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Case Report of Cardiac Allografts Retrieved From Human Donation After Circulatory Death (DCD) Donors - Assessment on Ex Vivo Beating Heart Perfusion Device
Abstracts S119 3( 10) Initial Experience With the Organ Care System in High Risk Donor/ Recipient Combination Orthotopic Heart Transplantation (OCTx) D. García Sáez , B. Zych, A. Sabashnikov, P. Mohite, F. De Robertis, T. Pitt, O. Maunz, C. Bowles, R. Hards, T. Bahrami, M. Amrani, N. Banner, A.R. Simon. Harefield Hospital NHS Trust, Harefield, London, United Kingdom. Purpose: Utilization of the organs from high risk donors may increase the number of OHTx, however, with possible detrimental effect on outcomes, especially when matched to high risk recipients. The Organ Care System (OCS) (TransMedics, Andover, MA, USA) provides a continuous donor heart perfusion at 34°C in a beating state with potential benefit for early posttransplant results. In this study we analyze the influence of this technique on OHTx early results in high risk donor/recipient group. Methods: Between February and November 2013 (n= 19) patients were transplanted using the OCS. All transplants were considered high risk based on A) donor factors: estimated ischemic time > 4 hours, LVEF < 50%, LV hypertrophy, cardiac arrest, smoking history, alcohol or drug abuse, increased troponin, diabetes, coronary artery disease and/or B) recipient factors: ventricular assist devices (VAD), infection and elevated pulmonary vascular resistance. Donor and recipient demographics and preoperative variables as well as recipient outcomes were analyzed. Results: Donor age: 38±12, gender F/M: 15.7/84.3%. n= 17 (89%) donors with at least one risk factor. Recipient age: 41±13, gender F/M 15.7/84.3%. n= 13 (68%) recipients with at least one risk factor, 17 (89%) on the urgent transplant waiting list. Mean heart cold ischemia 90±14 min. OCS perfusion time 280±103 min. (the longest run: 464 min.). Mean follow up: 132±84 (12 - 265 days); overall survival: 18 (95%) - one patient died 44 days after transplant due to bowel ischemia. Incidence of severe graft failure requiring ECMO: 1(5%). Duration of inotropic support: 106±80 hours; right ventricular failure requiring inotropic support/inhaled NO > 1 week: 3 (15%); Post operative blood loss in 24h 675±218 ml. ICU stay 9.3±10.4 days (2 - 44); hospital stay 33±22 days. At follow up biventricular graft function was well preserved with LV EF 65±6%. Conclusion: Continuous perfusion of beating donor heart at 34 °C is an excellent method of graft preservation providing a very good early outcome of OHTx in high risk donor/recipient population.
Organ Care System (OCS) device for 8 hrs, which allowed ex vivo beating heart assessment in working mode in addition to the standard resting mode. Functional & metabolic parameters were evaluated. The hearts were maintained in resting and working modes for 4 hours each. Results: During resting perfusion, heart 1 had favourable lactate profiles (lactate extraction) suggestive of viable myocardium, however remained > 5mmol/l. Heart 2 had an adverse lactate profile suggestive of ischaemic myocardium (Figure 1). In a working state, a left atrial pressure challenge was conducted. Heart 1 functioned better than Heart 2 (figure 1), with superior cardiac output and generated pressure. The inferiority of Heart 2 was likely the result of dual BD + DCD insult, decreased post-conditioning activation, and an undiagnosed patent foramen ovale. Conclusion: We report the first 2 DCD human hearts recovered on the OCS. Although these were not the ideal donors for DCD heart donation (donor 1 - age> 50, WIT > 30 mins; Donor 2 - BD + DCD, PFO), both demonstrated viability and the potential for DCD cardiac allografts. Further studies of ideal criteria DCD donors are underway.
3( 11) Case Report of Cardiac Allografts Retrieved From Human Donation After Circulatory Death (DCD) Donors - Assessment on Ex Vivo Beating Heart Perfusion Device A. Iyer ,1 L. Gao,1 M. Hicks,1 G. Kumarasinghe,1 P. Jansz,2 A. Jabbour,2 S. Al-Soufi,3 A. Aneman,4 G. Flynn,5 A. Rajamani,6 A. Cheng,7 R. Raper,8 D. Goh,9 M. MacPartlin,10 P. Saul,11 K. Dhital,2 P. Macdonald.2 1Transplantation Lab, Victor Chang Cardiac Research Institute, Darlinghurst, Australia; 2Heart & Lung Transplant Unit, St Vincent’s Hospital, Darlinghurst, Australia; 3Intensive Care Unit, St Vincent’s Hospital, Darlinghurst, Australia; 4Intensive Care Unit, Liverpool Hospital, Sydney, Australia; 5Intensive Care Unit, Prince of Wales Hospital, Sydney, Australia; 6Intensive Care Unit, Nepean Hospital, Sydney, Australia; 7Intensive Care Unit, St George Hospital, Sydney, Australia; 8Intensive Care Unit, Royal North Shore Hospital, Sydney, Australia; 9Intensive Care Unit, Westmead Hospital, Sydney, Australia; 10Intensive Care Unit, Wollongong Hospital, Wollongong, Australia; 11Intensive Care Unit, Newcastle Hospital, Newcastle, Australia. Purpose: Hearts from DCD donors are not used clinically due to concern of warm ischaemic injury. Our preclinical porcine studies have shown that, utilising a pharmacological post-conditioning strategy and ex vivo normothermic perfusion, warm ischaemic times (WIT) of ≤ 30 mins are tolerated with good recovery. We report the first two cases of human DCD donor heart resuscitation using this strategy. Methods: Donor 01 was a 62 y.o male with Guillain Barre Syndrome. WIT (b/w extubation & organ preservation) was 32 mins. Donor 2 was a 39 y.o male, with hypoxic encephalopathy (drug overdose). He was declared brain dead (BD), but subsequently exposed to 30 mins of WIT for the study. Post WIT, hearts were flushed with Celsior solution supplemented with postconditioning agents. Hearts were reperfused on a modified Transmedics
3( 12) Assessment of Myocardial Performance During Ex Vivo Heart Perfusion C.W. White ,1 Y. Li,2 A. Müller,2 E. Ambrose,2 B. Hiebert,1 T.W. Lee,3 R.C. Arora,1 G. Tian,4 J. Nagendran,5 L. Hryskho,2 D.H. Freed.5 1Cardiac Surgery, University of Manitoba, Winnipeg, MB, Canada; 2Institute of Cardiovascular Sciences, St. Boniface Research Center, Winnipeg, MB, Canada; 3Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada; 4National Research Council Institute for Biodiagnostics, Winnipeg, MB, Canada; 5Cardiac Surgery, University of Alberta, Edmonton, AB, Canada. Purpose: Ex vivo heart perfusion (EVHP) has been proposed as a means to resuscitate non-utilized donor hearts and expand the pool of organs available for transplantation. However, a reliable means of demonstrating organ viability prior to transplantation is required. Therefore, we sought to identify metabolic and functional parameters that correlated with myocardial performance during EVHP. Methods: Six normal pig hearts and 8 donation after circulatory death hearts were procured and perfused ex vivo with a donor blood-STEEN solution (hemoglobin concentration of 45 g/L). Hearts were transitioned into a working mode for assessments after 1, 3, and 5 hours of EVHP. Myocardial
Organ Care System (OCS) device for 8 hrs, which allowed ex vivo beating heart assessment in working mode in addition to the standard resting mode. Functional & metabolic parameters were evaluated. The hearts were maintained in resting and working modes for 4 hours each. Results: During resting perfusion, heart 1 had favourable lactate profiles (lactate extraction) suggestive of viable myocardium, however remained > 5mmol/l. Heart 2 had an adverse lactate profile suggestive of ischaemic myocardium (Figure 1). In a working state, a left atrial pressure challenge was conducted. Heart 1 functioned better than Heart 2 (figure 1), with superior cardiac output and generated pressure. The inferiority of Heart 2 was likely the result of dual BD + DCD insult, decreased post-conditioning activation, and an undiagnosed patent foramen ovale. Conclusion: We report the first 2 DCD human hearts recovered on the OCS. Although these were not the ideal donors for DCD heart donation (donor 1 - age> 50, WIT > 30 mins; Donor 2 - BD + DCD, PFO), both demonstrated viability and the potential for DCD cardiac allografts. Further studies of ideal criteria DCD donors are underway.
3( 11) Case Report of Cardiac Allografts Retrieved From Human Donation After Circulatory Death (DCD) Donors - Assessment on Ex Vivo Beating Heart Perfusion Device A. Iyer ,1 L. Gao,1 M. Hicks,1 G. Kumarasinghe,1 P. Jansz,2 A. Jabbour,2 S. Al-Soufi,3 A. Aneman,4 G. Flynn,5 A. Rajamani,6 A. Cheng,7 R. Raper,8 D. Goh,9 M. MacPartlin,10 P. Saul,11 K. Dhital,2 P. Macdonald.2 1Transplantation Lab, Victor Chang Cardiac Research Institute, Darlinghurst, Australia; 2Heart & Lung Transplant Unit, St Vincent’s Hospital, Darlinghurst, Australia; 3Intensive Care Unit, St Vincent’s Hospital, Darlinghurst, Australia; 4Intensive Care Unit, Liverpool Hospital, Sydney, Australia; 5Intensive Care Unit, Prince of Wales Hospital, Sydney, Australia; 6Intensive Care Unit, Nepean Hospital, Sydney, Australia; 7Intensive Care Unit, St George Hospital, Sydney, Australia; 8Intensive Care Unit, Royal North Shore Hospital, Sydney, Australia; 9Intensive Care Unit, Westmead Hospital, Sydney, Australia; 10Intensive Care Unit, Wollongong Hospital, Wollongong, Australia; 11Intensive Care Unit, Newcastle Hospital, Newcastle, Australia. Purpose: Hearts from DCD donors are not used clinically due to concern of warm ischaemic injury. Our preclinical porcine studies have shown that, utilising a pharmacological post-conditioning strategy and ex vivo normothermic perfusion, warm ischaemic times (WIT) of ≤ 30 mins are tolerated with good recovery. We report the first two cases of human DCD donor heart resuscitation using this strategy. Methods: Donor 01 was a 62 y.o male with Guillain Barre Syndrome. WIT (b/w extubation & organ preservation) was 32 mins. Donor 2 was a 39 y.o male, with hypoxic encephalopathy (drug overdose). He was declared brain dead (BD), but subsequently exposed to 30 mins of WIT for the study. Post WIT, hearts were flushed with Celsior solution supplemented with postconditioning agents. Hearts were reperfused on a modified Transmedics
3( 12) Assessment of Myocardial Performance During Ex Vivo Heart Perfusion C.W. White ,1 Y. Li,2 A. Müller,2 E. Ambrose,2 B. Hiebert,1 T.W. Lee,3 R.C. Arora,1 G. Tian,4 J. Nagendran,5 L. Hryskho,2 D.H. Freed.5 1Cardiac Surgery, University of Manitoba, Winnipeg, MB, Canada; 2Institute of Cardiovascular Sciences, St. Boniface Research Center, Winnipeg, MB, Canada; 3Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada; 4National Research Council Institute for Biodiagnostics, Winnipeg, MB, Canada; 5Cardiac Surgery, University of Alberta, Edmonton, AB, Canada. Purpose: Ex vivo heart perfusion (EVHP) has been proposed as a means to resuscitate non-utilized donor hearts and expand the pool of organs available for transplantation. However, a reliable means of demonstrating organ viability prior to transplantation is required. Therefore, we sought to identify metabolic and functional parameters that correlated with myocardial performance during EVHP. Methods: Six normal pig hearts and 8 donation after circulatory death hearts were procured and perfused ex vivo with a donor blood-STEEN solution (hemoglobin concentration of 45 g/L). Hearts were transitioned into a working mode for assessments after 1, 3, and 5 hours of EVHP. Myocardial