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Ran G, Wall AE, Narang N, Khush KK, Hoffman JRH, Zhang KC, Parker WF. Post-transplant survival after normothermic regional perfusion versus direct procurement and perfusion in donation after circulatory determination of death in heart transplantation. J Heart Lung Transplant 2024; 43:954-962. [PMID: 38423416 PMCID: PMC11090717 DOI: 10.1016/j.healun.2024.02.1456] [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: 09/21/2023] [Revised: 02/13/2024] [Accepted: 02/20/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Since 2019, the annual transplantation rate of hearts donated following circulatory death (DCD) has increased significantly in the United States. The 2 major heart procurement techniques following circulatory death are direct procurement and perfusion (DPP) and normothermic regional perfusion (NRP). Post-transplant survival for heart recipients has not been compared between these 2 techniques. METHODS This observational study uses data on adult heart transplants from donors after circulatory death from January 1, 2019 to December 31, 2021 in the Scientific Registry of Transplant Recipients. We identified comparable transplant cases across procurement types using propensity-score matching and measured the association between procurement technique and 1-year post-transplant survival using Kaplan-Meier and Cox proportional hazards model stratefied by matching pairs. RESULTS Among 318 DCD heart transplants, 216 (68%) were procured via DPP, and 102 (32%) via NRP. Among 22 transplant centers that accepted circulatory-death donors, 3 used NRP exclusively, and 5 used both procurement techniques. After propensity-score matching on recipient and donor factors, there was no significant difference in 1-year post-transplant survival (93.1% for NRP vs 91.1% for DPP, p = 0.79) between procurement techniques. CONCLUSIONS NRP and DPP procurements are associated with similar 1-year post-transplant survival. If NRP is ethically permissible and improves outcomes for abdominal organs, it should be the preferred procurement technique for DCD hearts.
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Affiliation(s)
- Gege Ran
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Anji E Wall
- Department of Transplant Surgery, Annette C. and Harrold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Nikhil Narang
- Department of Cardiology, Advocate Christ Medical Center, Chicago, Illinois; Department of Medicine, University of Illinois-Chicago, Chicago, Illinois
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Jordan R H Hoffman
- Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - Kevin C Zhang
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - William F Parker
- Department of Medicine, University of Chicago, Chicago, Illinois; Department of Public Health Sciences, University of Chicago, Chicago, Illinois; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois.
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2
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Simons JN, van der Graaf R, van Delden JJ. Cardiac organoids do not warrant additional moral scrutiny. BMC Med Ethics 2024; 25:61. [PMID: 38773517 PMCID: PMC11106857 DOI: 10.1186/s12910-024-01064-6] [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: 01/09/2024] [Accepted: 05/15/2024] [Indexed: 05/24/2024] Open
Abstract
Certain organoid subtypes are particularly sensitive. We explore whether moral intuitions about the heartbeat warrant unique moral consideration for newly advanced contracting cardiac organoids. Despite the heartbeat's moral significance in organ procurement and abortion discussions, we argue that this significance should not translate into moral implications for cardiac organoids.
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Affiliation(s)
- Jannieke N Simons
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Rieke van der Graaf
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes Jm van Delden
- Department of Bioethics and Health Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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3
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Omelianchuk A, Capron AM, Ross LF, Derse AR, Bernat JL, Magnus D. Neither Ethical nor Prudent: Why Not to Choose Normothermic Regional Perfusion. Hastings Cent Rep 2024. [PMID: 38768312 DOI: 10.1002/hast.1584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
In transplant medicine, the use of normothermic regional perfusion (NRP) in donation after circulatory determination of death raises ethical difficulties. NRP is objectionable because it restores the donor's circulation, thus invalidating a death declaration based on the permanent cessation of circulation. NRP's defenders respond with arguments that are tortuous and factually inaccurate and depend on introducing extraneous concepts into the law. However, results comparable to NRP's-more and higher-quality organs and more efficient allocation-can be achieved by removing organs from deceased donors and using normothermic machine perfusion (NMP) to support the organs outside the body, without jeopardizing confidence in transplantation's legal and ethical foundations. Given the controversy that NRP generates and the convoluted justifications made for it, we recommend a prudential approach we call "ethical parsimony," which holds that, in the choice between competing means of achieving a result, the ethically simpler one is to be preferred. This approach makes clear that policy-makers should favor NMP over NRP.
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Murphy NB, Shemie SD, Capron A, Truog RD, Nakagawa T, Healey A, Gofton T, Bernat JL, Fenton K, Khush KK, Schwartz B, Wall SP. Advancing the Scientific Basis for Determining Death in Controlled Organ Donation After Circulatory Determination of Death. Transplantation 2024:00007890-990000000-00733. [PMID: 38637919 DOI: 10.1097/tp.0000000000005002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
In controlled organ donation after circulatory determination of death (cDCDD), accurate and timely death determination is critical, yet knowledge gaps persist. Further research to improve the science of defining and determining death by circulatory criteria is therefore warranted. In a workshop sponsored by the National Heart, Lung, and Blood Institute, experts identified research opportunities pertaining to scientific, conceptual, and ethical understandings of DCDD and associated technologies. This article identifies a research strategy to inform the biomedical definition of death, the criteria for its determination, and circulatory death determination in cDCDD. Highlighting knowledge gaps, we propose that further research is needed to inform the observation period following cessation of circulation in pediatric and neonatal populations, the temporal relationship between the cessation of brain and circulatory function after the withdrawal of life-sustaining measures in all patient populations, and the minimal pulse pressures that sustain brain blood flow, perfusion, activity, and function. Additionally, accurate predictive tools to estimate time to asystole following the withdrawal of treatment and alternative monitoring modalities to establish the cessation of circulatory, brainstem, and brain function are needed. The physiologic and conceptual implications of postmortem interventions that resume circulation in cDCDD donors likewise demand attention to inform organ recovery practices. Finally, because jurisdictionally variable definitions of death and the criteria for its determination may impede collaborative research efforts, further work is required to achieve consensus on the physiologic and conceptual rationale for defining and determining death after circulatory arrest.
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Affiliation(s)
- Nicholas B Murphy
- Departments of Medicine and Philosophy, Western University, London, ON, Canada
| | - Sam D Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
- System Development, Canadian Blood Services, Ottawa, ON, Canada
| | - Alex Capron
- Gould School of Law and Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Robert D Truog
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
| | - Thomas Nakagawa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Andrew Healey
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- Divisions of Emergency and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Kathleen Fenton
- Advanced Technologies and Surgery Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Bryanna Schwartz
- Heart Development and Structural Diseases Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Division of Cardiology, Children's National Hospital, Washington, DC
| | - Stephen P Wall
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
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5
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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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6
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Zhou AL, Akbar AF, Kilic A. Normothermic regional perfusion in the United States: A call for improved data collection. J Heart Lung Transplant 2024:S1053-2498(24)01533-X. [PMID: 38521115 DOI: 10.1016/j.healun.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/08/2024] [Accepted: 03/18/2024] [Indexed: 03/25/2024] Open
Affiliation(s)
- Alice L Zhou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Armaan F Akbar
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
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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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8
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Spencer BL, Wilhelm SK, Urrea KA, Chakrabortty V, Sewera S, Mazur DE, Niman JB, Bartlett RH, Rojas-Peña A, Drake DH. Twenty-four-hour Normothermic Ex Vivo Heart Perfusion With Low Flow Functional Assessment in an Adult Porcine Model. Transplantation 2024:00007890-990000000-00670. [PMID: 38411562 DOI: 10.1097/tp.0000000000004956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Cold static storage and normothermic ex vivo heart perfusion are routinely limited to 6 h. This report describes intermittent left atrial (LA) perfusion that allows cardiac functional assessment in a working heart mode. METHODS Using our adult porcine model, general anesthesia was induced and a complete cardiectomy was performed following cardioplegic arrest. Back-table instrumentation was completed and normothermic ex vivo heart perfusion (NEHP) was initiated in a nonworking heart mode (Langendorff). After 1 h of resuscitation and recovery, LA perfusion was initiated and the heart was transitioned to a coronary flow-only working heart mode for 30 min. Baseline working heart parameters were documented and the heart was returned to nonworking mode. Working heart assessments were performed for 30 min every 6 h for 24 h. RESULTS Twenty-four-hour NEHP on 9 consecutive hearts (280 ± 42.1 g) was successful and no significant differences were found between working heart parameters at baseline and after 24 h of perfusion. There was no difference between initial and final measurements of LA mean pressures (5.0 ± 3.1 versus 9.0 ± 6.5 mm Hg, P = 0.22), left ventricular systolic pressures (44.3 ± 7.2 versus 39.1 ± 9.0 mm Hg, P = 0.13), mean aortic pressures (30.9 ± 5.8 versus 28.1 ± 8.1 mm Hg, P = 0.37), and coronary resistance (0.174 ± 0.046 versus 0.173 ± 0.066 mL/min/g, P = 0.90). There were also no significant differences between lactate (2.4 ± 0.5 versus 2.6 ± 0.4 mmol/L, P = 0.17) and glucose (173 ± 75 versus 156 ± 70 mg/dL, P = 0.37). CONCLUSIONS A novel model using intermittent LA perfusion to create a coronary flow-only working heart mode for assessment of ex vivo cardiac function has been successfully developed.
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Affiliation(s)
- Brianna L Spencer
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Spencer K Wilhelm
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Kristopher A Urrea
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Vikramjit Chakrabortty
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Sebastian Sewera
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | | | - Joseph B Niman
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Robert H Bartlett
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Alvaro Rojas-Peña
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
- Department of Surgery, Section of Transplantation, University of Michigan, Ann Arbor, MI
| | - Daniel H Drake
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
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9
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Joshi Y, Macdonald PS. Heart Transplantation From DCD Donors Enters the Mainstream. Transplantation 2023; 107:2449-2450. [PMID: 38010153 DOI: 10.1097/tp.0000000000004761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Affiliation(s)
- Yashutosh Joshi
- Heart Transplant Unit, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- Faculty of Medicine, St Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
| | - Peter S Macdonald
- Heart Transplant Unit, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- Faculty of Medicine, St Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
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10
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Johnson MD, Zimmerman KG, Nakashima T, Urrea KA, Rojas-Pena A, Bartlett RH, Drake DH. Artificial Intelligence-Assisted Strain Echocardiography in an Ex Vivo Heart. ASAIO J 2023; 69:e523-e525. [PMID: 37524082 DOI: 10.1097/mat.0000000000001994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Affiliation(s)
- Matthew D Johnson
- From the Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Karen G Zimmerman
- Department of Cardiology, Henry Ford Health System, Detroit, Michigan
| | - Takahiro Nakashima
- From the Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kristopher A Urrea
- From the Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Alvaro Rojas-Pena
- From the Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Robert H Bartlett
- From the Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Daniel H Drake
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
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11
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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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12
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Bernat JL. Challenges to Brain Death in Revising the Uniform Determination of Death Act: The UDDA Revision Series. Neurology 2023; 101:30-37. [PMID: 37400259 DOI: 10.1212/wnl.0000000000207334] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 03/07/2023] [Indexed: 07/05/2023] Open
Affiliation(s)
- James L Bernat
- From the Dartmouth Geisel School of Medicine, Hanover, NH.
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Murphy NB, Weijer C, Slessarev M, Chandler JA, Gofton T. Implications of the updated Canadian Death Determination Guidelines for organ donation interventions that restore circulation after determination of death by circulatory criteria. Can J Anaesth 2023; 70:591-595. [PMID: 37131028 PMCID: PMC10203003 DOI: 10.1007/s12630-023-02413-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 05/04/2023] Open
Affiliation(s)
- Nicholas B Murphy
- Departments of Medicine and Philosophy, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Charles Weijer
- Departments of Medicine, Epidemiology & Biostatistics, and Philosophy, Western University, London, ON, Canada
| | - Marat Slessarev
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Trillium Gift of Life Network, London, ON, Canada
| | | | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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Pasrija C, Tipograf Y, Shah AS, Trahanas JM. Normothermic regional perfusion for donation after circulatory death donors. Curr Opin Organ Transplant 2023; 28:71-75. [PMID: 36409266 DOI: 10.1097/mot.0000000000001038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE OF REVIEW This review is intended to provide an update on the logistics, technique, and outcomes associated with normothermic regional perfusion (NRP), as well as provide a discussion of the associated ethical issues. RECENT FINDINGS There has been renewed interest in utilizing NRP to increase quality and availability of organs from donation after circulatory death (DCD) donors. Our institution has increasing experience with thoraco-abdominal NRP (TA-NRP) in controlled DCD donors (cDCD), whereas abdominal NRP (A-NRP) has been used with success in both cDCD and uncontrolled DCD (uDCD). There is increasing evidence that NRP can be conducted in a practical and cost-efficient manner, and that the organ yield may be of better quality than standard direct procurement and perfusion (DPP). SUMMARY NRP is increasingly successful and will likely prove to be a superior method for cDCD recovery. However, before TA-NRP can be widely accepted the ethical debate surrounding this technique must be settled. VIDEO ABSTRACT http://links.lww.com/COOT/A11.
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Affiliation(s)
- Chetan Pasrija
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Entwistle JW. Invited commentary: When perfusion is not circulation. Artif Organs 2023; 47:246-247. [PMID: 36576449 DOI: 10.1111/aor.14486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- John W Entwistle
- Division of Cardiothoracic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Peled H, Mathews S, Rhodes D, Bernat JL. Normothermic Regional Perfusion Requires Careful Ethical Analysis Before Adoption Into Donation After Circulatory Determination of Death. Crit Care Med 2022; 50:1644-1648. [PMID: 36227032 DOI: 10.1097/ccm.0000000000005632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Harry Peled
- Providence St Jude Medical Center, Fullerton, CA
| | | | - David Rhodes
- Providence St Jude Medical Center, Fullerton, CA
| | - James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, NH
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Murphy N, Lingard L, Blackstock L, Ott M, Slessarev M, Basmaji J, Brahmania M, Healey A, Shemie S, Skaro A, Wilson L, Weijer C. Protocol for a qualitative pilot study to explore ethical issues and stakeholder trust in the use of normothermic regional perfusion in organ donation in Canada. BMJ Open 2022; 12:e067515. [PMID: 36175093 PMCID: PMC9528605 DOI: 10.1136/bmjopen-2022-067515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION The process of controlled organ donation after circulatory determination of death (cDCDD) results in ischaemic injury to organs and leads to poorer outcomes in organ recipients. Although not yet used in Canada, normothermic regional perfusion (NRP) is a perfusion technology used postmortem with cDCDD donors to selectively restore perfusion of oxygenated blood to target organs in situ, reversing ischaemic injury and improving organ viability and post-transplant outcomes. However, NRP poses significant ethical challenges. To preserve trust in deceased donation, these ethical challenges must be addressed to the satisfaction of Canadian stakeholders before NRP's implementation. This study will identify ethical issues pertaining to NRP and explore perspectives of NRP among key stakeholders. By developing an explanatory framework delineating how stakeholder perceptions of NRP's ethical implications impact trust in Canada's donation and transplantation systems, this study will inform the development of responsible policy on NRP's use in Canada. METHODS AND ANALYSIS This study includes two workstreams. Workstream 1 is a scoping review of medical and bioethical literature to identify ethical issues stemming from NRP. We will apply a common search string across Medline, PubMed (other than Medline) and Embase to identify relevant articles. We will identify grey literature through Google searches, websites of organ donation organisations and consultation with our research network. No date limits will be applied. All peer-reviewed publications, commentaries, editorials or documents that engage with ethical issues in NRP (or conceptual and empirical issues as they relate to these ethical issues) will be included. News articles, conference abstracts and publications not in English will be excluded. Workstream 2 consists of interviews with healthcare providers, institutional stakeholders, organ recipients and deceased donors' family members (n=24-36), as well as focus groups with healthcare providers involved in deceased donation and transplantation (n=20-32). Constructivist grounded theory methodology will guide data collection and analysis in workstream 2. ETHICS AND DISSEMINATION This study was approved by Western University's research ethics committee (Western REM; ID: 120001). All participants will be asked to provide written informed consent to participate. Findings will be shared with Canadian organ donation and transplantation organisations, presented at national conferences and published in medical journals.
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Affiliation(s)
- Nicholas Murphy
- Philosophy and Medicine, Western University, London, Ontario, Canada
| | - Lorelei Lingard
- Centre for Education Research and Innovation and Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | | | - Mary Ott
- Department of Medicine, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Marat Slessarev
- Department of Medicine, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
- Regional Medical Lead, Trillium Gift of Life Network, Toronto, Ontario, Canada
- London Health Sciences Centre, London, Ontario, Canada
| | - John Basmaji
- London Health Sciences Centre, London, Ontario, Canada
- Departments of Medicine and Epidemiology & Biostatistics, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Mayur Brahmania
- London Health Sciences Centre, London, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Andrew Healey
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Trillium Gift of Life Network, Toronto, Ontario, Canada
| | - Sam Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
- Canadian Blood Services, Ottawa, Ontario, Canada
| | - Anton Skaro
- London Health Sciences Centre, London, Ontario, Canada
- Department of Surgery, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | | | - Charles Weijer
- Departments of Medicine, Epidemiology & Biostatistics, and Philosophy, Western University, London, Ontario, Canada
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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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Peled H, Bernat JL. Why arch vessel ligation is unethical for thoracoabdominal normothermic regional perfusion. J Thorac Cardiovasc Surg 2022; 164:e93. [PMID: 35624054 DOI: 10.1016/j.jtcvs.2022.04.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/04/2022] [Accepted: 04/16/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Harry Peled
- Department of Cardiology and Critical Care, Providence St Jude Medical Center, Fullerton, Calif
| | - James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, NH
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Reply: Tying off brain vessels: Can that be ok? J Thorac Cardiovasc Surg 2022; 164:e93-e94. [DOI: 10.1016/j.jtcvs.2022.04.041] [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: 04/29/2022] [Revised: 04/29/2022] [Accepted: 04/30/2022] [Indexed: 11/22/2022]
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Commentary: At least we still have taxes. J Thorac Cardiovasc Surg 2022; 164:156-157. [DOI: 10.1016/j.jtcvs.2022.03.002] [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: 03/01/2022] [Revised: 03/01/2022] [Accepted: 03/01/2022] [Indexed: 11/18/2022]
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Commentary: Normothermic Regional Perfusion: Ethical Issues in Thoracic Organ Donation: An Important Discussion, but Stop the Press! J Thorac Cardiovasc Surg 2022; 164:155-156. [DOI: 10.1016/j.jtcvs.2022.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 11/18/2022]
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