts range from genetic approaches and nanotechnology to cellular therapies, involving mesenchymal stem cell application. Despite tremendous potential, prior to clinical transition, more data is needed. SUMMARY Collectively, machine perfusion constitutes the vanguard in thoracic organ transplantation research with extensive potential for expanding the donor pool, enhancing transplant outcomes as well as developing novel therapy approaches.
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Affiliation(s)
- Maximilian J Roesel
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
- Institute of Medical Immunology, Charite Universitaetsmedizin Berlin, Berlin, Germany
| | - Bettina Wiegmann
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- DFG Priority Program SPP 2014, German Research Foundation, Bonn, Germany
| | - Fabio Ius
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Jasper Iske
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
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11
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Okumura K, Misawa R, Ohira S, Dhand A, Kai M, Sogawa H, Veillette G, John D, Diflo T, Nishida S. Does utilization of heart machine perfusion for donation after cardiac death transplantation affect outcomes of other abdominal transplanted organs? Clin Transplant 2022; 36:e14751. [PMID: 35706100 DOI: 10.1111/ctr.14751] [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: 05/01/2022] [Revised: 05/15/2022] [Accepted: 06/03/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Machine perfusion of heart for donation after circulatory death (DCD) is being increasingly utilized. Current protocols for utilizing heart DCD's machine perfusion might prolong donor warm ischemic time for nonheart organs. The aim of this study was to analyze the effects of utilizing heart machine perfusion on liver and kidney transplants from the same donor. METHODS We analyzed data of DCD donors from the United Network for Organ Sharing (UNOS) from January-2020 to September-2021 among two groups: donors with heart machine perfusion (HM) and without heart machine perfusion (NHM). Propensity score (PS) matching was performed to compare the short-term outcomes of liver and kidney transplants between two groups. RESULTS Total of 102 liver and 319 kidney transplants were performed using organs from donors with HM. After PS matching, no statistically significant difference was seen in 1-year graft survival (GS) for both liver and kidney transplants between two groups (liver HM 90.6% vs. NHM 90.2%, p = .47; kidney HM 95.2% vs. NHM 92.9%, p = .40). There was no difference in the delayed graft function (DGF) rates in kidney transplantation (KT) (HM 42% vs. NHM 35%, p = .062). CONCLUSION Utilization of heart machine perfusion in DCD donors had no significant impact on 1-year outcomes of liver and kidney transplantation.
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Affiliation(s)
- Kenji Okumura
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Ryosuke Misawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Suguru Ohira
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA.,Department of Surgery, Division of Cardiothoracic Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Abhay Dhand
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA.,Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Masashi Kai
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA.,Department of Surgery, Division of Cardiothoracic Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Hiroshi Sogawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Gregory Veillette
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Devon John
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Thomas Diflo
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Seigo Nishida
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
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12
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Madan S, Saeed O, Forest SJ, Goldstein DJ, Jorde UP, Patel SR. Feasibility and Potential Impact of Heart Transplantation From Adult Donors After Circulatory Death. J Am Coll Cardiol 2021; 79:148-162. [PMID: 34922742 DOI: 10.1016/j.jacc.2021.10.042] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/18/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND A shortage of donation after brain death (DBD) donors for heart transplantation (HT) persists. Recent improvements in organ procurement from donation after circulatory death (DCD) donors and promising early results of DCD-HTs from Europe and Australia have renewed interest in DCD-HT. OBJECTIVES The current study evaluated donor and recipient characteristics, early outcomes, and potential impact of adult DCD-HT in the United States. METHODS The United Network for Organ Sharing registry was used to identify and compare adult DCD donors based on their use for HT between January 2020 and February 2021. Adult DCD-HTs with available post-HT outcomes data were compared with contemporary adult DBD-HTs during study period using Cox-regression analysis and propensity-matching. RESULTS Of the 3,611 adult DCD donors referred during the study period, 136 were used for HT. DCD donors used for HT were younger (median age 29 years), and most were male (90%), and blood type O (79%). On comparing DCD-HT (n = 127) and DBD-HT (n = 2,961) meeting study criteria and with available data on post-HT outcomes, there was no significant difference in 30-day or 6-month mortality, primary graft failure up to 30 days, or other outcomes including in-hospital stroke, pacemaker insertion, hemodialysis, and post-HT length of hospital stay. Results were similar in propensity matched DCD-HT and DBD-HT cohorts. The number of potential adult DCD donors referred has increased substantially (n = 871 in 2010 to n = 3,045 in 2020), and the authors estimated that widespread adoption of DCD-HT could lead to approximately 300 additional adult HTs in the United States annually. CONCLUSIONS This preliminary analysis of adult DCD-HTs from the United States showed favorable early outcomes and suggested a potential for substantial increase in adult HT volumes with use of DCD donors.
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Affiliation(s)
- Shivank Madan
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Omar Saeed
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Stephen J Forest
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Daniel J Goldstein
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Snehal R Patel
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
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13
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Da Silveira Cavalcante L, Tessier SN. Zebrafish as a New Tool in Heart Preservation Research. J Cardiovasc Dev Dis 2021; 8:39. [PMID: 33917701 PMCID: PMC8068018 DOI: 10.3390/jcdd8040039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/05/2021] [Accepted: 04/07/2021] [Indexed: 12/25/2022] Open
Abstract
Heart transplantation became a reality at the end of the 1960s as a life-saving option for patients with end-stage heart failure. Static cold storage (SCS) at 4-6 °C has remained the standard for heart preservation for decades. However, SCS only allows for short-term storage that precludes optimal matching programs, requires emergency surgeries, and results in the unnecessary discard of organs. Among the alternatives seeking to extend ex vivo lifespan and mitigate the shortage of organs are sub-zero or machine perfusion modalities. Sub-zero approaches aim to prolong cold ischemia tolerance by deepening metabolic stasis, while machine perfusion aims to support metabolism through the continuous delivery of oxygen and nutrients. Each of these approaches hold promise; however, complex barriers must be overcome before their potential can be fully realized. We suggest that one barrier facing all experimental efforts to extend ex vivo lifespan are limited research tools. Mammalian models are usually the first choice due to translational aspects, yet experimentation can be restricted by expertise, time, and resources. Instead, there are instances when smaller vertebrate models, like the zebrafish, could fill critical experimental gaps in the field. Taken together, this review provides a summary of the current gold standard for heart preservation as well as new technologies in ex vivo lifespan extension. Furthermore, we describe how existing tools in zebrafish research, including isolated organ, cell specific and functional assays, as well as molecular tools, could complement and elevate heart preservation research.
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Affiliation(s)
- Luciana Da Silveira Cavalcante
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 2114, USA;
- Shriners Hospitals for Children, Boston, MA 2114, USA
| | - Shannon N. Tessier
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 2114, USA;
- Shriners Hospitals for Children, Boston, MA 2114, USA
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14
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Javier MFDM, Javier Delmo EM, Hetzer R. Heart transplantation: the Berlin experience and perspectives. Cardiovasc Diagn Ther 2021; 11:243-253. [PMID: 33708496 DOI: 10.21037/cdt-20-290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In patients with end-stage heart failure, heart transplants are now an ingrained practice, as they provide satisfying long-term results with good predictability and quality of life. The successful outcome has evolved from the development of effective immunosuppression, recognition of allograft rejection through diagnostic modalities and improvement in donor organ perfusion. Unfortunately, transplant availability is constrained by the shortage of donor organs and is therefore considered a casuistic therapy. The outcome is defined by unwanted effects of immunosuppressants, increased tumor occurrence and chronic transplant angiopathies. In the long term, patients fear primarily the occurrence of renal insufficiency and secondly osteoporosis with its skeletal complications and corresponding pain. Nevertheless, the overall quality of life is not very limited; on the contrary, patients demonstrate a surprisingly meaningful lives 10-20 years after the transplant. Their physical presentation is similar to those with varying co-morbidities. Most of the 20-year surviving patients are physically active and happy with their daily lives. Medical ambition has seen heart transplantation become reality and develop into an influential force regarding heart surgery, immunology, pharmacology, organ logistics and medical ethics. Its development has also molded our definitions of death and has driven public and health care approval of medical advances. It has provided a strong solidarity among politicians, sociologists, physicians and citizens. Problems regarding ethics continue to endure, and will forecast heart transplants as a defining, but temporary era in human medicine. The donor organ shortage has stimulated the use of resuscitated donor hearts and encouraged exploration and advancement of mechanical circulatory support systems and xenotransplantation as alternatives in the management of end-stage heart failure.
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Zhang H, Viveiros A, Nikhanj A, Nguyen Q, Wang K, Wang W, Freed DH, Mullen JC, MacArthur R, Kim DH, Tymchak W, Sergi CM, Kassiri Z, Wang S, Oudit GY. The Human Explanted Heart Program: A translational bridge for cardiovascular medicine. Biochim Biophys Acta Mol Basis Dis 2021; 1867:165995. [PMID: 33141063 PMCID: PMC7581399 DOI: 10.1016/j.bbadis.2020.165995] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 10/12/2020] [Accepted: 10/15/2020] [Indexed: 12/17/2022]
Abstract
The progression of cardiovascular research is often impeded by the lack of reliable disease models that fully recapitulate the pathogenesis in humans. These limitations apply to both in vitro models such as cell-based cultures and in vivo animal models which invariably are limited to simulate the complexity of cardiovascular disease in humans. Implementing human heart tissue in cardiovascular research complements our research strategy using preclinical models. We established the Human Explanted Heart Program (HELP) which integrates clinical, tissue and molecular phenotyping thereby providing a comprehensive evaluation into human heart disease. Our collection and storage of biospecimens allow them to retain key pathogenic findings while providing novel insights into human heart failure. The use of human non-failing control explanted hearts provides a valuable comparison group for the diseased explanted hearts. Using HELP we have been able to create a tissue repository which have been used for genetic, molecular, cellular, and histological studies. This review describes the process of collection and use of explanted human heart specimens encompassing a spectrum of pediatric and adult heart diseases, while highlighting the role of these invaluable specimens in translational research. Furthermore, we highlight the efficient procurement and bio-preservation approaches ensuring analytical quality of heart specimens acquired in the context of heart donation and transplantation.
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Affiliation(s)
- Hao Zhang
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Anissa Viveiros
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Department of Physiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Anish Nikhanj
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Quynh Nguyen
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Kaiming Wang
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Wei Wang
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Darren H Freed
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - John C Mullen
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Roderick MacArthur
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel H Kim
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Wayne Tymchak
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Consolato M Sergi
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Division of Anatomical Pathology, Department of Laboratory Medicine & Pathology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Zamaneh Kassiri
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Department of Physiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Shaohua Wang
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Gavin Y Oudit
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
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Rajab TK, Chen S, Nadig SN, Atkinson C. Surgical Innovation: Heart Transplantation After Cardiac Death. Surg Innov 2020; 28:656-658. [PMID: 33345738 DOI: 10.1177/1553350620975625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Taufiek Konrad Rajab
- Lee Patterson Allen Transplant Immunobiology Laboratory, Department of Surgery, 2345Medical University of South Carolina, USA.,Division of Cardiothoracic Surgery, 2345Medical University of South Carolina, USA
| | - Sarah Chen
- Division of Cardiothoracic Surgery, 2345Medical University of South Carolina, USA
| | - Satish N Nadig
- Lee Patterson Allen Transplant Immunobiology Laboratory, Department of Surgery, 2345Medical University of South Carolina, USA
| | - Carl Atkinson
- Lee Patterson Allen Transplant Immunobiology Laboratory, Department of Surgery, 2345Medical University of South Carolina, USA
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17
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Fernández AR, Sánchez-Tarjuelo R, Cravedi P, Ochando J, López-Hoyos M. Review: Ischemia Reperfusion Injury-A Translational Perspective in Organ Transplantation. Int J Mol Sci 2020; 21:ijms21228549. [PMID: 33202744 PMCID: PMC7696417 DOI: 10.3390/ijms21228549] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 02/07/2023] Open
Abstract
Thanks to the development of new, more potent and selective immunosuppressive drugs together with advances in surgical techniques, organ transplantation has emerged from an experimental surgery over fifty years ago to being the treatment of choice for many end-stage organ diseases, with over 139,000 organ transplants performed worldwide in 2019. Inherent to the transplantation procedure is the fact that the donor organ is subjected to blood flow cessation and ischemia during harvesting, which is followed by preservation and reperfusion of the organ once transplanted into the recipient. Consequently, ischemia/reperfusion induces a significant injury to the graft with activation of the immune response in the recipient and deleterious effect on the graft. The purpose of this review is to discuss and shed new light on the pathways involved in ischemia/reperfusion injury (IRI) that act at different stages during the donation process, surgery, and immediate post-transplant period. Here, we present strategies that combine various treatments targeted at different mechanistic pathways during several time points to prevent graft loss secondary to the inflammation caused by IRI.
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Affiliation(s)
- André Renaldo Fernández
- Immunology, Universitary Hospital Marqués de Valdecilla- Research Institute IDIVAL Santander, 390008 Santander, Spain;
| | - Rodrigo Sánchez-Tarjuelo
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (R.S.-T.); (J.O.)
- Immunología de Trasplantes, Centro Nacional de Microbiología, Instituto de Salud Carlos III, 28220 Majadahonda (Madrid), Spain
| | - Paolo Cravedi
- Department of Medicine, Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| | - Jordi Ochando
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (R.S.-T.); (J.O.)
- Immunología de Trasplantes, Centro Nacional de Microbiología, Instituto de Salud Carlos III, 28220 Majadahonda (Madrid), Spain
| | - Marcos López-Hoyos
- Immunology, Universitary Hospital Marqués de Valdecilla- Research Institute IDIVAL Santander, 390008 Santander, Spain;
- Red de Investigación Renal (REDINREN), 28040 Madrid, Spain
- Correspondence: ; Tel.: +34-942-292759
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Kjaergaard B, Danielsen AV, Simonsen C, Wiberg S. A paramilitary retrieval team for accidental hypothermia. Insights gained from a simple classification with advanced treatment over 16 years in Denmark. Resuscitation 2020; 156:114-119. [DOI: 10.1016/j.resuscitation.2020.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/20/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
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Rajab TK, Jaggers J, Campbell DN. Donation after circulatory death determination pediatric heart transplantation and 10-year outcomes. J Heart Lung Transplant 2020; 39:491-492. [DOI: 10.1016/j.healun.2020.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/10/2020] [Accepted: 02/12/2020] [Indexed: 12/11/2022] Open
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20
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Rajab TK, Jaggers J, Campbell DN. Heart transplantation following donation after cardiac death: History, current techniques, and future. J Thorac Cardiovasc Surg 2020; 161:1335-1340. [PMID: 32245667 DOI: 10.1016/j.jtcvs.2020.02.085] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/02/2020] [Accepted: 02/08/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Taufiek Konrad Rajab
- Division of Congenital Cardiac Surgery, Children's Hospital Colorado, University of Colorado, Aurora, Colo.
| | - James Jaggers
- Division of Congenital Cardiac Surgery, Children's Hospital Colorado, University of Colorado, Aurora, Colo
| | - David N Campbell
- Division of Congenital Cardiac Surgery, Children's Hospital Colorado, University of Colorado, Aurora, Colo
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Honarmand K, Parsons Leigh J, Basmaji J, Martin CM, Sibbald R, Nagpal D, Lau V, Priestap F, De S, Healey A, Dhanani S, Weiss MJ, Shemie S, Ball IM. Attitudes of healthcare providers towards cardiac donation after circulatory determination of death: a Canadian nation-wide survey. Can J Anaesth 2020; 67:301-312. [PMID: 31898778 DOI: 10.1007/s12630-019-01559-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/19/2019] [Accepted: 08/19/2019] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The number of patients on cardiac transplant waitlists exceeds the number of available donor organs. Cardiac donation is currently limited to those declared dead by neurologic criteria in all but three countries. Cardiac donation after circulatory determination of death (cardiac DCDD) can be conducted using direct procurement and perfusion (DPP) or normothermic regional perfusion (NRP). Implementation of cardiac DCDD in many countries has been slowed by ethical debates within the donation and transplantation community. We conducted a national survey to determine the perceptions of healthcare providers regarding cardiac DCDD. METHODS We conducted an electronic survey of 398 healthcare providers who are involved in the management of heart donors and/or heart transplant recipients in Canada (226 nurses, 82 critical care physicians, 31 donation specialists, and 59 transplant specialists). Our primary outcomes were their attitudes towards and concerns regarding cardiac DCDD protocols and their implementation in Canada. We distributed the survey electronically through several Canadian donation and transplantation organizations. RESULTS We identified that 361 of 391 respondents (92.3%; 95% confidence interval [CI], 89.6 to 95.1) believed that DPP is acceptable, and 329 of 377 respondents (87.3%; 95% CI, 83.9 to 90.7) supported its implementation in Canada. We found that 301 of 384 respondents (78.4%; 95% CI, 74.2 to 82.6) believed that NRP is acceptable and 266 of 377 respondents (70.6%; 95% CI, 66.0 to 75.2) supported its implementation in Canada. CONCLUSION This is the first survey describing the attitudes of healthcare providers towards cardiac DCDD. We identified widespread support for cardiac DCDD and its implementation in Canada among Canadian healthcare providers within the organ donation and transplantation community in Canada.
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Affiliation(s)
- Kimia Honarmand
- Department of Medicine, Western University, London Health Sciences Centre, London, ON, Canada.
| | - Jeanna Parsons Leigh
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - John Basmaji
- Department of Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Claudio M Martin
- Department of Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Robert Sibbald
- Department of Family Medicine, Western University, London, ON, Canada
| | - Dave Nagpal
- Department of Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Vince Lau
- Department of Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Fran Priestap
- Department of Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Sabe De
- Division of Cardiology, Western University, London, ON, Canada
| | - Andrew Healey
- Trillium Gift of Life Network, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sonny Dhanani
- Department of Pediatrics, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Division of Pediatric Critical Care, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Matthew J Weiss
- Division of Pediatric Intensive Care, Centre-Mère Enfant Soleil du CHU de Québec, Québec City, QC, Canada
- Department of Pediatrics, Faculté de Médecine, Université Laval, Québec City, QC, Canada
- Population Health and Optimal Health Practices Research Unit, Traumatology-Emergency-Critical Care Medicine, Université Laval, CHU de Québec - Université Laval Research Center, Québec City, QC, Canada
| | - Sam Shemie
- Deceased Organ Donation, Canadian Blood Services and Division of Critical Care Medicine, Montreal Children's Hospital and McGill University Health Centre & Research Institute, Montreal, QC, Canada
| | - Ian M Ball
- Department of Medicine, Western University, London Health Sciences Centre, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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22
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Jawitz OK, Milano C. Is it time for the United States to engage in heart transplantation using donation after circulatory death? J Thorac Cardiovasc Surg 2019; 159:512-513. [PMID: 31679700 DOI: 10.1016/j.jtcvs.2019.07.147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Carmelo Milano
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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23
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Sweitzer NK. Apophenia and the Crafting of a Circulation: Heart Failure Issue. Circ Heart Fail 2019; 11:e005027. [PMID: 29664410 DOI: 10.1161/circheartfailure.118.005027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nancy K Sweitzer
- From the Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson.
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