1
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Hoffman JRH, Hartwig MG, Cain MT, Rove JY, Siddique A, Urban M, Mulligan MS, Bush EL, Balsara K, Demarest CT, Silvestry SC, Wilkey B, Trahanas JM, Pretorius VG, Shah AS, Moazami N, Pomfret EA, Catarino PA. Consensus Statement: Technical Standards for Thoracoabdominal Normothermic Regional Perfusion. Ann Thorac Surg 2024; 118:778-791. [PMID: 39023462 DOI: 10.1016/j.athoracsur.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Thoracoabdominal normothermic regional perfusion (TA-NRP) has emerged as a powerful technique for optimizing organ procurement from donation after circulatory death donors. Despite its rapid adoption, standardized guidelines for TA-NRP implementation are lacking, prompting the need for consensus recommendations to ensure safe and effective utilization of this technique. METHODS A working group composed of members from The American Society of Transplant Surgeons, The International Society of Heart and Lung Transplantation, The Society of Thoracic Surgeons, and The American Association for Thoracic Surgery was convened to develop technical guidelines for TA-NRP. The group systematically reviewed existing literature, consensus statements, and expert opinions to identify key areas requiring standardization, including predonation evaluation, intraoperative management, postdonation procedures, and future research directions. RESULTS The working group formulated recommendations encompassing donor evaluation and selection criteria, premortem testing and therapeutic interventions, communication protocols, and procedural guidelines for TA-NRP implementation. These recommendations aim to facilitate coordination among transplant teams, minimize variability in practice, and promote transparency and accountability throughout the TA-NRP process. CONCLUSIONS The consensus guidelines presented herein serve as a comprehensive framework for the successful and ethical implementation of TA-NRP programs in organ procurement from donation after circulatory death donors. By providing standardized recommendations and addressing areas of uncertainty, these guidelines aim to enhance the quality, safety, and efficiency of TA-NRP procedures, ultimately contributing to improved outcomes for transplant recipients.
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Affiliation(s)
- Jordan R H Hoffman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Matthew G Hartwig
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael T Cain
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Jessica Y Rove
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Aleem Siddique
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Marian Urban
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Michael S Mulligan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - Errol L Bush
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Medicine, Baltimore, Maryland
| | - Keki Balsara
- Department of Cardiothoracic Surgery, MedStar Washington Hospital Center, Washington, DC
| | - Caitlin T Demarest
- Section of Surgical Sciences, Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Barbara Wilkey
- Department of Anesthesia, Section of Cardiothoracic Anesthesia, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - John M Trahanas
- Section of Surgical Sciences, Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Victor G Pretorius
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of California, San Diego, California
| | - Ashish S Shah
- Section of Surgical Sciences, Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, New York
| | - Elizabeth A Pomfret
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado.
| | - Pedro A Catarino
- Department of Cardiac Surgery, Cedars Sinai Medical Center, Los Angeles, California
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2
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Allen ES, Stephens LD, Weber N, Brubaker AL, Hudson K, Pretorius V, Schnickel G, Kopko PM. Providing red blood cells to facilitate organ transplant via normothermic perfusion techniques: A single-center experience. Transfusion 2024. [PMID: 39180488 DOI: 10.1111/trf.17994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/30/2024] [Accepted: 08/08/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Normothermic regional perfusion (NRP) and normothermic machine perfusion (NMP) are organ procurement and transport techniques that can improve organ quality, facilitate longer transport, and reduce postoperative complications, increasing organ availability and improving outcomes. NRP and NMP often require allogeneic red blood cells (RBCs). Our academic transfusion service began providing RBCs to support NRP and NMP for adult heart transplant (HT), orthotopic liver transplant (OLT), and multiorgan transplant (MOT) in August 2020. METHODS This single-center, retrospective study describes the implementation process and analyzes the characteristics of RBC support during the first 3 years of the perfusion programs. Timing and quantity of units issued and used, organ recipient demographics, and transplant outcomes were obtained from transfusion service and electronic medical records. RESULTS From 2020 to 2023, the transfusion service received 233 requests to support NRP and NMP perfusion cases. Of these, 105 cases resulted in RBC use, and units were returned or discarded in 112 cases. A total of 131 patients received perfusion-facilitated transplants (92 HT, 27 OLT, and 12 MOT). The majority of perfusion-facilitated HTs utilized NRP (81/92, 88%), whereas most perfusion-facilitated OLTs utilized NMP (21/27, 78%). Across all 233 requests, a total of 381 RBC units were used to facilitate 131 transplants, averaging 2.91 units/transplant. DISCUSSION Provision of RBCs for NRP and NMP techniques represents a novel method for transfusion services to support and facilitate life-saving organ transplants with only modest product use, about three RBC units per organ transplant in this single-center study.
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Affiliation(s)
- Elizabeth S Allen
- Department of Pathology, University of California San Diego, La Jolla, California, USA
| | - Laura D Stephens
- Department of Pathology, University of California San Diego, La Jolla, California, USA
| | - Nesinee Weber
- University of California San Diego Health, La Jolla, California, USA
| | - Aleah L Brubaker
- Division of Transplant and Hepatobiliary Surgery, Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Ken Hudson
- University of California San Diego Health, La Jolla, California, USA
| | - Victor Pretorius
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Gabriel Schnickel
- Division of Transplant and Hepatobiliary Surgery, Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Patricia M Kopko
- Department of Pathology, University of California San Diego, La Jolla, California, USA
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Hoffman JRH, Hartwig MG, Cain MT, Rove JY, Siddique A, Urban M, Mulligan MS, Bush EL, Balsara K, Demarest CT, Silvestry SC, Wilkey B, Trahanas JM, Pretorius VG, Shah AS, Moazami N, Pomfret EA, Catarino PA. Consensus Statement: Technical Standards for Thoracoabdominal Normothermic Regional Perfusion. Transplantation 2024; 108:1669-1680. [PMID: 39012953 DOI: 10.1097/tp.0000000000005101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
BACKGROUND Thoracoabdominal normothermic regional perfusion (TA-NRP) has emerged as a powerful technique for optimizing organ procurement from donation after circulatory death donors. Despite its rapid adoption, standardized guidelines for TA-NRP implementation are lacking, prompting the need for consensus recommendations to ensure safe and effective utilization of this technique. METHODS A working group composed of members from The American Society of Transplant Surgeons, The International Society of Heart and Lung Transplantation, The Society of Thoracic Surgeons, and The American Association for Thoracic Surgery was convened to develop technical guidelines for TA-NRP. The group systematically reviewed existing literature, consensus statements, and expert opinions to identify key areas requiring standardization, including predonation evaluation, intraoperative management, postdonation procedures, and future research directions. RESULTS The working group formulated recommendations encompassing donor evaluation and selection criteria, premortem testing and therapeutic interventions, communication protocols, and procedural guidelines for TA-NRP implementation. These recommendations aim to facilitate coordination among transplant teams, minimize variability in practice, and promote transparency and accountability throughout the TA-NRP process. CONCLUSIONS The consensus guidelines presented herein serve as a comprehensive framework for the successful and ethical implementation of TA-NRP programs in organ procurement from donation after circulatory death donors. By providing standardized recommendations and addressing areas of uncertainty, these guidelines aim to enhance the quality, safety, and efficiency of TA-NRP procedures, ultimately contributing to improved outcomes for transplant recipients.
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Affiliation(s)
- Jordan R H Hoffman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Matthew G Hartwig
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Michael T Cain
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Jessica Y Rove
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Aleem Siddique
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Marian Urban
- Division of Cardiothoracic Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Michael S Mulligan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA
| | - Errol L Bush
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Medicine, Baltimore, MD
| | - Keki Balsara
- Department of Cardiothoracic Surgery, MedStar Washington Hospital Center, Washington, DC
| | - Caitlin T Demarest
- Section of Surgical Sciences, Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Barbara Wilkey
- Department of Anesthesia, Section of Cardiothoracic Anesthesia, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - John M Trahanas
- Section of Surgical Sciences, Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Victor G Pretorius
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of California, San Diego, CA
| | - Ashish S Shah
- Section of Surgical Sciences, Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, NY
| | - Elizabeth A Pomfret
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Pedro A Catarino
- Department of Cardiac Surgery, Cedars Sinai Medical Center, Los Angeles, CA
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Alarfaj M, Shah Z. Pro: Normothermic Regional Perfusion Should Be Utilized in Orthotopic Heart Transplantation. J Cardiothorac Vasc Anesth 2024; 38:1808-1811. [PMID: 38834444 DOI: 10.1053/j.jvca.2024.03.031] [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] [Received: 03/17/2024] [Accepted: 03/22/2024] [Indexed: 06/06/2024]
Affiliation(s)
- Mohammad Alarfaj
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS; Internal Medicine Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Zubair Shah
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS
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Wall A, Gupta A, Testa G. Abdominal normothermic regional perfusion in the United States: current state and future directions. Curr Opin Organ Transplant 2024; 29:175-179. [PMID: 38506730 DOI: 10.1097/mot.0000000000001144] [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: 03/21/2024]
Abstract
PURPOSE OF REVIEW Normothermic regional perfusion (NRP) is a novel procurement technique for donation after circulatory death (DCD) in the United States. It was pioneered by cardiothoracic surgery programs and is now being applied to abdominal-only organ donors by abdominal transplant programs. RECENT FINDINGS Liver and kidney transplantation from thoracoabdominal NRP (TA-NRP) donors in the United States was found to have lower rates of delayed kidney graft function and similar graft and patient survival versus recipients of cardiac super rapid recovery (SRR) DCD donors. The excellent outcomes with NRP have prompted the expansion of NRP technology to abdominal transplant programs. SUMMARY Excellent early outcomes with liver and kidney transplantation have prompted the growth of NC-NRP procurement for abdominal-only DCD donors across the US, and now requires standardization of technical and nontechnical aspects of this procedure.
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Brubaker AL, Sellers MT, Abt PL, Croome KP, Merani S, Wall A, Abreu P, Alebrahim M, Baskin R, Bohorquez H, Cannon RM, Cederquist K, Edwards J, Huerter BG, Hobeika MJ, Kautzman L, Langnas AN, Lee DD, Manzi J, Nassar A, Neidlinger N, Nydam TL, Schnickel GT, Siddiqui F, Suah A, Taj R, Taner CB, Testa G, Vianna R, Vyas F, Montenovo MI. US Liver Transplant Outcomes After Normothermic Regional Perfusion vs Standard Super Rapid Recovery. JAMA Surg 2024; 159:677-685. [PMID: 38568597 PMCID: PMC10993160 DOI: 10.1001/jamasurg.2024.0520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/06/2024] [Indexed: 04/06/2024]
Abstract
Importance Normothermic regional perfusion (NRP) is an emerging recovery modality for transplantable allografts from controlled donation after circulatory death (cDCD) donors. In the US, only 11.4% of liver recipients who are transplanted from a deceased donor receive a cDCD liver. NRP has the potential to safely expand the US donor pool with improved transplant outcomes as compared with standard super rapid recovery (SRR). Objective To assess outcomes of US liver transplants using controlled donation after circulatory death livers recovered with normothermic regional perfusion vs standard super rapid recovery. Design, Setting, and Participants This was a retrospective, observational cohort study comparing liver transplant outcomes from cDCD donors recovered by NRP vs SRR. Outcomes of cDCD liver transplant from January 2017 to May 2023 were collated from 17 US transplant centers and included livers recovered by SRR and NRP (thoracoabdominal NRP [TA-NRP] and abdominal NRP [A-NRP]). Seven transplant centers used NRP, allowing for liver allografts to be transplanted at 17 centers; 10 centers imported livers recovered via NRP from other centers. Exposures cDCD livers were recovered by either NRP or SRR. Main Outcomes and Measures The primary outcome was ischemic cholangiopathy (IC). Secondary end points included primary nonfunction (PNF), early allograft dysfunction (EAD), biliary anastomotic strictures, posttransplant length of stay (LOS), and patient and graft survival. Results A total of 242 cDCD livers were included in this study: 136 recovered by SRR and 106 recovered by NRP (TA-NRP, 79 and A-NRP, 27). Median (IQR) NRP and SRR donor age was 30.5 (22-44) years and 36 (27-49) years, respectively. Median (IQR) posttransplant LOS was significantly shorter in the NRP cohort (7 [5-11] days vs 10 [7-16] days; P < .001). PNF occurred only in the SRR allografts group (n = 2). EAD was more common in the SRR cohort (123 of 136 [56.1%] vs 77 of 106 [36.4%]; P = .007). Biliary anastomotic strictures were increased 2.8-fold in SRR recipients (7 of 105 [6.7%] vs 30 of 134 [22.4%]; P = .001). Only SRR recipients had IC (0 vs 12 of 133 [9.0%]; P = .002); IC-free survival by Kaplan-Meier was significantly improved in NRP recipients. Patient and graft survival were comparable between cohorts. Conclusion and Relevance There was comparable patient and graft survival in liver transplant recipients of cDCD donors recovered by NRP vs SRR, with reduced rates of IC, biliary complications, and EAD in NRP recipients. The feasibility of A-NRP and TA-NRP implementation across multiple US transplant centers supports increasing adoption of NRP to improve organ use, access to transplant, and risk of wait-list mortality.
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Affiliation(s)
- Aleah L. Brubaker
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
| | - Marty T. Sellers
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Tennessee Donor Services, Nashville
| | - Peter L. Abt
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - Kristopher P. Croome
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Transplant, Mayo Clinic Florida, Jacksonville
| | - Shaheed Merani
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, University of Nebraska Medical Center, Omaha
| | - Anji Wall
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Phillipe Abreu
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | | | - Roy Baskin
- Methodist Transplant Specialists, Dallas, Texas
| | - Humberto Bohorquez
- Department of Surgery, Ochsner School of Medicine, New Orleans, Louisiana
| | - Robert M. Cannon
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Kelly Cederquist
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - John Edwards
- Gift of Life Donor Program, Philadelphia, Pennsylvania
| | | | - Mark J. Hobeika
- J.C. Walter Jr Transplant Center, Houston Methodist Hospital, Houston, Texas
| | | | - Alan N. Langnas
- Department of Surgery, University of Nebraska Medical Center, Omaha
| | - David D. Lee
- Department of Surgery, Loyola University, Chicago, Illinois
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Joao Manzi
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | - Ahmed Nassar
- Department of Surgery, Emory University, Atlanta, Georgia
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | | | - Trevor L. Nydam
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Division of Transplant Surgery, University of Colorado, Aurora
| | - Gabriel T. Schnickel
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
| | - Farjad Siddiqui
- Department of Surgery, The Ohio State University, Columbus
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Ashley Suah
- Department of Surgery, Emory University, Atlanta, Georgia
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Raeda Taj
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | | | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Rodrigo Vianna
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | - Frederick Vyas
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - Martin I. Montenovo
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Vanderbilt University, Nashville, Tennessee
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