Circulatory Death Heart Transplantation Research Articles

(233) - Donation After Circulatory Death Heart Transplantation - Withdrawal Practices and Location Matter!

(233) - Donation After Circulatory Death Heart Transplantation - Withdrawal Practices and Location Matter!

(517) - Donation After Circulatory Death Heart Transplantation with Ex-Vivo Perfusion: Is It Ready for Prime Time?

(517) - Donation After Circulatory Death Heart Transplantation with Ex-Vivo Perfusion: Is It Ready for Prime Time?

(429) - Early Cardiac and Renal Complication Risk in Donor After Circulatory Death Heart Transplantation

(429) - Early Cardiac and Renal Complication Risk in Donor After Circulatory Death Heart Transplantation

(238) - Role of Traditional Cardiac Biomarkers in Donation After Circulatory Death Heart Transplantation

(238) - Role of Traditional Cardiac Biomarkers in Donation After Circulatory Death Heart Transplantation

Can we safely expand the donation after circulatory death donor heart pool by extending the donor age limit?

ObjectiveThis study evaluates the impact of donor age on outcomes following donation after circulatory death heart transplantation. MethodsThe United Network for Organ Sharing registry was queried to analyze adult recipients who underwent isolated donation after circulatory heart transplantation from January 1, 2019, to September 30, 2023. The cohort was stratified into 2 groups according to donor age, where advanced donor age was defined as 40 years or more. Outcomes were 90-day and 1-year post-transplant survival. Propensity score matching was performed. Subgroup analysis was performed to evaluate the effects of recipient age on 90-day survival among the recipients with advanced-age donors. ResultsA total of 994 recipients were included in the study period, and 161 patients (17.1%) received allografts from advanced-age donors. During the study period, the annual incidence of donation after circulatory heart transplantation with advanced-age donors substantially increased. The recipients with advanced-age donors had similar 90-day and 1-year post-transplant survivals compared with the recipients with younger donors. The comparable 90-day survival persisted in a propensity score–matched comparison. In the subgroup analysis among the recipients with advanced-age donors, the recipients aged 60 years or more had significantly reduced 90-day survival compared with the recipients aged less than 60 years. ConclusionsThe use of appropriately selected donation after circulatory donors aged 40 years or more has similar survival compared with that of younger donors. With careful candidate risk stratification and selection, consideration of using donation after circulatory donors aged more than 40 years may further ameliorate ongoing organ shortage with comparable early post-transplant outcomes.

Financial impact of donation after circulatory death heart transplantation: A single-center analysis.

Clinical success of donation after circulatory death (DCD) heart transplantation is leading to growing adoption of this technique. In comparison to procurement from a brain-dead donor, DCD requires additional resources. The economic impact of DCD heart transplantation from the hospital perspective is not well known. We compared the financial data of patients who received DCD allografts to those who received a DBD organ at our institution from January 1, 2021 to December 31, 2022. We also compared the cost of ex-situ machine perfusion to in-situ organ perfusion employed during DCD recovery. We performed 58 DBD and 22 DCD heart-alone transplantations during the study period. Out of 22 DCD grafts, 16 were recovered with thoracoabdominal normothermic regional perfusion (TA-NRP) and six with direct procurement followed by normothermic machine perfusion (DP-NMP). The contribution margin per case for DBD versus DCD was $234,362 and $235,440 (P=.72). The direct costs did not significantly differ between the two groups ($171,949 and 186,250; P=.49). In comparing the two methods of procuring hearts from DCD donors, the direct cost of TA-NRP was $155,955 in comparison to $223,399 for DP-NMP (P=.21). This difference translated into a clinically meaningful but not statistically significant greater contribution margin for TA-NRP ($242, 657vs. $175,768; P=.34). Our data showed that the adoption of DCD procurement did not have a negative financial impact on the contribution margin in our institution. Programs considering starting DCD heart transplantation, and those who are currently performing DCD procurement should evaluate their own financial situation.

Effects of ketone body 3-hydroxybutyrate on cardiac and mitochondrial function during donation after circulatory death heart transplantation

Normothermic regional perfusion (NRP) allows assessment of therapeutic interventions prior to donation after circulatory death transplantation. Sodium-3-hydroxybutyrate (3-OHB) increases cardiac output in heart failure patients and diminishes ischemia–reperfusion injury, presumably by improving mitochondrial metabolism. We investigated effects of 3-OHB on cardiac and mitochondrial function in transplanted hearts and in cardiac organoids. Donor pigs (n = 14) underwent circulatory death followed by NRP. Following static cold storage, hearts were transplanted into recipient pigs. 3-OHB or Ringer’s acetate infusions were initiated during NRP and after transplantation. We evaluated hemodynamics and mitochondrial function. 3-OHB mediated effects on contractility, relaxation, calcium, and conduction were tested in cardiac organoids from human pluripotent stem cells. Following NRP, 3-OHB increased cardiac output (P < 0.0001) by increasing stroke volume (P = 0.006), dP/dt (P = 0.02) and reducing arterial elastance (P = 0.02). Following transplantation, infusion of 3-OHB maintained mitochondrial respiration (P = 0.009) but caused inotropy-resistant vasoplegia that prevented weaning. In cardiac organoids, 3-OHB increased contraction amplitude (P = 0.002) and shortened contraction duration (P = 0.013) without affecting calcium handling or conduction velocity. 3-OHB had beneficial cardiac effects and may have a potential to secure cardiac function during heart transplantation. Further studies are needed to optimize administration practice in donors and recipients and to validate the effect on mitochondrial function.

Outcomes Of Donor Circulatory Death Heart Transplantation In Recipients With Durable Left Ventricular Assist Device

Outcomes Of Donor Circulatory Death Heart Transplantation In Recipients With Durable Left Ventricular Assist Device

Abstract 13887: Longitudinal Trends in Donor and Recipient Risk Profile, and Clinical Outcomes, for Donation After Circulatory Death Heart Transplantation

Background: The US rate of Donation after Circulatory Death (DCD) Heart Transplant (HT) increased threefold from 2020 to 2022. While early analyses of DCD HT have suggested similar outcomes compared to donation after brain death HT, this may be the result of a restrictive DCD donor and recipient selection process, intended to minimize risk in the first US DCD HT cohorts. Hypothesis: We hypothesized that risk profiles for DCD HT donors and recipients have increased over time, as DCD HT has rapidly expanded. We sought to identify longitudinal changes in risk profiles for DCD donors and recipients from 2019-2023, and determine if such changes have impacted post-DCD HT clinical outcomes. Methods: We analyzed the UNOS thoracic organ database from December 2019 to March 2023. DCD HT donor and recipient risk characteristics were evaluated over time for significant trend. One-year recipient survival was compared over time. Results: During the study period, 716 DCD HT were performed. Recipients were mostly male (79%), Caucasian (68%), and had mean age of 54 years. Over time, several donor and recipient characteristics were significantly different (Table, Figure). Donors were older, and had increased BMI, creatinine, and agonal phase to cross-clamp time, although overall lower ischemic time. Recipients were more likely to be status 1 or 2, and had increased BMI, waitlist time, creatinine, and CPRA. Donor and recipient comorbidities and mechanical support use were unchanged. Post-HT survival over time was unchanged. Conclusions: Since the first US DCD HT, several donor and recipient risk-factors have increased. These increased risk profiles have not translated into reduced one-year survival.

Longitudinal Trends in Donor and Recipient Risk Profile, and Clinical Outcomes, for Donation After Circulatory Death Heart Transplantation.

Longitudinal Trends in Donor and Recipient Risk Profile, and Clinical Outcomes, for Donation After Circulatory Death Heart Transplantation.

Early national trends of lung allograft use during donation after circulatory death heart procurement in the United States

ObjectiveInnovative technology such as normothermic regional perfusion and the Organ Care System has expanded donation after circulatory death heart transplantation. We wanted to investigate the impact of donation after circulatory death heart procurement in concurrent lung donation and implantation at a national level. MethodsWe reviewed the United Network for Organ Sharing database for heart donation between December 2019 and March 2022. Donation after circulatory death donors were separated from donation after brain death donors and further categorized based on concomitant organ procurement of lung and heart, or heart only. ResultsA total of 8802 heart procurements consisted of 332 donation after circulatory death donors and 8470 donation after brain death donors. Concomitant lung procurement was lower among donation after circulatory death donors (19.3%) than in donation after brain death donors (38.0%, P < .001). The transplant rate of lungs in the setting of concomitant procurement is 13.6% in donation after circulatory death, whereas it is 38% in donation after brain death (P < .001). Of the 121 lungs from 64 donation after circulatory death donors, 22 lungs were retrieved but discarded (32.2%). Normothermic regional perfusion was performed in 37.3% of donation after circulatory death donors, and there was no difference in lung use between normothermic regional perfusion versus direct procurement and perfusion (20.2% and 18.8%). There was also no difference in 1-year survival between normothermic regional perfusion and direct procurement and perfusion. ConclusionsAlthough national use of donation after circulatory death hearts has increased, donation after circulatory death lungs has remained at a steady state. The implantation of lungs after concurrent procurement with the heart remains low, whereas transplantation of donation after circulatory death hearts is greater than 90%. The use of normothermic regional perfusion lungs has been controversial, and we report comparable 1-year outcomes to standard donation after circulatory death lungs. Further studies are warranted to investigate the underlying mechanisms of normothermic regional perfusion on lung function.

The effect of warm ischemia and donor ejection fraction on 30-day mortality after donation after circulatory death heart transplantation: A national database analysis

Donation after circulatory death (DCD) donor hearts recovered using the direct procurement and perfusion method experience variable durations of warm ischemia at the time of procurement (WIP). We used the Organ Procurement and Transplantation Network database to assess the effect of WIP on 30-day mortality after DCD heart transplantation. The analysis evaluated outcomes in 237 recipients of DCD heart transplantation, demonstrating an optimal WIP cut point of <36minutes. Multivariable logistic regression modeling identified donor left ventricular ejection fraction (LVEF) <60% as an independent predictor of 30-day mortality. The area under the receiver operating characteristic curve for predicting 30-day mortality based on WIP ≥36minutes and donor LVEF <60% was 0.90. Based on these findings, we do not recommend proceeding with DCD heart transplantation for patients with WIP ≥36minutes, particularly in donors with LVEF <60%.

(111) Pushing The Boundaries of Donation After Circulatory Death Heart Transplantation - The Australian Experience

(111) Pushing The Boundaries of Donation After Circulatory Death Heart Transplantation - The Australian Experience

(191) Impact of Functional Warm Ischemic Time on Short Term Outcomes in Donation after Circulatory Death Heart Transplantation

(191) Impact of Functional Warm Ischemic Time on Short Term Outcomes in Donation after Circulatory Death Heart Transplantation

(1067) Donation after Circulatory Death Heart Transplantation Reduces Length of Stay and Associated Costs: A Single Center Comparison

(1067) Donation after Circulatory Death Heart Transplantation Reduces Length of Stay and Associated Costs: A Single Center Comparison

Impact of donation after circulatory death heart transplantation on waitlist outcomes and transplantation activity.

Donation after circulatory death (DCD) heart transplantation has been shown to have comparable outcomes to transplantation using brain death donors (DBDs). This study evaluates the impact of this alternative source of allografts on waitlist mortality and transplant volume. We compared waitlist mortality and transplant rates in patients who were registered before (2019 period) and after we adopted DCD heart transplantation (2021 period). We identified 111 patients who were on the waiting list in 2019 and 77 patients who were registered during 2021. Total number of donor organ offers received in 2019 was 385 (178 unique donors) versus 3450 (1145 unique donors) in 2021. More than 40% of all donors in 2021 were DCDs. Waitlist mortality was comparable for patients in 2019 and 2021 (18/100 person-years in 2019 vs. 26/100 person-years in 2021, p=.49). The transplant rate was 67/100 person-years in 2019 versus 207/100 person-years in 2021 (p<.001). After adjusting for acuity status, gender, blood type, and weight, patients listed in 2021 had 2.08 times greater chance of transplantation compared to patients listed in 2019 (HR 2.08, 95% confidence interval [CI] 1.26-3.45, p=.004). Use of DCD donor hearts significantly increased heart transplant rate in our institution.

Ex-situ oxygenated hypothermic machine perfusion in donation after circulatory death heart transplantation following either direct procurement or in-situ normothermic regional perfusion

Heart transplantation in donation after circulatory death (DCD) relies on warm perfusion using either in situ normothermic regional perfusion (NRP) or ex situ normothermic machine perfusion. In this study, we explore an alternative: oxygenated hypothermic machine perfusion (HMP) using a novel clinically applicable perfusion system, which is compared to NRP with static cold storage (SCS). In a porcine model, a DCD setting was simulated, followed by either (1) NRP and SCS (2) NRP and HMP with the XVIVO Heart preservation system or (3) direct procurement (DPP) and HMP. After preservation, heart transplantation (HTX) was performed. After weaning from cardiopulmonary bypass (CPB), biventricular function was assessed by admittance and Swan-Ganz catheters. Only transplanted hearts in the HMP groups showed significantly increased biventricular contractility (end-systole elastance) 2 hour post-CPB (left ventricle absolute change: NRP HMP: +1.8 ± 0.56, p=0.047, DPP HMP: +1.5 ± 0.43, p=0.045 and NRP SCS: +0.97 ± 0.47 mmHg/ml, p=0.21; right ventricle absolute change: NRP HMP: +0.50 ± 0.12, p=0.025, DPP HMP: +0.82 ± 0.23, p=0.039 and NRP SCS: +0.28 ± 0.26, p=0.52) while receiving significantly less dobutamine to maintain a cardiac output >4l/min compared to SCS. Diastolic function was preserved in all groups. Post-HTX, both HMP groups showed significantly less increments in plasma troponin T compared to SCS. In DCD HTX, increased biventricular contractility post-HTX was only observed in hearts preserved with HMP. In addition, the need for inotropic support and signs of myocardial damage were lower in the HMP groups. DCD HTX can be successfully performed using DPP followed by preservation with HMP in a preclinical setting.

Early Outcomes of Donation After Circulatory Death Heart Transplantation with Thoracoabdominal Normothermic Regional Perfusion

<h3>Purpose</h3> To evaluate the early outcomes of donation after circulatory death (DCD) heart transplantation using thoracoabdominal normothermic regional perfusion (TA-NRP). <h3>Methods</h3> The study is designed as a single center prospective study with single arm. Institutional Review Board approved this pilot for a total number of 60 potential DCD heart recipients using grafts recovered with TA-NRP technique (IRB#460-20-FB). The first patient was enrolled on January 3rd 2021. The anticipated study duration is one year for a total of 10 transplant procedures. Recipient inclusion criteria are age ≥ 19 years, signed informed consent, and eligibility for heart transplantation based on standardized institutional criteria. Patients listed for dual organ transplantation and patients with previous cardiac operation including durable LVAD implantation will also be included. All hearts will be recovered with TA-NRP after no more than 30 minutes of warm ischemia (defined as the time period commencing from SBP < 50 mmHg to in-situ reperfusion). TA-NRP protocol is summarized in Figure 1. Acceptance for transplantation will be based upon the functional assessment with TEE and invasive hemodynamic measurements combined with the visual inspection after separation from mechanical support. Grafts will be recovered using 2,000mL of Celsior® for cardio protection, and transported with colds storage. All implantation procedures will be performed at our institution. Recipients will receive standardized immunosuppression and infection prophylaxis and will undergo rejection surveillance with serial endomyocardial biopsies. <h3>Endpoints</h3> Primary outcome is 30-day patient survival. Secondary outcomes are primary graft dysfunction and inotropic score at 72 hours, ICU and hospital length of stay, ventilation duration, and the need for renal replacement therapy.

Impact of Donation After Circulatory Death Heart Transplantation on Waitlist Outcomes and Transplantation Activity

<h3>Purpose</h3> To assess the impact of increased availability of donor hearts from donors after circulatory death on waiting list and heart transplantation activity. <h3>Methods</h3> We compared changes in waitlist activity and transplant volumes in patients before and after we adopted DCD heart transplantation into our program. Outcomes of patients who were on the waiting list between January and August 2020 (Period 1) were compared to those listed between January and August 2021 (Period 2). <h3>Results</h3> Waitlist volumes were 10.6 patients listed per month in Period 1 (N = 85) and 7.5 patients in Period 2 (N = 60). The median waitlist time to transplant decreased from 339 days in Period 1 to 77 days in Period 2 (<i>P</i> = .035). The transplant rate increased from 92 per 100 patient-years in Period 1 to 186 per 100 patient-years in Period 2 (<i>P</i> = .004). No status 5 and 6 recipients were transplanted in Period 1 as opposed to 13% in Period 2 (Figure 1). Waitlist mortality rate, hospital stay post-transplantation, and post-transplant mortality did not differ significantly between the time periods. <h3>Conclusion</h3> This single-center retrospective analysis suggests that the use of DCD donor hearts may result in a reduced HTx waitlist time and an increased transplant rate. DCD increases organ availability to recipients in lowers status categories. In addition, transplanting DCD donor hearts can provide comparable short-term post-transplant outcomes to DBD. Figure 1. Transplant activity stratified by recipient status.

Donation after circulatory death heart transplantation in the United States: An early report of donor characteristics.

In the United States, heart transplantation continues to be constrained by a limited supply of donor organs. Over the past decade, we have seen a dramatic rise in the number of candidates listed for heart transplantation, with the number of transplants performed increasing, although at a lesser rate.1 A multitude of efforts are being undertaken to increase the size of the donor pool, including the transplantation of expanded-criteria donor hearts, the use of normothermic ex vivo perfusion techniques, as well as a renewed interest in transplanting hearts following donation after circulatory death (DCD).