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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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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] [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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Zong J, Ye W, Yu J, Zhang X, Cui J, Chen Z, Li Y, Wang S, Ran S, Niu Y, Luo Z, Li X, Zhao J, Hao Y, Xia J, Wu J. Outcomes of Heart Transplantation From Donation After Circulatory Death: An Up-to-Date Systematic Meta-analysis. Transplantation 2024:00007890-990000000-00720. [PMID: 38578698 DOI: 10.1097/tp.0000000000005017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
BACKGROUND Donation after circulatory death (DCD) heart transplantation (HTx) significantly expands the donor pool and reduces waitlist mortality. However, high-level evidence-based data on its safety and effectiveness are lacking. This meta-analysis aimed to compare the outcomes between DCD and donation after brain death (DBD) HTxs. METHODS Databases, including MEDLINE, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials, were systematically searched for randomized controlled trials and observational studies reporting the outcomes of DCD and DBD HTxs published from 2014 onward. The data were pooled using random-effects models. Risk ratios (RRs) with 95% confidence intervals (CIs) were used as the summary measures for categorical outcomes and mean differences were used for continuous outcomes. RESULTS Twelve eligible studies were included in the meta-analysis. DCD HTx was associated with lower 1-y mortality rate (DCD 8.13% versus DBD 10.24%; RR = 0.75; 95% CI, 0.59-0.96; P = 0.02) and 5-y mortality rate (DCD 14.61% versus DBD 20.57%; RR = 0.72; 95% CI, 0.54-0.97; P = 0.03) compared with DBD HTx. CONCLUSIONS Using the current DCD criteria, HTx emerges as a promising alternative to DBD transplantation. The safety and feasibility of DCD hearts deserve further exploration and investigation.
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Affiliation(s)
- Junjie Zong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Center for Translational Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Weicong Ye
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Center for Translational Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jizhang Yu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xi Zhang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jikai Cui
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhang Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Center for Translational Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yuan Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Song Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shuan Ran
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yuqing Niu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zilong Luo
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaohan Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jiulu Zhao
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yanglin Hao
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jiahong Xia
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Center for Translational Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, Hubei, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei, China
- Institute of Translational Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jie Wu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Center for Translational Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Key Laboratory of Organ Transplantation, Ministry of Education, Chinese Academy of Medical Sciences, Wuhan, Hubei, China
- NHC Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei, China
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei, China
- Institute of Translational Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Dann TM, Spencer BL, Wilhelm SK, Drake SK, Bartlett RH, Rojas-Pena A, Drake DH. Donor heart refusal after circulatory death: An analysis of United Network for Organ Sharing refusal codes. JTCVS OPEN 2024; 18:91-103. [PMID: 38690428 PMCID: PMC11056494 DOI: 10.1016/j.xjon.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 05/02/2024]
Abstract
Objective Donor hearts procured after circulatory death (DCD) may significantly increase the number of hearts available for transplantation. The purpose of this study was to analyze current DCD and brain-dead donor (DBD) heart transplantation rates and characterize organ refusal using the most up-to-date United Network for Organ Sharing (UNOS) and Organ Procurement and Transplantation Network data. Methods We analyzed UNOS and Organ Procurement and Transplantation Network DBD and DCD candidate, transplantation, and demographic data from 2020 through 2022 and 2022 refusal code data to characterize DCD heart use and refusal. Subanalyses were performed to characterize DCD donor demographics and regional transplantation rate variance. Results DCD hearts were declined 3.37 times more often than DBD hearts. The most frequently used code for DCD refusal was neurologic function, related to concerns of a prolonged dying process and organ preservation. In 2022, 92% (1329/1452) of all DCD refusals were attributed to neurologic function. When compared with DBD, DCD donor hearts were more frequently declined as the result of prolonged warm ischemic time (odds ratio, 5.65; 95% confidence interval, 4.07-7.86) and other concerns over organ preservation (odds ratio, 4.06; 95% confidence interval, 3.33-4.94). Transplantation rate variation was observed between demographic groups and UNOS regions. DCD transplantation rates are currently experiencing second order polynomial growth. Conclusions DCD donor hearts are declined more frequently than DBD. DCD heart refusals result from concerns over a prolonged dying process and organ preservation. Heart transplantation rates may be substantially improved by ex situ hemodynamic assessment, adoption of normothermic regional perfusion guidelines, and quality initiatives.
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Affiliation(s)
- Tyler M. Dann
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, Mich
| | - Brianna L. Spencer
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, Mich
| | - Spencer K. Wilhelm
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, Mich
| | - Sarah K. Drake
- Information School, University of Wisconsin, Madison, Wis
| | - Robert H. Bartlett
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, Mich
| | - Alvaro Rojas-Pena
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, Mich
- Department of Surgery, Section of Transplantation, University of Michigan Medical School, Ann Arbor, Mich
| | - Daniel H. Drake
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, Mich
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Mich
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5
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Bakhtiyar SS, Maksimuk TE, Gutowski J, Park SY, Cain MT, Rove JY, Reece TB, Cleveland JC, Pomposelli JJ, Bababekov YJ, Nydam TL, Schold JD, Pomfret EA, Hoffman JRH. Association of procurement technique with organ yield and cost following donation after circulatory death. Am J Transplant 2024:S1600-6135(24)00237-5. [PMID: 38521350 DOI: 10.1016/j.ajt.2024.03.027] [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: 01/13/2024] [Revised: 03/15/2024] [Accepted: 03/15/2024] [Indexed: 03/25/2024]
Abstract
Donation after circulatory death (DCD) could account for the largest expansion of the donor allograft pool in the contemporary era. However, the organ yield and associated costs of normothermic regional perfusion (NRP) compared to super-rapid recovery (SRR) with ex-situ normothermic machine perfusion, remain unreported. The Organ Procurement and Transplantation Network (December 2019 to June 2023) was analyzed to determine the number of organs recovered per donor. A cost analysis was performed based on our institution's experience since 2022. Of 43 502 donors, 30 646 (70%) were donors after brain death (DBD), 12 536 (29%) DCD-SRR and 320 (0.7%) DCD-NRP. The mean number of organs recovered was 3.70 for DBD, 3.71 for DCD-NRP (P < .001), and 2.45 for DCD-SRR (P < .001). Following risk adjustment, DCD-NRP (adjusted odds ratio 1.34, confidence interval 1.04-1.75) and DCD-SRR (adjusted odds ratio 2.11, confidence interval 2.01-2.21; reference: DBD) remained associated with greater odds of allograft nonuse. Including incomplete and completed procurement runs, the total average cost of DCD-NRP was $9463.22 per donor. By conservative estimates, we found that approximately 31 donor allografts could be procured using DCD-NRP for the cost equivalent of 1 allograft procured via DCD-SRR with ex-situ normothermic machine perfusion. In conclusion, DCD-SRR procurements were associated with the lowest organ yield compared to other procurement methods. To facilitate broader adoption of DCD procurement, a comprehensive understanding of the trade-offs inherent in each technique is imperative.
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Affiliation(s)
- Syed Shahyan Bakhtiyar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA.
| | - Tiffany E Maksimuk
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - John Gutowski
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - Sarah Y Park
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Michael T Cain
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - Jessica Y Rove
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - T Brett Reece
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - Joseph C Cleveland
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
| | - James J Pomposelli
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Yanik J Bababekov
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Trevor L Nydam
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Jesse D Schold
- Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
| | - Elizabeth A Pomfret
- University of Colorado Hospital Transplant Center, Aurora, Colorado, USA; Division of Transplant Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA
| | - Jordan R H Hoffman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado, USA; University of Colorado Hospital Transplant Center, Aurora, Colorado, USA
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Motter JD, Jaffe IS, Moazami N, Smith DE, Kon ZN, Piper GL, Sommer PM, Reyentovich A, Chang SH, Aljabban I, Montgomery RA, Segev DL, Massie AB, Lonze BE. Single center utilization and post-transplant outcomes of thoracoabdominal normothermic regional perfusion deceased cardiac donor organs. Clin Transplant 2024; 38:e15269. [PMID: 38445531 DOI: 10.1111/ctr.15269] [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: 10/11/2023] [Revised: 01/26/2024] [Accepted: 02/09/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Thoracoabdominal normothermic regional perfusion (TA-NRP) following cardiac death is an emerging multivisceral organ procurement technique. Recent national studies on outcomes of presumptive TA-NRP-procured organs are limited by potential misclassification since TA-NRP is not differentiated from donation after cardiac death (DCD) in registry data. METHODS We studied 22 donors whose designees consented to TA-NRP and organ procurement performed at our institution between January 20, 2020 and July 3, 2022. We identified these donors in SRTR to describe organ utilization and recipient outcomes and compared them to recipients of traditional DCD (tDCD) and donation after brain death (DBD) organs during the same timeframe. RESULTS All 22 donors progressed to cardiac arrest and underwent TA-NRP followed by heart, lung, kidney, and/or liver procurement. Median donor age was 41 years, 55% had anoxic brain injury, 45% were hypertensive, 0% were diabetic, and median kidney donor profile index was 40%. TA-NRP utilization was high across all organ types (88%-100%), with a higher percentage of kidneys procured via TA-NRP compared to tDCD (88% vs. 72%, p = .02). Recipient and graft survival ranged from 89% to 100% and were comparable to tDCD and DBD recipients (p ≥ .2). Delayed graft function was lower for kidneys procured from TA-NRP compared to tDCD donors (27% vs. 44%, p = .045). CONCLUSION Procurement from TA-NRP donors yielded high organ utilization, with outcomes comparable to tDCD and DBD recipients across organ types. Further large-scale study of TA-NRP donors, facilitated by its capture in the national registry, will be critical to fully understand its impact as an organ procurement technique.
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Affiliation(s)
- Jennifer D Motter
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Ian S Jaffe
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Deane E Smith
- Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Zachary N Kon
- Department of Cardiothoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Greta L Piper
- Department of Cardiothoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Philip M Sommer
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Alex Reyentovich
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Stephanie H Chang
- Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Imad Aljabban
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Surgery, Columbia University School of Medicine, New York, New York, USA
| | - Robert A Montgomery
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Dorry L Segev
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
- Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | - Allan B Massie
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Bonnie E Lonze
- Department of Surgery, NYU Grossman School of Medicine, New York, New York, USA
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Abstract
PURPOSE OF REVIEW The use of cardiac transplantation following circulatory death (DCD) has been limited worldwide. Concerns about cardiac function after warm ischemia and the potential for decreased graft function have been important considerations in this hesitancy. In addition, ethical and legal questions about the two widely used organ procurement methods have led to discussions and public education in many countries. RECENT FINDINGS Publication of a US randomized trial of cardiac transplantation following DCD has shown that it is both feasible and has similar short-term outcomes compared with cardiac transplantation following brain death (DBD). These data support those from both Australia and the UK who have largest experience to date. SUMMARY The adoption of cardiac transplantation following circulatory death has increased overall cardiac transplantation in those transplant centers who have incorporated these donors. Short term outcomes for DCD organ procurement methods are similar to those outcomes using DBD hearts. Continued study and standardization of warm ischemic times will allow for better comparisons of organ procurement techniques and organ optimization. The ethical concerns about procurement methods, in addition to a discussion of procurement costs and feasibility will need to be addressed further in the efforts to expand the organ pool and increase overall cardiac transplantation numbers.
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Affiliation(s)
- Savitri Fedson
- Michael E. DeBakey VA Medical Center, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
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8
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Zhou AL, Leng A, Ruck JM, Akbar AF, Desai NM, King EA. Kidney Donation After Circulatory Death Using Thoracoabdominal Normothermic Regional Perfusion: The Largest Report of the United States Experience. Transplantation 2024; 108:516-523. [PMID: 37691154 PMCID: PMC10840803 DOI: 10.1097/tp.0000000000004801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
BACKGROUND Thoracoabdominal normothermic regional perfusion (TA-NRP) has been increasingly used for donation after circulatory death (DCD) procurements in the United States. We present the largest report of outcomes of kidney transplants performed using DCD donor grafts perfused with TA-NRP. METHODS Adult DCD kidney transplants between 2020 and 2022 in the United Network for Organ Sharing database were included. Donors with ≥50 min between asystole and aortic cross-clamp time in which the heart was also transplanted were considered TA-NRP donors. All other donors were considered direct recovery donors. Multivariable regressions were used to assess delayed graft function, as well as posttransplant survival and all-cause graft failure at 30, 90, and 180 d. A propensity-matched analysis of cohorts matched on donor Kidney Donor Profile Index was performed. RESULTS Of the 16 140 total DCD kidney transplants performed during the study period, 306 (1.9%) used TA-NRP. TA-NRP donors were younger ( P < 0.001) and had lower Kidney Donor Profile Index ( P < 0.001) compared with direct recovery donors. Recipients receiving grafts recovered using TA-NRP were younger ( P < 0.001) and more likely to be blood group O ( P < 0.001). Transplants using TA-NRP had lower likelihood of delayed graft function (adjusted odds ratio 0.22 [95% confidence interval, 0.15-0.31], P < 0.001) but similar 180-d survival ( P = 0.8) and all-cause graft failure ( P = 0.3) as transplants using direct recovery grafts. These inferences were unchanged on propensity-matched analysis. CONCLUSIONS Our results demonstrate that kidney transplants using TA-NRP DCD allografts have positive short-term mortality and graft survival outcomes, with significantly decreased rates of delayed graft function compared with direct recovery DCD grafts.
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Affiliation(s)
- Alice L. Zhou
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Albert Leng
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jessica M. Ruck
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Armaan F. Akbar
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Niraj M. Desai
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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9
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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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10
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Spencer PJ, Saddoughi SA, Choi K, Dickinson TA, Richman A, Reynolds FA, Villavicencio MA. Heart-Lung Transplantation From Donation After Circulatory Death Using Mobile Normothermic Regional Perfusion. ASAIO J 2024; 70:e13-e15. [PMID: 37549658 DOI: 10.1097/mat.0000000000002029] [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: 08/09/2023] Open
Abstract
Combined heart-lung transplant (HTLx) is the most durable treatment available for end-stage heart and lung failure. Many patients are unable to receive combined organs due to organ availability and allocation policies prioritizing separate heart or lung transplantation. While an average of 45 HTLxs have been performed per year in the United States half the listed patients do not receive organs. Recently, donation after circulatory death (DCD) utilizing normothermic regional perfusion (NRP) has been utilized for heart allografts with excellent results, and here, we present a case utilizing mobile NRP to procure a heart and lung block from a circulatory death donor and successful implantation for a recipient in a separate center.
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Affiliation(s)
- Philip J Spencer
- From the Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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11
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DiChiacchio L, Goodwin ML, Kagawa H, Griffiths E, Nickel IC, Stehlik J, Selzman CH. Heart Transplant and Donors After Circulatory Death: A Clinical-Preclinical Systematic Review. J Surg Res 2023; 292:222-233. [PMID: 37657140 DOI: 10.1016/j.jss.2023.07.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 09/03/2023]
Abstract
INTRODUCTION Heart transplantation is the treatment of choice for end-stage heart failure. There is a mismatch between the number of donor hearts available and the number of patients awaiting transplantation. Expanding the donor pool is critically important. The use of hearts donated following circulatory death is one approach to increasing the number of available donor hearts. MATERIALS AND METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines utilizing Pubmed/MEDLINE and Embase. Articles including adult human studies and preclinical animal studies of heart transplantation following donation after circulatory death were included. Studies of pediatric populations or including organs other than heart were excluded. RESULTS Clinical experience and preclinical studies are reviewed. Clinical experience with direct procurement, normothermic regional perfusion, and machine perfusion are included. Preclinical studies addressing organ function assessment and enhancement of performance of marginal organs through preischemic, procurement, preservation, and reperfusion maneuvers are included. Articles addressing the ethical considerations of thoracic transplantation following circulatory death are also reviewed. CONCLUSIONS Heart transplantation utilizing organs procured following circulatory death is a promising method to increase the donor pool and offer life-saving transplantation to patients on the waitlist living with end-stage heart failure. There is robust ongoing preclinical and clinical research to optimize this technique and improve organ yield. There are also ongoing ethical considerations that must be addressed by consensus before wide adoption of this approach.
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Affiliation(s)
- Laura DiChiacchio
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Matthew L Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Hiroshi Kagawa
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Eric Griffiths
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Ian C Nickel
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Josef Stehlik
- Division of Cardiology, University of Utah, Salt Lake City, Utah
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah.
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12
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Cain MT, Park SY, Schäfer M, Hay-Arthur E, Justison GA, Zhan QP, Campbell D, Mitchell JD, Randhawa SK, Meguid RA, David EA, Reece TB, Cleveland JC, Hoffman JR. Lung recovery utilizing thoracoabdominal normothermic regional perfusion during donation after circulatory death: The Colorado experience. JTCVS Tech 2023; 22:350-358. [PMID: 38152164 PMCID: PMC10750961 DOI: 10.1016/j.xjtc.2023.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/22/2023] [Accepted: 09/21/2023] [Indexed: 12/29/2023] Open
Abstract
Objective Donation after circulatory death (DCD) procurement and transplantation after thoracoabdominal normothermic regional perfusion (TA-NRP) remains a novel technique to improve cardiac and hepatic allograft preservation but may be complicated by lung allograft pulmonary edema. We present a single-center series on early implementation of a lung-protective protocol with strategies to mitigate posttransplant pulmonary edema in DCD lung allografts after TA-NRP procurement. Methods Data from all lung transplantations performed using a TA-NRP procurement strategy from October 2022 to April 2023 are presented. Donor management consisted of key factors to reduce lung allograft pulmonary edema: aggressive predonation and early posttransplant diuresis, complete venous drainage at TA-NRP initiation, and early pulmonary artery venting upon initiation of systemic perfusion. Donor and recipient characteristics, procurement characteristics such as TA-NRP intervals, and 30-day postoperative outcomes were assessed. Results During the study period, 8 lung transplants were performed utilizing TA-NRP procurement from DCD donors. Donor ages ranged from 16 to 39 years and extubation time to declaration of death ranged from 10 to 90 minutes. Time from declaration to TA-NRP initiation was 7 to 17 minutes with TA-NRP perfusion times of 49 to 111 minutes. Median left and right allograft warm ischemia times were 55.5 minutes (interquartile range, 46.5-67.5 minutes) and 41.0 minutes (interquartile range, 39.0-53.0 minutes, respectively, with 2 recipients supported with cardiopulmonary bypass or venoarterial extracorporeal membrane oxygenation during implantation. No postoperative extracorporeal membrane oxygenation was required. There were no pulmonary-related deaths; however, 1 patient died from complications of severe necrotizing pancreatitis with a normal functioning allograft. All patients were extubated within 24 hours. Index intensive care unit length of stay ranged from 3 to 11 days with a hospital length of stay of 13 to 37 days. Conclusions Despite concern regarding quality of DCD lung allografts recovered using the TA-NRP technique, we report initial success using this procurement method. Implementation of strategies to mitigate pulmonary edema can result in acceptable outcomes following lung transplantation. Demonstration of short- and long-term safety and efficacy of this technique will become increasingly important as the use of TA-NRP for thoracic and abdominal allografts in DCD donors expands.
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Affiliation(s)
- Michael T. Cain
- Division of Cardiothoracic Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colo
| | - Sarah Y. Park
- Division of Cardiothoracic Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colo
| | - Michal Schäfer
- Division of Cardiothoracic Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colo
| | - Emily Hay-Arthur
- Division of Cardiothoracic Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colo
| | - George A. Justison
- Division of Cardiothoracic Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colo
| | - Qui Peng Zhan
- Division of Cardiothoracic Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colo
| | - David Campbell
- Division of Cardiothoracic Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colo
| | - John D. Mitchell
- Division of Cardiothoracic Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colo
| | - Simran K. Randhawa
- Division of Cardiothoracic Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colo
| | - Robert A. Meguid
- Division of Cardiothoracic Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colo
| | - Elizabeth A. David
- Division of Cardiothoracic Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colo
| | - T. Brett Reece
- Division of Cardiothoracic Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colo
| | - Joseph C. Cleveland
- Division of Cardiothoracic Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colo
| | - Jordan R.H. Hoffman
- Division of Cardiothoracic Surgery, University of Colorado Denver Anschutz Medical Campus, Aurora, Colo
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13
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Wisel SA, Steggerda JA, Thiessen C, Roll GR, Chen Q, Thomas J, Kaur B, Catarino P, Chikwe J, Kim IK. Preserved 2-y Liver Transplant Outcomes Following Simultaneous Thoracoabdominal DCD Organ Procurement Despite Effects on Liver Utilization Rate. Transplant Direct 2023; 9:e1528. [PMID: 37876918 PMCID: PMC10593259 DOI: 10.1097/txd.0000000000001528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/14/2023] [Accepted: 06/30/2023] [Indexed: 10/26/2023] Open
Abstract
Background Current techniques for donation after circulatory determination of death (DCD) heart procurement, through either direct procurement and machine perfusion or thoracoabdominal normothermic regional perfusion (NRP), have demonstrated excellent heart transplant outcomes. However, the impact of thoracoabdominal DCD (TA-DCD) heart procurement on liver allograft outcomes and utilization is poorly understood. Methods One hundred sixty simultaneous heart and liver DCD donors were identified using the United Network for Organ Sharing/Organ Procurement and Transplantation Network database between December 2019 and July 2021. Liver outcomes from TA-DCD donors were stratified by heart procurement technique and evaluated for organ utilization, graft survival, and patient survival. Results were compared with abdominal-only DCD (A-DCD; n = 1332) and donation after brain death (DBD; n = 12 891) liver transplants during the study interval. Kaplan-Meier methods with log-rank testing were used to evaluate patient and graft survival. Results One hundred thirty-three of 160 livers procured from TA-DCD donors proceeded to transplant. TA-DCD donors were younger (mean 28.26 y; P < 0.0001) with lower body mass index (mean 26.61; P < 0.0001) than A-DCD and DBD donors. TA-DCD livers had equivalent patient survival ( P = 0.893) and superior graft survival (P = 0.009) compared with A-DCD. TA-DCD livers had higher rates of organ discard for long warm ischemia time (37.0%) than A-DCD (20.5%) and DBD (0.5%; P < 0.0001), with direct procurement and machine perfusion procurements leading to a higher discard rate (18.5%) than NRP procurements (7.4%). Conclusions Liver transplants after TA-DCD donation demonstrated equivalent patient outcomes and excellent graft outcomes. NRP procurements resulted in the lowest rate of organ discard after DCD donation and may represent an optimal strategy to maximize organ utilization.
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Affiliation(s)
- Steven A. Wisel
- Department of Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Justin A. Steggerda
- Department of Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Carrie Thiessen
- Division of Transplant Surgery, University of Wisconsin, Madison, WI
| | - Garrett R. Roll
- Division of Transplantation, University of California, San Francisco, San Francisco, CA
| | - Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jason Thomas
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Bhupinder Kaur
- Department of Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Pedro Catarino
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Irene K. Kim
- Department of Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
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14
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Siddiqi HK, Trahanas J, Xu M, Wells Q, Farber-Eger E, Pasrija C, Amancherla K, Debose-Scarlett A, Brinkley DM, Lindenfeld J, Menachem JN, Ooi H, Pedrotty D, Punnoose L, Rali AS, Sacks S, Wigger M, Zalawadiya S, McMaster W, Devries S, Shah A, Schlendorf K. Outcomes of Heart Transplant Donation After Circulatory Death. J Am Coll Cardiol 2023; 82:1512-1520. [PMID: 37793748 DOI: 10.1016/j.jacc.2023.08.006] [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: 06/21/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Heart transplantation using donation after circulatory death (DCD) allografts is increasingly common, expanding the donor pool and reducing transplant wait times. However, data remain limited on clinical outcomes. OBJECTIVES We sought to compare 6-month and 1-year clinical outcomes between recipients of DCD hearts, most of them recovered with the use of normothermic regional perfusion (NRP), and recipients of donation after brain death (DBD) hearts. METHODS We conducted a single-center retrospective observational study of all adult heart-only transplants from January 2020 to January 2023. Recipient and donor data were abstracted from medical records and the United Network for Organ Sharing registry, respectively. Survival analysis and Cox regression were used to compare the groups. RESULTS During the study period, 385 adults (median age 57.4 years [IQR: 48.0-63.7 years]) underwent heart-only transplantation, including 122 (32%) from DCD donors, 83% of which were recovered with the use of NRP. DCD donors were younger and had fewer comorbidities than DBD donors. DCD recipients were less often hospitalized before transplantation and less likely to require pretransplantation temporary mechanical circulatory support compared with DBD recipients. There were no significant differences between groups in 1-year survival, incidence of severe primary graft dysfunction, treated rejection during the first year, or likelihood of cardiac allograft vasculopathy at 1 year after transplantation. CONCLUSIONS In the largest single-center comparison of DCD and DBD heart transplantations to date, outcomes among DCD recipients are noninferior to those of DBD recipients. This study adds to the published data supporting DCD donors as a safe means to expand the heart donor pool.
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Affiliation(s)
- Hasan K Siddiqi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - John Trahanas
- Department of Cardiothoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Quinn Wells
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric Farber-Eger
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chetan Pasrija
- Department of Cardiothoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kaushik Amancherla
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alexandra Debose-Scarlett
- Department of Cardiothoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - D Marshall Brinkley
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan N Menachem
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Henry Ooi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Medicine, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Dawn Pedrotty
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Medicine, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Lynn Punnoose
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aniket S Rali
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Suzanne Sacks
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark Wigger
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Medicine, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sandip Zalawadiya
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William McMaster
- Department of Cardiothoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Steven Devries
- Department of Cardiothoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish Shah
- Department of Cardiothoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly Schlendorf
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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15
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Kagawa H, Goodwin M, Stehlik J, Campsen J, Baker T, Selzman CH. A Case Report of Triple Organ Transplantation From a Donor After Circulatory Death Using Thoraco-Abdominal Normothermic Regional Perfusion. Transplant Proc 2023; 55:1883-1887. [PMID: 37612153 DOI: 10.1016/j.transproceed.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023]
Abstract
Organ transplantation with donation after circulatory death can potentially increase the donor pool. Here, we report the rare case of triple-organ (heart/liver/kidney) transplantation from a donor after circulatory death using thoraco-abdominal normothermic regional perfusion. The recipient was a 61-year-old man with end-stage heart failure, liver failure, and kidney failure secondary to arrhythmogenic right ventricular dysplasia. He received a heart/liver/kidney transplantation from a donor after circulatory death. The course was complicated with primary graft dysfunction of the heart that resolved on postoperative day 3. The patient was discharged on postoperative day 39. He has no evidence for rejection on heart biopsy, and all 3 organs exhibit stable function. The use of donation after cardiac death donors greatly increases the donor pool and should be considered for patients requiring multiorgan transplantation. The use of thoraco-abdominal normothermic reperfusion is not only a feasible method for multiorgan procurement but also provides enhanced protection for all transplanted organs.
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Affiliation(s)
- Hiroshi Kagawa
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Matthew Goodwin
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jeffrey Campsen
- Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Talia Baker
- Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
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16
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Frontera JA, Lewis A, James L, Melmed K, Parent B, Raz E, Hussain ST, Smith DE, Moazami N. Thoracoabdominal normothermic regional perfusion in donation after circulatory death does not restore brain blood flow. J Heart Lung Transplant 2023; 42:1161-1165. [PMID: 37211334 DOI: 10.1016/j.healun.2023.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/28/2023] [Accepted: 05/14/2023] [Indexed: 05/23/2023] Open
Abstract
Use of thoracoabdominal normothermic regional perfusion (TA-NRP) during donation after circulatory death (DCD) is an important advance in organ donation. Prior to establishing TA-NRP, the brachiocephalic, left carotid, and left subclavian arteries are ligated, thereby eliminating anterograde brain blood flow via the carotid and vertebral arteries. While theoretical concerns have been voiced that TA-NRP after DCD may restore brain blood flow via collaterals, there have been no studies to confirm or refute this possibility. We evaluated brain blood flow using intraoperative transcranial Doppler (TCD) in two DCD TA-NRP cases. Pre-extubation, anterior and posterior circulation brain blood flow waveforms were present in both cases, similar to the waveforms detected in a control patient on mechanical circulatory support undergoing cardiothoracic surgery. Following declaration of death and initiation of TA-NRP, no brain blood flow was detected in either case. Additionally, there was absence of brainstem reflexes, no response to noxious stimuli and no respiratory effort. These TCD results demonstrate that DCD with TA-NRP did not restore brain blood flow.
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Affiliation(s)
- Jennifer A Frontera
- Department of Neurology, Division of Neurocritical Care, NYU Grossman School of Medicine, New York, New York.
| | - Ariane Lewis
- Department of Neurology, Division of Neurocritical Care, NYU Grossman School of Medicine, New York, New York
| | - Les James
- Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, New York, New York
| | - Kara Melmed
- Department of Neurology, Division of Neurocritical Care, NYU Grossman School of Medicine, New York, New York
| | - Brendan Parent
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Eytan Raz
- Department of Radiology, Division of Neuroradiology, NYU Grossman School of Medicine, New York, New York
| | - Syed T Hussain
- Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, New York, New York
| | - Deane E Smith
- Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, New York, New York
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Grossman School of Medicine, New York, New York
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17
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Kaffka genaamd Dengler SE, Vervoorn MT, Brouwer M, de Jonge J, van der Kaaij NP. Dilemmas concerning heart procurement in controlled donation after circulatory death. Front Cardiovasc Med 2023; 10:1225543. [PMID: 37583588 PMCID: PMC10424927 DOI: 10.3389/fcvm.2023.1225543] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/11/2023] [Indexed: 08/17/2023] Open
Abstract
With an expanding population at risk for heart failure and the resulting increase in patients admitted to the waiting list for heart transplantation, the demand of viable organs exceeds the supply of suitable donor hearts. Use of hearts after circulatory death has reduced this deficit. Two primary techniques for heart procurement in circulatory death donors have been described: direct procurement and perfusion and thoraco-abdominal normothermic regional perfusion. While the former has been accepted as an option for heart procurement in circulatory death donors, the latter technique has raised some ethical questions in relation to the dead donor rule. In this paper we discuss the current dilemmas regarding these heart procurement protocols in circulatory death donors.
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Affiliation(s)
| | - M. T. Vervoorn
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - M. Brouwer
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - J. de Jonge
- Department of Surgery, Erasmus Medical Center Transplant Institute, Rotterdam, Netherlands
| | - N. P. van der Kaaij
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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18
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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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19
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Zhou AL, Ruck JM, Casillan AJ, Larson EL, Shou BL, Karius AK, Ha JS, Shah PD, Merlo CA, Bush EL. Early United States experience with lung donation after circulatory death using thoracoabdominal normothermic regional perfusion. J Heart Lung Transplant 2023; 42:693-696. [PMID: 36990867 PMCID: PMC10192114 DOI: 10.1016/j.healun.2023.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/10/2023] [Accepted: 03/02/2023] [Indexed: 03/11/2023] Open
Abstract
Thoracoabdominal normothermic regional perfusion (TA-NRP) has recently begun being utilized in the United States for recovery of cardiothoracic allografts from some donors after circulatory death (DCD), but data on lungs recovered in this method is limited to case reports. We conducted a national retrospective review of lung transplants from DCD donors recovered using TA-NRP. Of the 434 total DCD lung transplants performed between January 2020 and March 2022, 17 were recovered using TA-NRP. Compared to direct recovery DCD transplants, recipients of TA-NRP DCD transplants had lower likelihood of ventilation >48 hours (23.5% vs 51.3%, p = 0.027) and similar likelihood of predischarge acute rejection, requirement for extracorporeal membrane oxygenation at 72 hours, hospital lengths of stay, and survival at 30, 60, and 90 days post-transplant. These early data suggest that DCD lung recovery using TA-NRP might be a safe way to further expand the donor pool and warrant further study.
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Affiliation(s)
- Alice L Zhou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jessica M Ruck
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Alfred J Casillan
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Emily L Larson
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Benjamin L Shou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Alexander K Karius
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jinny S Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Pali D Shah
- Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Christian A Merlo
- Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
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Gelzinis TA, Ungerman E, Jayaraman AL, Bartels S, Bond JA, Hayanga HK, Patel B, Khoche S, Subramanian H, Ball R, Knight J, Choi C, Ellis S. The Year in Cardiothoracic Transplant Anesthesia: Selected Highlights From 2021 Part II: Cardiac Transplantation. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00339-7. [PMID: 37353423 DOI: 10.1053/j.jvca.2023.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 06/25/2023]
Abstract
This article spotlights the research highlights of this year that specifically pertain to the specialty of anesthesia for heart transplantation. This includes the research on recent developments in the selection and optimization of donors and recipients, including the use of donation after cardiorespiratory death and extended criteria donors, the use of mechanical circulatory support and nonmechanical circulatory support as bridges to transplantation, the effect of COVID-19 on heart transplantation candidates and recipients, and new advances in the perioperative management of these patients, including the use of echocardiography and postoperative outcomes, focusing on renal and cerebral outcomes.
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Affiliation(s)
| | - Elizabeth Ungerman
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Arun L Jayaraman
- Department of Anesthesiology and Perioperative Medicine, Department of Critical Care Medicine, Mayo Clinic, Pheonix, AZ
| | - Steven Bartels
- Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, IL
| | - Jonathan A Bond
- Division of Adult Cardiothoracic Anesthesiology, University of Kentucky, Lexington, KY
| | - Heather K Hayanga
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology, West Virginia University, WV
| | - Bhoumesh Patel
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
| | - Swapnil Khoche
- Department of Anesthesiology, University of California, San Diego, CA
| | - Harikesh Subramanian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Ryan Ball
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Joshua Knight
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Christine Choi
- Department of Anesthesiology, University of California, San Diego, CA
| | - Sarah Ellis
- Department of Anesthesiology, University of California, San Diego, CA
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21
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Anwar IJ, Luo X. Research Highlights. Transplantation 2023; 107:1008-1009. [PMID: 37779417 DOI: 10.1097/tp.0000000000004631] [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)
| | - Xunrong Luo
- Department of Medicine, Division of Nephrology, Duke University, Durham, NC
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Chen Q, Emerson D, Megna D, Osho A, Roach A, Chan J, Rowe G, Gill G, Esmailian F, Chikwe J, Egorova N, Kirklin JK, Kobashigawa J, Catarino P. Heart transplantation using donation after circulatory death in the United States. J Thorac Cardiovasc Surg 2023; 165:1849-1860.e6. [PMID: 36049965 DOI: 10.1016/j.jtcvs.2022.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/14/2022] [Accepted: 05/05/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Heart donation after circulatory death was recently reintroduced in the United States with hopes of increasing donor heart availability. We examined its national use and outcomes. METHODS The United Network for Organ Sharing database was used to identify validated adult patients undergoing heart transplantation using donation after circulatory death donors (n = 266) and donation after brain death donors (n = 5998) between December 1, 2019, and December 31, 2021, after excluding heart-lung transplants. Propensity score matching was used to create more balanced groups for comparison. RESULTS The monthly percentage of donation after circulatory death heart transplant increased from 2.5% in December 2019 to 6.8% in December 2021 (P < .001). Twenty-two centers performed donation after circulatory death heart transplants, ranging from 1 to 75 transplants per center. Four centers performed 70% of the national volume. Recipients of donation after circulatory death hearts were more likely to be clinically stable (80.4% vs 41.1% in status 3-6, P < .001), to have type O blood (58.3% vs 39.9%, P < .001), and to wait longer after listing (55, interquartile range, 15-180 days vs 32, interquartile range, 9-160 days, P = .003). Six-month survival was 92.1% (95% confidence interval, 91.3-92.8) after donation after brain death heart transplants and 92.6% (95% confidence interval, 88.1-95.4) after donation after circulatory death heart transplants (hazard ratio, 0.94, 95% confidence interval, 0.57-1.54, P = .79). Outcomes in propensity-matched patients were similar except for higher rates of treated acute rejection in donation after circulatory death transplants before discharge (14.4% vs 8.8%, P = .01). In donation after circulatory death heart recipients, outcomes did not differ based on the procurement technique (normothermic regional perfusion vs direct procurement and perfusion). CONCLUSIONS Heart transplantation with donation after circulatory death donors has short-term survival comparable to donation after brain death transplants. Broader implementation could substantially increase donor organ availability.
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Affiliation(s)
- Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Dominick Megna
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Asishana Osho
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Amy Roach
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Joshua Chan
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Georgina Rowe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - George Gill
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Fardad Esmailian
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif.
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James K Kirklin
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Ala
| | - Jon Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Pedro Catarino
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
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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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Normothermic Regional Perfusion Can Improve Both Utilization and Outcomes in DCD Liver, Kidney, and Pancreas Transplantation. Transplant Direct 2023; 9:e1450. [PMID: 36845854 PMCID: PMC9945290 DOI: 10.1097/txd.0000000000001450] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/12/2022] [Accepted: 01/04/2023] [Indexed: 02/22/2023] Open
Abstract
Normothermic regional perfusion (NRP) has gained widespread adoption in multiple European countries. The aim of this study was to examine the influence of thoracoabdominal-NRP (TA-NRP) on the utilization and outcomes of liver, kidney, and pancreas transplantation in the United States. Methods Using the US national registry data between 2020 and 2021, donation after circulatory death (DCD) donors were separated into 2 groups: DCD with TA-NRP and without TA-NRP. There were 5234 DCD donors; among them 34 donors were with TA-NRP. After 1:4 propensity score matching, the utilization rates were compared between DCD with and without TA-NRP. Results Although the utilization rates of kidney and pancreas were comparable (P = 0.71 and P = 0.06, 94.1% versus 95.6% and 8.8% versus 2.2%, respectively), that of liver in DCD with TA-NRP was significantly higher (P < 0.001; 70.6% versus 39.0%). Among 24 liver transplantations, 62 kidney transplantations, and 3 pancreas transplantations from DCD with TA-NRP, there were 2 liver grafts and 1 kidney graft that failed within 1 y after transplantation. Conclusions TA-NRP in the United States significantly increased the utilization rate of abdominal organs from DCD donors with comparable outcomes after transplantation. Increasing use of NRP may expand the donor pool without compromising transplant outcomes.
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Blitzer D, Baran DA, Lirette S, Copeland JG, Copeland H. Does donor treatment with inotropes and/or vasopressors impact post-transplant outcomes? Clin Transplant 2023; 37:e14912. [PMID: 36650699 DOI: 10.1111/ctr.14912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/07/2022] [Accepted: 01/05/2023] [Indexed: 01/19/2023]
Abstract
PURPOSE The purpose was to evaluate the effects of the most commonly used cardiac donor inotropes/vasopressors on subsequent post-heart transplant survival. METHODS Adult heart transplant recipients from January 2000 to June 2022 were identified in the United Network for Organ Sharing (UNOS) database. Exclusion criteria included: multiorgan transplants, donor age < 15, and recipient age < 18. Donors receiving vasoactive medications at the time of procurement were compared to donors not receiving these medications. Those on vasoactive medications were stratified by medication: phenylephrine, dopamine, dobutamine, norepinephrine and epinephrine, the combination of these agents, and the concomitant administration of vasopressin with any single agent alone or in combination. The primary area of interest was short-and-long-term survival. Survival at 30 days, 1 year, and long-term (Median = 13.6 years) was compared using logistic and Cox models to quantify survival endpoints. RESULTS A total of 45,198 donors met inclusion criteria and had data on the use of vasoactive agents available. Mean donor age was 32.3 years with 71% male. Vasoactive medications and potential combinations included phenylephrine in 8156 donors (18.0%), dopamine in 9550 (21.1%), dobutamine in 718 (1.6%), epinephrine in 332 (.73%), and norepinephrine in 4854 (10.7%). A total of 25,856 donors (57.2%) were receiving vasopressin at the time of procurement. There was no impact of donor inotropes on 30-day survival. Donors receiving one inotrope and no vasopressin were associated with increased 1 year mortality (OR 1.14; p = .021), as were donors receiving 2+ inotropes and no vasopressin (OR 1.26; p = .006). For individual agents, 1 year mortality was increased for dopamine (OR 1.11; p = .042) and epinephrine (OR 1.59; p = .004). CONCLUSIONS There is no difference in heart transplant recipient survival at 30 days when the donor is receiving inotropes without vasopressin at the time of procurement. Inotropic support without vasopressin is associated with greater 1 year mortality. The impact of donor inotropic support on long term heart transplant survival, and the interaction with vasopressin warrants further study.
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Affiliation(s)
- David Blitzer
- Columbia University, Department of Surgery, Division of Cardiovascular Surgery, New York, New York, USA
| | - David A Baran
- Cleveland Clinic Heart Vascular and Thoracic Institute, Weston, Florida, USA
| | | | - Jack G Copeland
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Hannah Copeland
- Lutheran Hospital - Fort Wayne, Cleveland, Indiana, USA.,Indiana University School of Medicine - Fort Wayne (IUSM-FW), Fort Wayne, Indiana, USA
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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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Kwon JH, Ghannam AD, Shorbaji K, Welch B, Hashmi ZA, Tedford RJ, Kilic A. Early Outcomes of Heart Transplantation Using Donation After Circulatory Death Donors in the United States. Circ Heart Fail 2022; 15:e009844. [PMID: 36214116 DOI: 10.1161/circheartfailure.122.009844] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Limited donor availability and evolution in procurement techniques have renewed interest in heart transplantation (HT) with donation after circulatory death (DCD). The aim of this study is to evaluate outcomes of HT using DCD in the United States. METHODS The United Network for Organ Sharing registry was used to identify adult HT recipients from 2019 to 2021. Recipients were stratified between DCD and donation after brain death. Propensity-score matching was performed. Cox proportional hazards was used to identify independent predictors of 1-year mortality. Kaplan-Meier analysis was used to estimate 1-year survival. RESULTS Of 7496 HTs, 229 DCD and 7267 donation after brain death recipients were analyzed. The frequency of DCD HT increased from 0.2% of all HT in 2019 to 6.4% in 2021 (P<0.001), and the number of centers performing DCD HT increased from 3 of 120 centers to 20 of 121 centers (P<0.001). DCD donors were more likely to be younger, male, and White. After propensity matching, 1-year survival was 92.5% for DCD versus 90.3% for donation after brain death (hazard ratio, 0.80 [95% CI, 0.44-1.43]; P=0.44). Among DCD HTs, increasing recipient age and waitlist time predicted 1-year mortality on univariable analysis. CONCLUSIONS Rates of DCD HT in the United States are increasing. This practice appears safe and feasible as mortality outcomes are comparable to donation after brain death. Although this study represents early adopting centers, outcomes of the experience for DCD HT in the United States is consistent with existing international data and encourages broader utilization of this practice.
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Affiliation(s)
- Jennie H Kwon
- Division of Cardiothoracic Surgery, Department of Surgery (J.H.K., A.D.G., K.S., B.W., Z.A.H., A.K.), Medical University of South Carolina, Charleston
| | - Alexander D Ghannam
- Division of Cardiothoracic Surgery, Department of Surgery (J.H.K., A.D.G., K.S., B.W., Z.A.H., A.K.), Medical University of South Carolina, Charleston
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Department of Surgery (J.H.K., A.D.G., K.S., B.W., Z.A.H., A.K.), Medical University of South Carolina, Charleston
| | - Brett Welch
- Division of Cardiothoracic Surgery, Department of Surgery (J.H.K., A.D.G., K.S., B.W., Z.A.H., A.K.), Medical University of South Carolina, Charleston
| | - Z A Hashmi
- Division of Cardiothoracic Surgery, Department of Surgery (J.H.K., A.D.G., K.S., B.W., Z.A.H., A.K.), Medical University of South Carolina, Charleston
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine (R.J.T.), Medical University of South Carolina, Charleston
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Department of Surgery (J.H.K., A.D.G., K.S., B.W., Z.A.H., A.K.), Medical University of South Carolina, Charleston
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D'Alessandro DA, Wolfe SB, Osho AA, Drezek K, Prario MN, Rabi SA, Michel E, Tsao L, Coglianese E, Doucette M, Zlotoff DA, Newton-Cheh C, Thomas SS, Ton VK, Sutaria N, Schoenike MW, Christ AM, Paneitz DC, Madsen JC, Pierson R, Lewis GD. Hemodynamic and Clinical Performance of Hearts Donated After Circulatory Death. J Am Coll Cardiol 2022; 80:1314-1326. [PMID: 36175050 DOI: 10.1016/j.jacc.2022.07.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/27/2022] [Accepted: 07/14/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Donor organ demand continues to outpace supply in heart transplantation. Utilization of donation after circulatory death (DCD) hearts could significantly increase heart donor availability for patients with advanced heart failure. OBJECTIVES The purpose of this study was to describe hemodynamic and clinical profiles of DCD hearts in comparison to standard of care (SOC) hearts donated after brain death (DBD). METHODS This single-center retrospective cohort study of consecutive heart transplant recipients analyzed right heart catheterization measurements, inotrope scores, echocardiograms, and clinical outcomes between DCD and DBD heart recipients. RESULTS Between April 2016 and February 2022, 47 DCD and 166 SOC hearts were transplanted. Median time from DCD consent to transplant was significantly shorter compared with SOC waiting list time (17 days [6-28 days] vs 70 days [23-240 days]; P < 0.001). Right heart function was significantly impaired in DCD recipients compared with SOC recipients 1 week post-transplant (higher median right atrial pressure (10 mm Hg [8-13 mm Hg] vs 7 mm Hg [5-11 mm Hg]; P < 0.001), higher right atrial pressure to pulmonary capillary wedge pressure ratio (0.64 [0.54-0.82] vs 0.57 [0.43-0.73]; P = 0.016), and lower pulmonary arterial pulsatility index (1.66 [1.27-2.50] vs 2.52 [1.63-3.82]; P < 0.001), but was similar between groups by 3 weeks post-transplant. DCD and SOC recipient mortality was similar at 30 days (DCD 0 vs SOC 2%; P = 0.29) and 1 year post-transplant (DCD 3% vs SOC 8%; P = 0.16). CONCLUSIONS DCD heart utilization is associated with transient post-transplant right heart dysfunction and short-term clinical outcomes otherwise similar to transplantation using DBD hearts.
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Affiliation(s)
- David A D'Alessandro
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Stanley B Wolfe
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Asishana A Osho
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kamila Drezek
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Monica N Prario
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - S Alireza Rabi
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eriberto Michel
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lana Tsao
- Division of Cardiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Erin Coglianese
- Division of Cardiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Meaghan Doucette
- Division of Cardiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel A Zlotoff
- Division of Cardiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher Newton-Cheh
- Division of Cardiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sunu S Thomas
- Division of Cardiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Van-Khue Ton
- Division of Cardiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nilay Sutaria
- Division of Cardiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mark W Schoenike
- Division of Cardiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anastasia M Christ
- Division of Cardiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dane C Paneitz
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joren C Madsen
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Richard Pierson
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gregory D Lewis
- Division of Cardiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA. https://twitter.com/GLewisCardiol
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Wisneski A, Smith JW, Nguyen TC, Fiedler AG. Molecules, Machines, and the Perfusate Milieu: Organ Preservation and Emerging Concepts for Heart Transplant. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:363-367. [PMID: 36271669 DOI: 10.1177/15569845221127305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Andrew Wisneski
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, CA, USA
| | - Jason W Smith
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, CA, USA
| | - Tom C Nguyen
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, CA, USA
| | - Amy G Fiedler
- Division of Cardiothoracic Surgery, Department of Surgery, University of California San Francisco, CA, USA
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30
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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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31
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Andrijevic D, Vrselja Z, Lysyy T, Zhang S, Skarica M, Spajic A, Dellal D, Thorn SL, Duckrow RB, Ma S, Duy PQ, Isiktas AU, Liang D, Li M, Kim SK, Daniele SG, Banu K, Perincheri S, Menon MC, Huttner A, Sheth KN, Gobeske KT, Tietjen GT, Zaveri HP, Latham SR, Sinusas AJ, Sestan N. Cellular recovery after prolonged warm ischaemia of the whole body. Nature 2022; 608:405-412. [PMID: 35922506 PMCID: PMC9518831 DOI: 10.1038/s41586-022-05016-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 06/23/2022] [Indexed: 02/05/2023]
Abstract
After cessation of blood flow or similar ischaemic exposures, deleterious molecular cascades commence in mammalian cells, eventually leading to their death1,2. Yet with targeted interventions, these processes can be mitigated or reversed, even minutes or hours post mortem, as also reported in the isolated porcine brain using BrainEx technology3. To date, translating single-organ interventions to intact, whole-body applications remains hampered by circulatory and multisystem physiological challenges. Here we describe OrganEx, an adaptation of the BrainEx extracorporeal pulsatile-perfusion system and cytoprotective perfusate for porcine whole-body settings. After 1 h of warm ischaemia, OrganEx application preserved tissue integrity, decreased cell death and restored selected molecular and cellular processes across multiple vital organs. Commensurately, single-nucleus transcriptomic analysis revealed organ- and cell-type-specific gene expression patterns that are reflective of specific molecular and cellular repair processes. Our analysis comprises a comprehensive resource of cell-type-specific changes during defined ischaemic intervals and perfusion interventions spanning multiple organs, and it reveals an underappreciated potential for cellular recovery after prolonged whole-body warm ischaemia in a large mammal.
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Affiliation(s)
- David Andrijevic
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,These authors contributed equally: David Andrijevic, Zvonimir Vrselja, Taras Lysyy, Shupei Zhang
| | - Zvonimir Vrselja
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,These authors contributed equally: David Andrijevic, Zvonimir Vrselja, Taras Lysyy, Shupei Zhang
| | - Taras Lysyy
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Department of Surgery, Yale School of Medicine New Haven, New Haven, CT, USA.,These authors contributed equally: David Andrijevic, Zvonimir Vrselja, Taras Lysyy, Shupei Zhang
| | - Shupei Zhang
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Department of Genetics, Yale School of Medicine, New Haven, CT, USA.,These authors contributed equally: David Andrijevic, Zvonimir Vrselja, Taras Lysyy, Shupei Zhang
| | - Mario Skarica
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Ana Spajic
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - David Dellal
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Stephanie L. Thorn
- Yale Translational Research Imaging Center, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Robert B. Duckrow
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Shaojie Ma
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Phan Q. Duy
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA.,Medical Scientist Training Program (MD-PhD), Yale School of Medicine, New Haven, CT, USA
| | - Atagun U. Isiktas
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Dan Liang
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Mingfeng Li
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Suel-Kee Kim
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA
| | - Stefano G. Daniele
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA.,Medical Scientist Training Program (MD-PhD), Yale School of Medicine, New Haven, CT, USA
| | - Khadija Banu
- Department of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Sudhir Perincheri
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Madhav C. Menon
- Department of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Anita Huttner
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Kevin N. Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.,Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Kevin T. Gobeske
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Gregory T. Tietjen
- Department of Surgery, Yale School of Medicine New Haven, New Haven, CT, USA.,Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Hitten P. Zaveri
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Stephen R. Latham
- Interdisciplinary Center for Bioethics, Yale University, New Haven, CT, USA
| | - Albert J. Sinusas
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA.,Department of Biomedical Engineering, Yale University, New Haven, CT, USA.,Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA.,Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Nenad Sestan
- Department of Neuroscience, Yale School of Medicine, New Haven, CT, USA. .,Department of Genetics, Yale School of Medicine, New Haven, CT, USA. .,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA. .,Department of Comparative Medicine, Yale School of Medicine, New Haven, CT, USA. .,Program in Cellular Neuroscience, Neurodegeneration and Repair, Yale School of Medicine, New Haven, CT, USA. .,Yale Child Study Center, New Haven, CT, USA.
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32
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DeCamp M, Snyder Sulmasy L, Fins JJ. POINT: Does Normothermic Regional Perfusion Violate the Ethical Principles Underlying Organ Procurement? Yes. Chest 2022; 162:288-290. [PMID: 35940651 DOI: 10.1016/j.chest.2022.03.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/08/2022] [Indexed: 10/16/2022] Open
Affiliation(s)
- Matthew DeCamp
- Center for Bioethics and Humanities & Division of General Internal Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO.
| | - Lois Snyder Sulmasy
- Center for Ethics and Professionalism, American College of Physicians, Philadelphia, PA
| | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY; Solomon Center for Health Law & Policy, Yale Law School, New Haven, CT
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33
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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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34
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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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35
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Entwistle JW, Drake DH, Fenton KN, Smith MA, Sade RM. Normothermic Regional Perfusion: Ethical Issues in Thoracic Organ Donation. Ann Thorac Surg 2022; 114:44-51. [PMID: 35589419 DOI: 10.1016/j.athoracsur.2022.01.058] [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: 11/06/2021] [Accepted: 01/12/2022] [Indexed: 11/18/2022]
Affiliation(s)
- John W Entwistle
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel H Drake
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Michael A Smith
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert M Sade
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina.
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36
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Entwistle JW, Drake DH, Fenton KN, Smith MA, Sade RM. Normothermic regional perfusion: Ethical issues in thoracic organ donation. J Thorac Cardiovasc Surg 2022; 164:147-154. [PMID: 35369998 DOI: 10.1016/j.jtcvs.2022.01.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/05/2022] [Accepted: 01/12/2022] [Indexed: 01/20/2023]
Affiliation(s)
- John W Entwistle
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pa
| | - Daniel H Drake
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | | | - Michael A Smith
- Norton Thoracic Institute, St Joseph's Hospital and Medical Center, Phoenix, Ariz
| | - Robert M Sade
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC.
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37
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Editorial: cardiovascular anaesthesiology. Curr Opin Anaesthesiol 2022; 35:1-4. [PMID: 34932519 DOI: 10.1097/aco.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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38
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Kwon JH, Kilic A. Commentary: Hope on the Horizon: Heart Transplantation with Donation after Circulatory Death. JTCVS Tech 2022; 12:108-109. [PMID: 35403014 PMCID: PMC8987596 DOI: 10.1016/j.xjtc.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 01/16/2022] [Accepted: 02/15/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
| | - Arman Kilic
- Address for reprints: Arman Kilic, MD, Division of Cardiothoracic Surgery, Medical University of South Carolina, 30 Courtenay Dr, MSC 295, Suite BM279, Charleston, SC 29425.
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39
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Moazami N, Smith D, Galloway A. Logistics for Expanding Heart Transplantation from Donation after Circulatory Death using Normothermic Regional Perfusion. JTCVS Tech 2022; 12:110-112. [PMID: 35403040 PMCID: PMC8987364 DOI: 10.1016/j.xjtc.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/12/2022] [Indexed: 11/25/2022] Open
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40
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Jawitz OK, Milano C. Commentary: An innovative strategy for expanding the donor pool. J Thorac Cardiovasc Surg 2021; 164:571-572. [PMID: 34417037 DOI: 10.1016/j.jtcvs.2021.08.007] [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: 08/02/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, 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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41
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D'Alessandro D, Pierson RN. Commentary: A long road back to the beginning. J Thorac Cardiovasc Surg 2021; 164:569-570. [PMID: 34509295 PMCID: PMC10176788 DOI: 10.1016/j.jtcvs.2021.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 11/16/2022]
Affiliation(s)
- David D'Alessandro
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Richard N Pierson
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
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