Ventricular Assist Devices: From Bridge to Transplantation to Bridge to Organ Donation

Organ donation from extracorporeal membrane oxygenation and ventricular assist devices in Victoria, Australia: Characteristics and trends

Objective

To describe the characteristics and the trend of organ donation from donors on extracorporeal membrane oxygenation (ECMO) or ventricular assist devices (LVAD).

Design

Retrospective, observational, cohort study from June 2014 to June 2021.

Setting

A multicentre study in Victoria, Australia, using DonateLife Victoria databases.

Participants

All patients on ECMO/LVAD were referred to DonateLife for organ donation.

Main outcome measures

Number, proportion, time trend and type of organ donations from the patients on ECMO/LVAD.

Results

There were 78 donor referrals [mean (SD) age 42 (18.8) yrs, 56 (72 %) males] from patients on Veno-arterial ECMO (73 %), Veno-venous ECMO (16 %) or LVAD (6.4 %), of which 37 (47 %) donated. The annual median (IQR) referral and donation rates were 8 (5-10)/year and 4 (3-7)/year, respectively. Medical contraindications were the main reason for declining organ donation [21(51 %)]. Donation after neurological determination of death (DNDD) occurred in 20 (54 %), and donation after circulatory determination of death (DCDD) in 17 (46 %). The median (IQR) time from admission to referral for donation was longer in DCDD compared to DNDD patients. Eighty-three organs were retrieved from 37 donors (2.24 organs per donor), out of which 68 organs (82 %) were transplanted in 68 recipients. Kidneys were the most common organs retrieved (73 %) and transplanted (79 %).

Conclusion

Organ donation on ECMO/LVAD occurs only in half of the referred patients. Further studies are needed to ascertain the barriers to donations and to assess the long-term outcomes of these donations.

Liver transplantation from brain-dead donors on mechanical circulatory support: a systematic review of the literature

Mechanical circulatory support (MCS) refers to a range of rescue devices to assist circulation for the treatment of heart failure, including venoarterial extracorporeal membrane oxygenation (VA-ECMO) and ventricular assist devices (VADs). This review aims at evaluating the transplant outcome of the livers procured from brain-dead donors on MCS, who are currently considered as having extended criteria. We identified 22 records (17 on VA-ECMO and 5 on VADs), most of which (68.2%) were case reports. We performed a meta-analysis only when the outcome was reported homogeneously among studies; otherwise, we illustrated the results with narrative synthesis. A total of 156 liver transplants (LTs) have been reported, where VA-ECMO was initiated in the donor with resuscitative intent or as a bridge to donation. Early graft survival approached 100% in most studies. The pooled rate of primary nonfunction was 1% (95% CI: 0-3%). Only three successful LTs from VAD donors have been reported. Particular attention should be paid to cardiological history, biochemical tests, and imaging, as well as MCS parameters, to determine graft eligibility for transplantation. Although further analysis is needed in this field, the results of this review advocate a more systematic consideration of brain-dead patients on MCS as potential liver donors.