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UPDATE IN CARDIOTHORACIC TRANSPLANTATION

UPDATE IN CARDIOTHORACIC TRANSPLANTATION. Bartlomiej Zych, Diana Gracia-Saez, and Andre R Simon . Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Harefield Hospital, London , United Kingdom. Heart transplant activity UK.

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UPDATE IN CARDIOTHORACIC TRANSPLANTATION

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  1. UPDATE IN CARDIOTHORACIC TRANSPLANTATION Bartlomiej Zych, Diana Gracia-Saez, and Andre R Simon . Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Harefield Hospital, London, United Kingdom.

  2. Heart transplant activity UK

  3. Lung and heart/lung transplant activity UK

  4. UK Donor Scout Pilot Project • Early aggressive donor assessment and management including: • Invasive hemodynamic monitoring. • TOE. • Bronchoscopy. • Performed by dedicated cardiothoracic transplant teams.

  5. Principle of donor management “… in essence, donor management is a continuation of previous critical care management but with a shift in goals’’ McKeown DW. et al. BJA 2012

  6. Impact of brain stem death on cardiovascular system and lungs.

  7. Impact of brain stem death on cardiovascular system and lungs. Arab D et al. Intensive Care Med 2003

  8. Impact of brain stem death on carrdiovascular system and lungs. • Phase I - Catecholamine Storm/hypertension: • Increase in ICP , compensatory hypertension. • Marked sympathetic stimulation, intense vasoconstriction, • raised SVR. • Consequences: • Central redistribution of blood, increased afterload • decreased coronary flow, subendocardial ischemia. • 20 - 25% DBD donors with myocardial injury, approx. 40% with echocardiographic proven myocardial dysfunction. • Pulmonary oedema: raised hydrostatic pulmonary • pressure, endothelial damage – catecholamines.

  9. Impact of brain stem death on cardiovascular system and lungs. • Phase II: Hypotension and hemodynamic instability. • Neurogeniccomponent • Result of defective vasomotor control and subsequent, • progressive loss of SVR. • Hypovolaemic component • Therapeutic dehydration for cerebral oedema. • Haemorrhage. • Diabetes insipidus with massive diuresis. • Osmotic diuresis due to hyperglycaemia. • Cardiogenic component • Hypothermic depression of myocardial contractility. • Left ventricular dysfunction (catecholamine storm).

  10. Impact of brain stem death on cardiovascular system and lungs.

  11. Impact of brain stem death on cardiovascular system and lungs. • Incidence of pathophysiological changes following brain stem death: Physiologic changes During Brain Stem Death – Lessons for Management of the Organ Donor. The Journal of Heart & Lung Transplantation Sept 2004 (suppl) McKeown DW. et al. BJA 2012

  12. Cardiovascular Management McKeown DW. et al. BJA 2012

  13. Changes in UK transplant activity 2013-2014

  14. Changes in UK transplant activity 2013-2014

  15. Transmedics – Organ Care System for heart • Preservation-transport of acontinuously perfused, beating heart at 34°C. • Avoids the negative effect of prolongedcold ischemic storage. • Additional assessment options.

  16. Transmedics – Organ Care System for heart

  17. At Donor site • Donor management; Weaning inotropes, Hematocrit > 30% • Donor blood collection (1500 ml) inmediately before aortic X Clamp • Heart cannulation and instrumentation to OCS™ • Heart management and assessment on OCS: • Perfusion parameters (Aortic Pressure- AOP , Coronary flow-CF) • Lactate: Venous < Arterial << 5 mmol/L and Lactate decreasing over time indicate good myocardial perfusion

  18. ZONAL Northwich East Surrey Southampton x2 Oxford x3 St George’s x2 Charing Cross St Mary’s Extending Safe Retrieval Range Using OCS NON ZONAL Barnsley Milton Keynes Glasgow Kings London Bath Newcastle x2 Dublin North Wales Exeter Yeovil district Edinburgh x3 Ashford x2 Belfast Plymouth . Aberdeen . . Edinburgh Glasgow . Newcastle . Belfast . Manchester . . Dublin Nottingham Oxford . London . . Bristol . Cardiff Bath

  19. OCS Case Series22February 2013 – 29 April 2014 Donor Hearts Assessed on OCS 36 Hearts Transplanted 30 Turned Down After OCS Assessment = 6 Stable Perfusion & Lactate Profile Significant down-time Rising Lactate Unstable perfusion parameters 1 patient died after 44 days (Death not related with heart function)

  20. Donor-Recipient Profile

  21. Donor-Recipient Profile

  22. Donor-Recipient Profile

  23. Donor-Recipient Profile

  24. Donor-Recipient Profile

  25. Donation after circulatory death - DCD • Braindeaddonors (DBD) arethemainsource of theorgans for transplantation. • Donationaftercirculatorydead (DCD) donorswereintroduced to lungtransplantation by Lovein 1995. • Maastricht classification was introducedin 1995 and amendedin 2000. • Category I – dead on arrival to hosital • Category II – unsuccefulresuscitation • Category III – awaitingcardiacarrest • Category IV – cardiacarrestafterbraindeathdiagnosis • Category V – in-hospitalcardiacarrest

  26. Background • Organ donor shortage is a main limitation of transplantation. Only 20 % of actual donors are donating lungs. 2009 OPTN/SRTR Annual Report. Transplant Activity in the UK.. Activity Report 2009/2010. • Lungs tolerate well warm ischemia up to 60-90 minutes in research settings. • Egan TM et al. Ann Thorac Surg 1991;52:1113-1120 • Van Redmonck DE et al. Ann Surg 1998;228:788-796 • Loehe F et al. Ann Thorac Surg 2000;69:1556-1562 • Preliminary studies evaluating results of controlled DCD lung transplantation showed promising results comparable to standard procedures utilizing the organs from brain-dead donors. • De Oliveira NC et al. J Thora Cardiovasc Surg 2010;139:1306-1315 • De Vleeshauwer SI et al. J Heart Lung Transplant 2011;30:975-981 • Van De Wauwer C et al. Eur J Cardiothoracic Surg 2011; 39:e175-180

  27. Background • AGONAL TIME • WOT – CARDIAC ARREST • WARM ISCHEMIC TIME BEGINNING: • Sat O2<70% • SBP<50 mmHg • WARM ISCHEMIC TIME END • PA flush • Acceptable warm ischemic time up to 1 hour

  28. Management before Withdrawal of Life sustaining Treatment: “Maintenance of life-sustaining treatment may be considered to be in the best interests of someone who wanted to be a donor if it facilitates donation and does not cause them harm or distress, or place them at significant risk of experiencing harm or distress.” No treatment specifically aimed at organ donation should be instituted before the decision to withdraw treatment has been made. Potential DCD donors should be cared for by staff with the appropriate competencies, particularly in end of life care. This may involve moving a patient from the ED to an ICU if possible, according to local policy. DCD CONSENSUS MEETING REPORT (June 2010)

  29. Process of Withdrawal of Life Sustaining Treatment • Withdrawal of cardio-respiratory support should always be conducted under the close supervision of senior medical staff (ITU) • Airway management (differs across UK) • Actions after the withdrawal of Life Sustaining Treatment • Theatre teams are ready • Every 5 minutes coordinator to communicate vital signs • Abandon retrieval if patient remains stable for 120 min or • functional warm ischemia ( RR below 50 mmHg, O2Sat below 70%) exceeds 60 min for lungs (different for each organ)

  30. Diagnosis of death: • “the individual should be observed by the person responsible for confirming death for a minimum of five minutes to establish that irreversible cardio respiratory arrest has occurred” (Academy of Medical Royal Colleges Code of Practice) • Confirm absence of circulation: arterial line/ echocardiography/ asystole on ECG • No intervention that can potentially restore cerebral circulation and function is allowed under any circumstances!

  31. Process of organ retrieval • Patient transferred to theatre ( 5 min after cardiac arrest) • Reintubation –anaesthetist ( 10 min after cardiac arrest) • Bronchoscopy ( rule out aspiration, secretion) by one Surgeon Simultaneously by 2 Surgeon: • - opening of chest • - cross clamp on aorta ( isolate cerebral circulation) • - insertion of cannula into pulmonary artery • - ventilate lungs – recruit atelectatic lung areas • - start pulmoplegia • - apply topical cooling with crushed ice • Organ harvest

  32. Lungs from donation after circulatory death donors: an alternative source to brain-dead donors? Midterm results at a single institution Bartlomiej Zych,*, Aron-Frederik Popov, Mohamed Amrani, Toufan Bahrami, Karen Christina Redmond, Heike Krueger, Martin Carby and André Ruediger Simon European Journal of Cardio-Thoracic Surgery 2012 Sep;42(3):542-9

  33. Results Donorcharacteristics ICH – intracranial hemorrhage HBI – hypoxic brain injury TBI - traumatic brain injury CVA – cerebrovascular accident

  34. Results Recipient’s characteristics and postoperative outcome

  35. Survival p=ns 100% DCD DBD 80% 60% 40% 20% 0% 0.00 500.00 1000.00 1500.00 2000.00 Time after transplant (days) Patient at risk 1 year 2 years 3 years 4 years DCD 18(88.5%) 10(81.7%) 4(81.7%) 1(81.7%) DBD 93(86.5%) 61(76.6%) 32(74.8%) 5(70.9%) Results

  36. Freedom from BOS 100 % DCD DBD 80 % p=ns 60 % 40 % 20 % 0 % 0.00 500.00 1000.00 1500.00 2000.00 Time after transplantation (days) Patient at risk 1 year 2 years 3 years 4 years DCD 15(94.7%) 9(82.9%) 4(82.9%) 1(82.9%) DBD 85(90.6%) 54(82.8%) 29(80.8%) 3(80.8%) Results Lung function tests and freedom from BOS p=ns

  37. Results Primary Graft Dysfunction p=ns

  38. Results Rejection p=ns

  39. Conclusions • DCD lungs are a valuable source of good quality organs for transplantation providing a similar results compare to standard DBD lung transplantations.

  40. Thank you very much for your kind attention

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