Organ Retrieval Research Articles

Multi-organ retrieval in donation after brain stem death

Organ donation after brain stem death is quite common in the west. In India, the procedure is still gaining acceptance. The surgical steps for multi-organ retrieval have evolved in different centers with significant variations, and the scientific evidence levels for each technique are low. Organ retrieval requires a fairly rapid surgical technique to avoid ischemic injury to the target organs yet avoid iatrogenic injuries. This article offers and outline of the multi-organ donation procedure. It details the abdominal organ retrieval techniques and touches on thoracic organs and composite tissue grafts as well. It also briefly touches upon machine perfusion of organs.

High-dose ulinastatin to prevent late-onset acute renal failure after orthotopic liver transplantation

Purpose To compare the efficacy and safety of two distinct doses of ulinastatin on late-onset acute renal failure (LARF) following orthotopic liver transplantation (OLT). Methods The high-risk recipients that underwent OLT were divided into two groups according to ulinastatin dose: low-dose (LD) ulinastatin group, 0.8 million U/d; high-dose (HD) ulinastatin group, 1.6 million U/d. The primary outcome was the incidence of LARF, which was defined the newly onset acute kidney injury (AKI) stage III (KDIGO, 2012) within 7–28 post-transplant days. The second outcomes were early multiple organ retrieval assessments, length of hospital stay and safety events. Results A total of 174 recipients were included (LD ulinastatin group, n = 55; HD ulinastatin group, n = 119). There was no significant difference in the incidence of LARF between LD (8/55, 14.50%) and HD (9/119, 7.56%) ulinastatin groups (HD vs. LD, HR, 0.49; 95%CI, 0.17–1.37; p = .1295). Multivariate Cox proportion risk regression model revealed HD ulinastatin (HR, 0.57; 95%CI, 0.38–0.98; p = .0464) was an independent protective factor for LARF. Early lactate level, oxygenation, AKI stage, graft function, and sequential organ failure assessment [SOFA] score were significantly improved in HD ulinastatin group versus LD ulinastatin group. No significant adverse events were observed in either group. Conclusions Higher dose of ulinastatin (1.6 million U/d) might be preferable to prevent LARF after OLT, and it may contribute to the enhancement of early multiple organ recovery and thus attenuate the incidence of LARF.

Response to Shroff and Navin's article on "brain death" and "circulatory death" in IJME.

It was refreshing to read about the relevant real-life situations that we face in the ICU in the article by Drs Shroff and Navin in the October 2018 issue of IJME. I would like to highlight four different issues related to brain death and organ retrieval.

242.6: Outcome of kidney transplantation from donation after circulatory death.

Background: The use of organs from donors after circulatory death (DCD) has become standard practice in solid organ transplantation in most of the countries. However, it has not contributed much to increase the transplant numbers in India due to lack of proper guidelines for withdrawal of life support in the country’s Transplantation of Human Organs Act 1994. Transplantation of kidneys procured from DCD is being done by only a few centres in the country. This study reviews the outcome of kidney transplantation from donation after circulatory death at our centre. Methods: A retrospective, single-centre analysis of transplantation of kidneys procured from DCD donors. Out of 275 deceased donor transplants performed at our hospital form Feb 2011-Nov 2018, 24 were procured from 15 DCD donors. Seven donors had a cardiac arrest after the first brain death certifying committee evaluation. Five donors had cardiac arrest after brain death certification. Two donors were refused brain death certification due to confounding factors. One patient with terminal lung disease had cardiac arrest in ICU. After declaration of death, chest compressions were continued in 11/15 donors to maintain circulation and ventilation was continued till organ retrieval. Rapid organ retrieval was done using double balloon triple lumen catheter. All recipients received ATG or Simulect induction along with Tacrolimus, Mycophenolate and steroids. Results: During the study period thirty kidneys retrieved from 15 DCD donors, kidneys from 2 donors were not used for transplant due to high resistance during perfusion. One more kidney was not utilized as potential recipient withdrew consent at advanced stage. Rest 24 kidneys were used for transplant. 13 donors had head injury, one had CVA and one had terminal lung failure as cause of death. Mean donor age was 32.8 ± 13.6 years. Mean recipients age was 42.5 ± 11.3 years. All except 5 recipients required dialysis in postoperative period. One kidney had primary non functional whereas in one with dual kidney transplant, both kidneys had to be removed due to persistent severe interaoperative hypotension in the recipient. One graft was lost at 6 years. Mean warm ischemia time was 35.04 ± 11.0 minutes. Mean cold ischemia time was 06:51hrs. Mean creatinine at discharge was 1.49 ± 0.39 mg% and at the last follow-up of 33.9 + 22.7 months was 1.37 + 0.55mg %. Conclusions: Kidney transplantation from DCD donors yields good results in the long term. These DCD grafts may be a good option to cope with increasing organ shortages in order to expand the donor pool.

307.2: Successful liver and kidney transplantations from a donor with left ventricular assist device.

Background: Organ transplantation from donors with ventricular assist devices are not common. Here, we report organ retrieval from a donor with a left ventricular assist device (LVAD) who was on the heart transplant waiting list before brain death diagnosis. Presentation of Case: The organ donor was diagnosed with dilated cardiomyopathy and underwent LVAD surgery for bridging to heart transplantation in 2016. Brain death occurred 22 months after LVAD implantation at the age of 39 due to widespread intraparenchymal and subarachnoid hemorrhage. Brain death diagnosis was confirmed with brain perfusion SPECT (Tc-99m HMPAO). In accordance with the donor’s will, the relatives approved organ donation. The donor’s organ reserve was assessed to be suitable for liver and kidney transplants and proper donor care was given. During organ harvesting, cardiovascular surgeons accompanied the organ transplant team to control LVAD flow and ensure optimum organ perfusion. After a successful operation, the liver was transplanted to a patient awaiting liver transplantation for 13 years with a diagnosis of primary sclerosing cholangitis, the kidneys were transplanted to patients awaiting kidney transplantation for 31 and 14 years with diagnoses of nephrolithiasis and polycystic kidney disease, respectively. No complications occurred among the liver and kidney transplant recipients. Conclusions: There are very few reported donors with assist device. This is the first case of an organ donor with an assist device waiting for an organ transplantation who became an actual donor in our country.

P.169: Canada-DONATE: Preliminary results from a mutlicentre prospective observational study.

On behalf of the Canadian Critical Care Trials Group and. the Canadian Donation and Transplant Research Program. Background: Canadian donor management practices have not been reported. Our aim was to inform clinicians and other stakeholders about the range of current practices. Methods: We consecutively enrolled all consented adult deceased organ donors [donation after neurological determination of death (DND) and donation after circulatory determination of death (DCD)] in 32 participating hospitals across Canada, utilizing a waiver of research consent,. Research staff prospectively recorded detailed data from various hospital sources included death determination procedures, cardiopulmonary monitoring technologies, general prophylactic interventions, organ donation specific therapies and clinical complications, defined a priori, from one day prior to donation consent up to the time of organ recovery. Organ Donation Organizations provided reasons of organ decline, date, time and location of transplant procedure, and recipient age and sex. We formally compared practices across multiple provinces. Results: From August 2015 to August 2018, we screened 641 potential donors and enrolled 622, classified at baseline as having a neurological death (NDD donors; 403) or imminent circulatory death (DCD donors; 219). Mean age was 51.5 ± 16.6 and 40.0% were female. The most prevalent diagnoses leading to organ donation were anoxic brain injury (34.4%), brain hemorrhage (30.1%), brain trauma (23.6%), and stroke (6.6%). The mean time from donation consent to organ retrieval was similarly 1.6 days (±0.7SD) among NDD and DCD donors who ultimately donated organs. NDD donors, were more hemodynamically unstable: most received vasopressin and norepinephrine infusions, and a large majority received high-dose corticosteroids and intravenous thyroxine. Among DCD donors, 61.6% received corticosteroids, and 8.9% received thyroxine. Most donors (NDD and DCD) did not receive lung-protective tidal volumes or end expiratory pressures. Nutrition was generally continued for DCD donors, and discontinued for NDD donors. Case selection, death determinations, hormone, nutrition and heparin therapies all varied significantly across provinces. Conclusions: Study findings highlight areas for knowledge translation. Interprovincial discrepancies will pose unique challenges to national randomized trials.

Portable Microfluidic Biosensing System for Real-Time Analysis of Microdialysate in Transplant Kidneys.

Currently, there is a severe shortage of donor kidneys that are fit for transplantation, due in part to a lack of adequate viability assessment tools for transplant organs. This work presents the integration of a novel wireless two-channel amperometric potentiostat with microneedle-based glucose and lactate biosensors housed in a 3D printed chip to create a microfluidic biosensing system that is genuinely portable. The wireless potentiostat transmits data via Bluetooth to an Android app running on a tablet. The whole miniaturized system is fully enclosed and can be integrated with microdialysis to allow continuous monitoring of tissue metabolite levels in real time. We have also developed a wireless portable automated calibration platform so that biosensors can be calibrated away from the laboratory and in transit. As a proof of concept, we have demonstrated the use of this portable analysis system to monitor porcine kidneys for the first time from organ retrieval, through warm ischemia, transportation on ice, right through to cold preservation and reperfusion. The portable system is robust and reliable in the challenging conditions of the abattoir and during kidney transportation and can detect clear physiological changes in the organ associated with clinical interventions.

False-Positive Tumor During Organ Retrieval: All Cats Are Gray in the Dark

ObjectiveEfforts to expand the organ donor pool to meet growing transplant demands remains a top priority, as does maintaining the quality and safety standards of potential recipients. There is a short window of time from organ retrieval to decision making on organ acceptance, based on the available data. Furthermore, the limitations of intraoperative biopsy can often lead to donor or organ refusal due to a suspected tumor, which, if not confirmed in the final biopsy, results in the loss of a transplant opportunity. MethodsDonor characteristics and organs discarded on suspicion of neoplastic disease at the time of extraction were analyzed in Andalusia between January 2014 and July 2018. The variable analysis included sociodemographic data, type of donor, location of the potential malignancy, histopathologic examination, and discarded organs. ResultsA total of 43 cases were identified. The organs of 33 donors (76.7%) were discarded. Kidneys were the most frequent location for a suspected tumor (44%), followed by the liver (21%). In 18 of the 43 cases (42%), the suspected malignancy was not confirmed, and of these, only 3 livers and 1 kidney were implanted. Sixty potentially transplantable organs were discarded, including those that would have been extracted and/or implanted in the absence of a suspected tumor. ConclusionsThese results highlight the need not only to improve the accuracy of intraoperative biopsies but to seek new decision-making strategies for the short interval after organ retrieval. This involves avoiding both extremes of donation contraindications, while maintaining quality and safety standards.

Small renal lesions found during organ retrieval for transplantation purposes: Our experience in donors after brain death over a 8 years period

Small renal lesions found during organ retrieval for transplantation purposes: Our experience in donors after brain death over a 8 years period

Normothermic ex vivo lung perfusion: Does the indication impact organ utilization and patient outcomes after transplantation?

BackgroundEx vivo lung perfusion (EVLP) is being increasingly applied as a method to evaluate and treat donor lungs for transplantation. However, with the previous limited worldwide experience, no studies have been able to evaluate the impact of indication for EVLP on organ utilization rates and recipient outcomes after lung transplantation (LTx). We examined these outcomes in a large-cohort, single-center series of clinical EVLP cases. MethodsAll EVLP procedures performed at our institution between October 2008 and December 2017 were examined. The EVLPs were divided into 4 groups based on the indication for the procedure: group 1, high-risk brain death donors (HR-BDD); group 2, standard-risk donation after cardiac death (S-DCD); group 3, high-risk donation after cardiac death (HR-DCD); and group 4, logistics (LOGISTICS, the need for prolongation of preservation time or organ retrieval by a different transplantation team). ResultsDuring the study period, a total of 1106 lung transplants were performed in our institution. In this period, 372 EVLPs were performed, 255 (69%) of which were accepted for transplantation, resulting in 262 transplants. Utilization rates were 70% (140 of 198) for group 1, 82% (40 of 49) for group 2, 63% (69 of 109) for group 3, and 81% (13 of 16) for group 4 (P = .42, Fisher's exact test). Recipient age (P = .27) and medical diagnosis (P = .31) were not different across the 4 groups. Kaplan–Meier survival by EVLP indication group demonstrated no differences. Thirty-day mortality was 2.1% in group 1, 5% in group 2, 2.9% in group 3, and 0% in group 4 (P = .87, Fisher's exact test). The median days of mechanical ventilation, intensive care unit stay, and hospital stay were 2, 4, and 21 in group 1; 2, 3, and 21 in group 2; 3, 5, and 28 in group 3; and 2, 4, and 17 in group 4 (P = .29, .17, and .09, respectively, Kruskal–Wallis rank-sum test). ConclusionsClinical implementation of EVLP has allowed our program to expand the annual lung transplantation activity by 70% in this time period. It has improved confidence in the utilization of DCD lungs and BDD lungs, with an average 70% utilization of post-EVLP treated donor lungs with excellent outcomes, while addressing significant challenges in donor lung assessment and the logistics of “real-life” clinical lung transplantation.

Beyond Survival in Solid Organ Transplantation: A Summary of Expert Presentations from the Sandoz 6th Standalone Transplantation Meeting, 2018.

Beyond Survival in Solid Organ Transplantation: A Summary of Expert Presentations from the Sandoz 6th Standalone Transplantation Meeting, 2018.

Reasons Why Organs From Deceased Donors Were Not Accepted for Transplantation

IntroductionThe rate of organ donations from deceased donors in Turkey is among the lowest in the world. We analyzed the reasons why some potential donors whose families had given consent did not become actual solid organ donors. MethodsWe retrospectively reviewed the organ donation, retrieval, and transplantation registries of 102 potential donors from the Ministry of Health Organ and Tissue Transplant Coordination Centre of Istanbul Region from the year 2015. ResultsCardiac arrest occurred in 8 of the potential donors while waiting for organ procurement or during surgery. The organ specific suitability ratio was 83% for kidneys, 82% for livers, 72% for hearts, and 75% for lungs. Of these suitable organs, the transplantation rates were as follows: kidneys 88%, livers 70%, hearts 30%, and lungs 13%. Medical reasons (donor unsuitable) (14%–24%) and poor organ function (2%–24%) were the reasons most organs were not accepted for transplant. These reasons included diabetes insipidus, electrolyte imbalance caused by neuro-humoral changes, inotrope/vasopressor requirement for hemodynamic instability, hypoperfusion, and myocardial dysfunction after brain death. ConclusionThe mismatch between organ donation and demand is a major problem worldwide. In addition to low organ donation rates, late diagnosis of potential donors or inappropriate management of the pathophysiological consequences of brain death reduce the number of transplantable organs even more in our country. In order to overcome these setbacks, we need education programs to improve quality and decrease donor losses in an intensive care unit goal-directed protocol for the management of potential donors.

Incidence and Risk Factors for Systemic Infection in Deceased Donors

BackgroundOrgan donation shortage is the primary barrier to all organ transplantations.Infectious disease transmission through transplantation is considered controversial for organ retrieval. Donors with bacteremia and sepsis are considered controversial for organ retrieval due to potential transmission of an infectious agent to the recipient. MethodsWe retrospectively reviewed the results of bacterial culture of the donor's blood from peripheral venous or central venous catheter, urine, and bronchial aspiration from the organ donation registries of 102 potential donors from the Ministry of Health and Tissue Transplant Coordination Center of Istanbul Region in 2015. ResultsOf the 102 deceased donors included in the analysis, 24 (23.5%) had infection. The most common sites of infection were the bloodstream (41.6%) and the respiratory system (37.5%). The most common isolated pathogens of the bacterial cultures were Gram-positive bacteria (21), Gram-negative microorganisms (14), and Candida (1). The significant risk factor for infection was duration of stay at the intensive care unit (median: 5 day; 25–75%: 3–5 day) (odds ratio, 2.94; 95% confidence interval, 1.06–8.12; P < .05). The presence of infection in the donor accounted for a significant part of the reasons why the organs were not accepted for transplantation (kidneys 9%, liver 4%, heart 6%). ConclusionsThe study showed that deceased donors with prolonged stays in the intensive care unit have an increased risk for developing nosocomial infections; so there is a need for establishing and enforcing the prevention and control of infection in possible donors.

Uncontrolled donation after circulatory death and liver transplantation: evidence and unresolved issues.

This review aimed at summarizing the available evidence on liver transplantation from uncontrolled donation after circulatory death (uDCD) on differences in protocols, donor management, in and ex vivo perfusion techniques from center to center. Uncontrolled DCDs represent a unique, complex model of ischemia-reperfusion injury, so far not completely understood. Nevertheless, results on liver transplantation from uDCDs are promising in terms of long-term graft survival. True difficulties still remain since common/shared protocols are not achievable due to legal differences between countries (i.e. no touch period duration). To date, there is no reliable metrics to determine whether a liver is safe to be ex situ perfused or to be transplanted since existing criteria, as stated by investigators themselves, are so far arbitrary. Values and kinetics of transaminanes during normothermic regional perfusion (nRP) should not considered absolute contraindication at least for ex vivo perfusion. Intraoperative evaluation at organ recovery remains pivotal since macroscopic alterations (i.e. hepatic rupture, an abnormal appearance of gall bladder and choledocus) still represent contraindications for organ retrieval. Concerning ex vivo perfusion, the debate is still open, since the choice of type of machine perfusion (mainly hypothermic vs. normothermic) varies from center to center, mainly relying to the single center experience (especially in controlled DCD), surgeons' believes and/or criteria translated from animal models.

The future of organ perfusion and re-conditioning.

SummaryOrgan preservation and re‐conditioning using machine perfusion technologies continue to generate promising results in terms of viability assessment, organ utilization and improved initial graft function. Here, we summarize the latest findings and study the results of ex‐vivo/ex‐situ hypothermic (HMP) and normothermic machine perfusion (NMP) in the area of abdominal organ transplantation (kidney, liver, pancreas and intestine). We also consider the potential role of normothermic regional perfusion (NRP) to re‐condition donors after circulatory death organs before retrieval. The findings from clinical studies reported to date suggest that machine perfusion will offer real benefits when compared with conventional cold preservation. Several randomized trials are expected to report their findings within the next 2 years which may shed light on the relative merits of different perfusion methods and could indicate which perfusion parameters may be most useful to predict organ quality and viability. Further work is needed to identify composite endpoints that are relevant for transplanted organs that have undergone machine preservation. Multi‐centre trials to compare and analyse the combinations of NRP followed by HMP and/or NMP, either directly after organ retrieval using transportable devices or when back‐to‐base, are needed. The potential applications of machine preservation technology beyond the field of solid organ transplantation are also considered.

Fisiopatologia del rigetto acuto e cronico

Allograft rejection is defined as tissue injury produced by the effector mechanisms of the alloimmune response, leading to deterioration of graft function. There are two types of rejection: T-cell-mediated rejection (TCMR) and antibody-mediated rejection (AMR). Both types of rejection can be early or late, fulminant or indolent, as well as isolated or concomitant and can share pathologic features on biopsy. The immune response to an allograft is an ongoing dialogue between the innate and adaptive immune system, which if unresolved will lead to rejection of the transplanted cells, tissues, or organs. Activation of elements of the innate immune system, triggered by tissue injury sustained during cell isolation or organ retrieval and ischemia reperfusion, will initiate and amplify the adaptive response. T cells require a minimum of two signals for activation: antigen recognition and co-stimulation. Antibody-mediated rejection triggered by alloantibody binding and complement activation is increasingly recognized as a significant contribution to graft loss. Even though one component of the immune system may dominate and lead to rejection, this is usually multifactorial, resulting from the integration of multiple mechanisms. Identifying the molecular pathways that trigger rejection facilitates the identification of targets for the development of immunosuppressive drugs.

Donor-Bound Predictors for Primary Graft Function in Lung Transplantation - Results from a Prospective Multicenter Study

Purpose Acceptance rates of donor lungs differ substantially among transplant centers. This is mainly due to a lack of standardized functional parameters of the donor lungs, which can predict organ function after lung transplantation (LTx). Methods A prospective evaluation of lung donors were performed in three transplant centers between January 2017 and September 2018. Standardized ventilation settings were used to collect respiratory and hemodynamic parameters at the time of retrieval. Duration of mechanical ventilation after lung transplantation was defined as the primary end-point. Results A total of 151 lung donors were included in the study. Median donor age was 46 (12-80), median intubation time was 3 days (1-34), 44 (29.1%) donors had smoking history and 19 (12.6%) had chest trauma. At time of retrieval median P/F ratio was 413 mmHg (79-650), median dynamic compliance 45 ml/mbar (14-121) and median pCO2 40 (19-77). In 10 (6.6%) cases, purulent secretions were found during bronchoscopy. In 6 (3.9%) cases evaluation with EVLP followed organ retrieval. Median recipient age was 55 (18-69). The indications for LTx were: COPD (n=61, 40.4%), CF (n=38, 25.2%) and ILD (n=30, 19.9%). Median length of mechanical ventilation was 32 hours (range: 4 - 964). At 72 hours only 1 (0.7%) PGD grade 3 was recorded. P/F ratio at time of offer, donor intubation time, smoking history, donor age, P/F ratio and peak pressure at time of retrieval did not correlate with recipient length of mechanical ventilation and hospitalization time. On the contrary, dynamic compliance at the time of retrieval correlated inversely with recipient weaning time (rs= - 0.199, p Conclusion In this multicenter analysis of lung donor parameters and their relevance for early post-transplant outcome, we found that dynamic compliance of donor lungs was the only factor associated with recipient weaning and hospitalization time. This parameter may have the potential to improve organ selection and subsequently increase the donor pool.

Pediatric Lung Transplantation: Fit for Split?

Purpose The mortality of pediatric patients awaiting lung transplantation is high, among other things because shortage of adequate sized donors. Herein we present our approach for critically ill patients awaiting urgent lung transplantation, in which we extend our donor size criteria and perform volume trimming of the donor lung. Methods A retrospective single center study was performed, reviewing all pediatric lung transplant patients. Between March 2015 and January 2018 twenty patients underwent bilateral lung transplantation. Demography was analysed. The end points include survival outcome and lung function tests following surgery. Results Mean age was 10.6 years (SD 4.6). and mean weight was 31.1kg (SD 14.6). Nine patients had cystic fibrosis, nine pulmonary arterial hypertension and 2 bronchiolitis obliterans. The majority was female (n=11 or 55%). In nine (45%) patients lung trimming (T group) was performed. Lobar venous blood gases taken during organ retrieval were used as guidance to determine which lobe was resected. Univariate analysis revealed no statistical significant difference in mortality between the trimming and the non-trimming group. Lung function tests between 6 and 12 months after transplantation revealed a median FEV of 90% (Min 42% Max 121%) in the non-trimming (NT) group versus 61% (Min 56% Max 97%) in the T group. The median FVC1 in the NT group was 94% (Min 40% Max 119%) versus 59% (Min 55% Max 116%) in the T group. The difference was not statistically significant. Conclusion In summary, lung transplant volume reduction surgery either by anatomical or non-anatomical resection is a procedure that could offer results comparable to the conventional lung transplantation without additional morbidity or mortality. This strategy extends the lung donor pool, especially for the critically ill pediatric patients.

Ex-vivo Perfusion on Marginal Donors in Heart Transplantation: Clinical Resuts and Pathological Findings

Purpose The ex-vivo normothermic perfusion in Heart Transplantation (HTx) allows to expand the donor pool by reducing the ischemic time and providing graft evaluation. Aim of the study was to compare the traditional cold storage (CS) and ex-vivo normothermic perfusion (EVP) in HTx employing marginal donors. Methods Since 2011, 87 HTx employing marginal donors (age>55 years; expected ischemic time>4h; LVEF 14mm; drug abuse; cardiac arrest; CAD) in standard recipients has been performed, CS was utilized in 70 cases (80%) and EVP in 17 (20%). Pre-operative data, survival and complications at short and long term were analysed. Endomyocardial biopsies were collected at time of organ retrieval (T0), before implantation (T1) and after aortic declamping (T2) for light and electron mycroscopy. Blood samples were collected at T0 and T2 from coronary sinus and peripheral vein for metabolomic evaluation . Results Preoperative data were similar in the two groups. Three organs (15%) were considered not suitable for HTx after EVP. Ischemic time and surgical time were shorter in EVP group, which showed a better short and long term survival: a 5-year survival of 100% vs. 94%, 82% and 73% at 30-day, 1 and 5 years respectively in CS group (p=0.06) and less overall complications (65% vs. 89%, p=0.02). In CS group, endomyocardial biopsies showed a tendency for more prominent myocardial damage after heart reperfusion, especially underlined by mitochondrial and organelles dysfunction (figure1). Conclusion EVP permits to exclude not suitable grafts, to reduce complications and to obtain optimal HTx survival. Pathological findings show a tendency for better myocardial protection.

Can Donor Step Up Pressure Predict Primary Graft Dysfunction in Recipients Post Heart Transplantation?

Purpose Donor right ventricular (RV) function is difficult to assess prior to organ retrieval. The RV is also subjected to a multitude of insults post brainstem death which may be exacerbated by prolonged ischaemia prior to implantation. To date, there is no consensus on a method to accurately evaluate RV function in a transplant cohort. We propose using the ‘step-up’(Mean Pulmonary Arterial Pressure - Right Atrial Pressure) pressure as a tool to evaluate donor RV function. Our aim was to study this association and the incidence of Primary Graft Dysfunction Methods A retrospective review all patients who underwent heart transplantation between June 2010-October 2018 at our centre. We identified 92 donors who had invasive haemodynamic monitoring prior to retrieval at the donor hospitals. The primary endpoint for the study was ISHLT-defined PGD. We stratified the cohort into 2 categories of step-up pressure 10mmHg. Multivariable logistic regression analysis was performed to calculate the odds ratio of developing PGD in Group 2 compared to Group 1. Potential confounders adjusted for were donor age, donor inotrope score, warm ischaemic time, recipient pulmonary vascular resistance, donor-recipient gender mismatch and preoperative mechanical circulatory support in the recipient. Results The mean age of donors was 39.4±12.2years. There were 41(44.6%) female donors. The median age of recipients was 46.6±11.7 years. The incidence of PGD was 36(39%). Conclusion The step-up pressure is not a predictor of PGD in our cohort. Donor age and warm ischaemic time were both associated with PGD