Shorter Ischemia Time Research Articles

Effects of Donor Age and Ischemia Time on Outcome After Heart Transplant: A 10-Year Single-Center Experience.

In heart failure patients, heart transplant still remains the gold standard of care. Controversy prevails whether organs from older donors or with expected prolonged ischemia times may be accepted for transplant. Between 2010 and 2020, a total of 149 patients underwent heart transplant at our department. In a retrospective analysis, 4 different groups were defined according to donor age and total ischemia time. The younger group with short ischemia time consisted of 62 donors age < 50 years and total ischemia time < 240 minutes; the younger group with long ischemia time consisted of 32 donors age < 50 years and total ischemia time ≥ 240 minutes; the older group with short ischemia time consisted of 43 donors age ≥ 50 years and total ischemia time < 240 minutes; and the older group with long ischemia time consisted of 12 donors age ≥ 50 years and total ischemia time ≥ 240 minutes. Prolonged total ischemia time increased the risk of primary graft dysfunction (P = .02) and perioperative neurological events (P = .04). In contrast, there were no differences regarding durations of intensive care unit stay and hospital stay, perioperative bleeding, and renal failure. Although the younger donor age group showed excellent short-term survival (30-day survival rates of 97% for the younger group with short ischemia time and 91% for the younger group with long ischemia time), short-term and mid-term survival rates were impaired in patients with prolonged total ischemia time and older donor age (P = .02). Our results indicate that, in younger donors, prolonged ischemia times may be acceptable. However, in donors older than 50 years, the decision for acceptance as a donor should be made with great caution if the presumed ischemia time exceeds 4 hours.

The Impact of the COVID-19 Pandemic and the Importance of Telemedicine in Managing Acute ST Segment Elevation Myocardial Infarction Patients: Preliminary Experience and Literature Review.

The coronavirus disease 2019 (COVID-19), which is caused by a novel coronavirus (SARS-COV-2), has compromised health care systems and normal management of patients with cardiovascular diseases [1–3]. Patients with non-communicable diseases, including acute myocardial infarction (AMI) are vulnerable to this stress [4, 5]. Acute ST segment elevation myocardial infarction (STEMI), the most critical type of AMI, is associated with high mortality even with modern medicine [6–8]. Timely reperfusion therapy is critical for STEMI patients because a short ischemia time is associated with better clinical outcomes and lower acute and long -term mortality [9–12]. The COVID-19 pandemic placed the management of STEMI patients in a difficult situation due to the need to balance timely reperfusion therapy and maintaining strict infection control practices [13, 14]. Telemedicine, which is used to deliver health care services using information or communication technology, provides an opportunity to carry out the evaluation, diagnosis, and even monitor the patients after discharge when social distancing is needed [15]. In this article, we reported our preliminary experience with the usefulness of telemedicine in managing STEMI patients during the COVID-19 pandemic. We also provided a review of this topic.

Prasugrel compared to ticagrelor in primary PCI

Abstract Background Prasugrel and ticagrelor have similar recommendations in the setting of primary PCI by current guidelines. Data comparing both in daily clinical practice of primary PCI for ST-elevation myocardial infarction is limited. Purpose To compare the effect of prasugrel and ticagrelor on in-hospital outcomes after primary PCI. Methods and results We prospectively enrolled 5365 patients treated with prasugrel (n=2785, 51.9%) or ticagrelor (n=2580; 48.1%) in the setting of primary PCI from January 2011 to December 2018 in a nationwide registry. In-hospital outcomes were compared and multiple logistic regression analysis was performed. Prasugrel treated patients were younger, less often in cardiogenic shock, with lower rates of previous stroke and had shorter ischemic time. Both groups showed similar rates of previous MI, diabetes and current resuscitation. In the univariate analysis mortality was lower in patients with prasugrel (2.5% vs. 4.4% p&amp;lt;0.01). Similarly, MACE (3.3% vs. 5.3%, p&amp;lt;0.01) and NACE (4.0% vs. 5.7% p&amp;lt;0.01) were lower in prasugrel treated patients, whereas major bleeding events did not differ (0.4% vs. 0.6% p=0.24). After adjustment in multivariable analysis mortality (0.99 95% CI 0.57 to 1.72), MACE (OR 0.99 95% CI 0.65 to 1.52) as well as NACE (0.86 95% CI 0.61 to 1.22) did not differ in patients treated with prasugrel compared to ticagrelor. Conclusion Patients treated with prasugrel showed improved outcomes compared to ticagrelor in a large cohort of primary PCI. However, after adjustment for confounders the Advantage of prasugrel in primary PCI did not persist. Funding Acknowledgement Type of funding source: Other. Main funding source(s): Austrian Society of Cardiology

Impact of ischemia time on islet isolation success and posttransplantation outcomes: A retrospective study of 452 pancreas isolations.

Many variables impact islet isolation, including pancreas ischemia time. The ischemia time upper limit that should be respected to avoid a negative impact on the isolation outcome is not well defined. We have performed a retrospective analysis of all islet isolations in our center between 2008 and 2018. Total ischemia time, cold ischemia time, and organ removal time were analyzed. Isolation success was defined as an islet yield ≥200000 IEQ. Of the 452 pancreases included, 288 (64%) were successfully isolated. Probability of isolation success showed a significant decrease after 8 hours of total ischemia time, 7 hours of cold ischemia time, and 80 minutes of organ removal time. Although we observed an impact of ischemia time on islet yield, a probability of isolation success of 50% was still present even when total ischemia time exceeds 12 hours. Posttransplantation clinical outcomes were assessed in 32 recipients and no significant difference was found regardless of ischemia time. These data indicate that although shorter ischemia times are associated with better islet isolation outcomes, total ischemia time >12hours can provide excellent results in appropriately selected donors.

Experience of heart transplantation with an extended cold ischemic time of donor heart

Aim. A retrospective analysis of the outcomes of heart transplantation (HT) with extended cold ischemic time of donor heart (more than 4 hours) versus heart transplantation with short cold ischemia time (less than 4 hours).Material and methods. The retrospective analysis included 52 recipients who underwent HT in the period from July 20, 2012 to October 23, 2019 in Meshalkin National Medical Research Center. The patients were divided into two groups: group 1 (n=26) — orthotopic HT with extended cold ischemic time (more than 240 minutes), group 2 (n=26) — short cold ischemia time (less than 240 minutes). The effect of cold ischemia duration on hospital survival, the function of donor heart, and the postoperative course was assessed.Results. A retrospective analysis revealed a higher rate of hospital survival in the group of recipients with extended cold ischemic time (more than 240 minutes) 88,5% compared to 80,7% in the second group. There was no difference between the groups in the acute rejection rate, the need for inotropic agents, mechanical circulatory support, and cardiac pacing, as well as the incidence of postoperative renal failure and infectious complications.Conclusion. Due to the small number of patients, our experience in HT with extended cold ischemic time does not allow us to draw global conclusions, but a preliminary comparison of HT with extended and short cold ischemic time did not reveal significant advantages in one group or another. This provides a basis for further accumulation of experience and research.

Local versus distant lung donor procurement does not influence short-term clinical outcomes

ObjectiveThe purpose of this study was to recognize clinically meaningful differences in lung transplant outcomes based on local or distant lung procurement. This could identify if the lung allocation policy change would influence patient outcomes. MethodsThis single-center retrospective cohort study analyzed adult patients who underwent lung transplant from 2006 to 2017. Donor and recipient data were abstracted from a collaborative, prospective registry shared by our local organ procurement organization, and tertiary medical center. Short-term outcomes, 1-year survival, and hospitalization costs were compared between local and distant lung transplants defined by donor service area. ResultsOf the 722 lung transplants performed, 392 (54%) had local donors and 330 (46%) had distant donors. Donors were similar in age and cause of death. Recipients were significantly different in diagnosis and local recipients had lower median lung allocation scores (local, 37.3 and distant, 44.9; P < .01). Distant lung transplants had longer total ischemic times (local, 231 ± 52 minutes and distant, 313 ± 48 minutes; P < .01). The rate of major complications, length of hospital stay, and 1-year survival were similar between groups. Distant lung transplants were associated with higher median overall cost (local, $183,542 and distant, $229,871; P < .01). Local lung transplants were more likely to be performed during daytime (local, 333 out of 392 [85%] and distant, 291 out of 330 [61%]; P < .01). ConclusionsLocal lung transplants are associated with shorter ischemic times, lower cost, and greater likelihood of daytime surgery. Short- and intermediate-term outcomes are similar for lung transplants from local and distant donors. The new lung allocation policy, with higher proportion of distant lung transplants, is likely to incur greater costs but provide similar outcomes.

Strategies for liver transplantation during the SARS-CoV-2 outbreak: Preliminary experience from a single center in France.

Liver transplantation (LT) during the ongoing severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic is challenging given the urgent need to reallocate resources to other areas of patient care. Available guidelines recommend reorganizing transplant care, but data on clinical experience in the context of SARS‐CoV‐2 pandemic are scarce. Thus, we report strategies and preliminary results in LT during the peak of the SARS‐CoV‐2 pandemic from a single center in France. Our strategy to reorganize the transplant program included 4 main steps: optimization of available resources, especially intensive care unit capacity; multidisciplinary risk stratification of LT candidates on the waiting list; implementation of a systematic SARS‐CoV‐2 screening strategy prior to transplantation; and definition of optimal recipient‐donor matching. After implementation of these 4 steps, we performed 10 successful LTs during the peak of the pandemic with a short median intensive care unit stay (2.5 days), benchmark posttransplant morbidity, and no occurrence of SARS‐CoV‐2 infection during follow‐up. From this preliminary experience we conclude that efforts in resource planning, optimal recipient selection, and organ allocation strategy are key to maintain a safe LT activity. Transplant centers should be ready to readapt their practices as the pandemic evolves.

MP21-15 PREDICATIVE FACTORS AND ONCOLOGICAL OUTCOMES OF POSITIVE SURGICAL MARGINS FOLLOWING PARTIAL NEPHRECTOMY- WITH AN EMPHASIS ON SURGICAL EXPERIENCE

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy III (MP21)1 Apr 2020MP21-15 PREDICATIVE FACTORS AND ONCOLOGICAL OUTCOMES OF POSITIVE SURGICAL MARGINS FOLLOWING PARTIAL NEPHRECTOMY- WITH AN EMPHASIS ON SURGICAL EXPERIENCE Yasmin Abu-Ghanem*, Zohar Dotan, Issac Kaver, Dorit Zilberman, Edi Fridman, Jacob Ramon, and Ramat Gan Israel Yasmin Abu-Ghanem*Yasmin Abu-Ghanem* More articles by this author , Zohar DotanZohar Dotan More articles by this author , Issac KaverIssac Kaver More articles by this author , Dorit ZilbermanDorit Zilberman More articles by this author , Edi FridmanEdi Fridman More articles by this author , Jacob RamonJacob Ramon More articles by this author , and Ramat Gan IsraelRamat Gan Israel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000854.015AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The clinical significance of a positive surgical margin (PSM) following partial nephrectomy (PN) remains controversial. The purpose of the current study was to examine the predictive factors for PSM and its association with disease recurrence and mortality following PN for renal-cell carcinoma (RCC). METHODS: Study included 643 patients who underwent partial nephrectomy for RCC between the years 1988-2013. Survival was estimated using the Kaplan-Meier method and was compared with the log-rank test. Cox proportional hazard regression models were used to evaluate the association of PSM with outcome, controlling for clinicopathologic variables. RESULTS: PSM was encountered in 30 (4.7%) patients. On multivariable analysis, tumor size (P=0.01) and central lesions (P=0.04) were found to be associated with PSM. A positive margin was also associated with an increased risk of local recurrence on multivariable analysis (HR 5.8, 95% CI 1.01–33.2, P=0.04). In a stratified analysis based on surgical experience (first 0-150 cases, 150-300, 300-450 and above 450); the rate of PSM significantly decreased over the years (7.1%, 5.2% and 2.4% respectively), but slightly increased again in the last group of case up to 3.8%. Still, the incidence PSM was significantly lower in this group in comparison to the first (P=0.02). Further analysis revealed that patients included in the last group had also significantly larger tumours (P=0.01) and shorter ischemia time (P=0.01). CONCLUSIONS: Lesion size and central renal lesions are independent pre-operative risk factors for PSM in patients undergoing PN. The rate of PSM tends to decrease with increasing experience, yet it is still associated with increased risk of disease recurrence. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e323-e323 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yasmin Abu-Ghanem* More articles by this author Zohar Dotan More articles by this author Issac Kaver More articles by this author Dorit Zilberman More articles by this author Edi Fridman More articles by this author Jacob Ramon More articles by this author Ramat Gan Israel More articles by this author Expand All Advertisement PDF downloadLoading ...

Perioperative Characteristics Associated with Transfusion-Free Lung Transplantation

Blood transfusion during lung transplantation (LT) surgery is common. There is little evidence to identify potential candidates for transfusion-free LT surgery. We describe patient and procedural characteristics of LT patients in the era of ECMO and identify predictors of a successful transfusion-free surgery. In this single-center, retrospective analysis, all adult patients undergoing LT between 9/5/2016-2/28/2019 were included. Patients were grouped based on perioperative transfusions received over 72 hours; no products, 1-4 units PRBC, or >4 U PRBC. Donor and recipient characteristics were compared between the three groups by univariate and multivariate analysis. 241 LTs were performed over the time period; 235 were included and 6 multiorgan transplants were excluded. 41 patients (17.4%) received no blood transfusions, while 82.6% (N=194) received transfusions. Most patients (43%, N=101) received >4 U of product. Recipients requiring blood transfusions had associated prolonged ventilation, length of stay, PGD and worsened 1-year graft survival compared to those who did not. Donor characteristics were similar between groups (Fig 1). Older males with obstructive or restrictive lung disease undergoing an off-pump, single lung LT, with lower Lung Allocation Score (LAS), higher starting hemoglobin, shorter ischemic time and case length were associated with a transfusion free LT (Fig 1). In a multivariate analysis, positive predictors for transfusion-free LT included single LT (OR=6.27, p=0.0004), and higher preoperative hemoglobin (OR=1.35 per point, p.0231). Negative predictors included female sex (F v M, OR=0.13, p=0.0005) and higher LAS (OR=0.88 per point, p=0.0002). Predictors of transfusion free LT surgery include older males undergoing a single, off-pump LT procedure, with lower LAS scores and higher starting hemoglobin. This may guide decision making in exploring candidacy for transfusion-free LT or blood refusal patients in the era of ECMO.

Labile Heme Aggravates Renal Inflammation and Complement Activation After Ischemia Reperfusion Injury.

Background: Ischemia reperfusion injury (IRI) plays a major role in solid organ transplantation. The length of warm ischemia time is critical for the extent of tissue damage in renal IRI. In this experimental study we hypothesized that local release of labile heme in renal tissue is triggered by the duration of warm ischemia (15 vs. 45 min IRI) and mediates complement activation, cytokine release, and inflammation.Methods: To induce IRI, renal pedicle clamping was performed in male C57BL/6 mice for short (15 min) or prolonged (45 min) time periods. Two and 24 h after experimental ischemia tissue injury labile heme levels in the kidney were determined with an apo-horseradish peroxidase assay. Moreover, renal injury, cytokines, and C5a and C3a receptor (C5aR, C3aR) expression were determined by histology, immunohistochemistry and qPCR, respectively. In addition, in vitro studies stimulating bone marrow-derived macrophages with LPS and the combination of LPS and heme were performed and cytokine expression was measured.Results: Inflammation and local tissue injury correlated with the duration of warm ischemia time. Labile heme concentrations in renal tissue were significantly higher after prolonged (45 min) as compared to short (15 min) IRI. Notably, expression of the inducible heme-degrading enzyme heme oxygenase-1 (HO-1) was up-regulated in kidneys after prolonged, but not after short IRI. C5aR, the pro-inflammatory cytokines IL-6 and TNF-α as well as pERK were up-regulated after prolonged, but not after short ischemia times. Consecutively, neutrophil infiltration and up-regulation of pro-fibrotic cytokines such as CTGF and PAI were more pronounced in prolonged IRI in comparison to short IRI. In vitro stimulation of macrophages with LPS revealed that IL-6 expression was enhanced in the presence of heme. Finally, administration of the heme scavenger human serum albumin (HSA) reduced the expression of pro-inflammatory cytokines, C3a receptor and improved tubular function indicated by enhanced alpha 1 microglobulin (A1M) absorption after IRI.Conclusions: Our data show that prolonged duration of warm ischemia time increased labile heme levels in the kidney, which correlates with IRI-dependent inflammation and up-regulation of anaphylatoxin receptor expression.

Réimplantation du pouce après une ischémie prolongée et une exposition à des températures extrêmement chaudes : ces facteurs ont-ils une influence significative sur les résultats finaux ?

Historically, it has been stipulated that the success of replantation of amputations depends, among other factors, on the ischaemia time and temperature. For amputations involving the digits, replantation should take place in lees than 12 hours for warm ischaemia and lees than 24 hours for cold ischaemia Short report letter. We report a unique replantation of a completely amputated thumb following prolonged ischaemia time and hot weather exposure of about 40 °C. This is a case of a 30-year old, otherwise healthy non-smoker male who sustained an electrical saw injury to his left thumb. He was referred to our hospital 23 hours following the initial injury and only after having visited 3 different hospitals. At surgery, the wound was thoroughly irrigated and debrided and adequate shortening of the first metacarpal and proximal phalanx of the amputated thumb was performed. This was followed by first metacarpophalangeal joint arthrodesis using k-wires. The princeps pollicis artery was exposed and repaired and this was followed by repair of both the extensors and flexors. However, it was noted that the flexor pollicis longus was completely retracted proximally necessitating release of the carpal tunnel. The procedure was completed by reconstruction of the venous anastomosis, and exposure and repair of the digital nerves. Finally, a good wash was done and the skin was closed. The patient was placed on routine antibiotics and pentoxifylline. In our case, however, replantation was carried out with excellent final results, although the ischaemia time was 23 hours and the temperature was 40 °C. Mulders et al. described in their study that shorter ischaemia time is associated with successful replantation that replantation of parts of the hand should still be performed even if the ischemia time was prolonged (Lin et al., 2010). We also agree with Yu et al. in their meta-analysis that there was no significant association between ischaemia time and survival rate (Yu et al., 2015). Indeed, one may argue the role of leeching in the salvage of the replanted thumb. In our opinion, however, the decision to resort to such therapy was significant as rapid resolution and re-perfusion started to take place following its initiation. The authors believe that the hand is a crucial part of the body, and if possible, replantation should always be attempted.

Kidney Transplantation From Circulatory Death Donors: Monocentric Experience

BackgroundDonation after circulatory death (DCD) is an accepted strategy to widen organ procurement worldwide. Authorized centers in Italy are spreading, increasing kidney transplantation (KTX) from DCD donors (40 in 2017 vs 24 in 2016). In this study, we describe DCD KTX activity at the University of Modena and Reggio Emilia (Modena, Italy) since its beginning in November 2017. MethodsWe retrospectively studied DCD KTX performed in our center from November 2017 to June 2018. We considered donor characteristics (age, sex, cause of death) and recipient clinical data (length of hospital stay, serum creatinine, estimated glomerular filtration rate, delayed graft function [DGF]), primary nonfunction [PNF], HLA match). All the grafts underwent in situ normothermic (ExtraCorporeal Membrane Oxygenation-ECMO) and ex situ hypothermic oxygenated perfusion (HOPE) with Kidney Assist machines. We monitored ex situ perfusion solution biochemical (lactate dehydrogenase [LDH] and lactate) and dynamic (resistance and flow) parameters. A kidney biopsy was performed for allocation strategy according to Karpinski score. ResultsWe performed 6 kidney transplants (3 single and 3 double); the mean recipient (57.5 ± 4.9) and donor age (57.3 ± 7.5) were similar. Mean ECMO duration was 3 h 27 ± 57 min, HOPE was 4 h 47 min ± 119 min, lactate sample values (collected every 15 minutes from the beginning of perfusion) were always lower than1.6 mmol/L, and LDH maximum value was 400 UI/L. Median cold ischemia time was 11 h 18 min. Mean Karpinski score was 3.6; mean HLA match 1.7.We experienced 1 DGF (16.6%), no PNF, with a mean hospital stay of 14.6 days, mean creatinine at hospital discharge 2 ± 1.04 mg/dL), and mean eGFR 53.8 ±27.3 mL/min); at 1 month, mean creatinine and eGFR were 2 ± 1.34 mg/dL and 59.8 ± 24.5 mL/min, respectively. ConclusionsDCD is a promising resource for increasing organ donation. The Emilia Romagna regional organization allowed short ischemia times, with solid KTX outcomes, supporting further development of this program.

TIME AND MORTALITY IN ST ELEVATION MYOCARDIAL INFARCTION: INSIGHTS FROM THE TOTAL TRIAL

The effect of thrombus aspiration in patients with ST elevation myocardial infarction (STEMI) may differ based on ischemic time. Patients with short ischemic times have greater viable myocardium and so may derive greater benefit from thrombus aspiration. We sought to determine the effect of thrombus aspiration on mortality in patients presenting with STEMI based on total ischemic time (duration of symptom onset to first medical device time) and first medical contact to first device time. The TOTAL trial was an international multicenter randomized trial of 10,732 patients comparing routine thrombus aspiration plus percutaneous coronary intervention (PCI) vs PCI alone in STEMI patients undergoing primary PCI within 12 hours of symptom onset. We performed a subgroup analysis for total ischemic time and first medical contact to device time for the primary outcome (Cardiovascular death [CV], Myocardial Infarction [MI], cardiogenic shock and heart failure) and CV mortality. In addition, we used a multi-variable analysis to determine the impact on CV mortality at 1 year for total ischemic time (6 hours) and first medical contact to device (120min). In this international multicenter trial, 64% of patients achieved a first medical contact to device time within 120 minutes and 41% within 90 minutes. In terms of total ischemic time, 87% of patients presented within 6 hours of symptom onset. For the randomized comparison of thrombus aspiration, there was no significant benefit on the primary outcome and for CV death irrespective of total ischemic time and medical contact to device time (Figure 1). CV Mortality was higher in patients with longer total ischemic time (2.5%, 3.5%, 5.2% for < 2 hours, 2-6 hours, >6 hours, P=0.0005). Similarly, CV mortality was higher in patients with longer first medical contact to device time (2.4%, 2.9%, 3.5%, 4.7% for 120 min, P= 0.0001). In a step-wise multivariable analysis, both total ischemic time (>3 hours, hazard ratio 1.34; 95% CI 1.09-1.66) and first medical contact to device time (>90 minutes, hazard ratio 1.45; 95% CI 1.16-1.82) were independent predictors of CV mortality at 1 year. Irrespective of first medical contact to device time and total ischemic time, thrombus aspiration was not beneficial for the primary outcome or CV death. In the current STEMI era, both total ischemic time and first medical contact to device times are important and are independent predictors of CV mortality.

Characteristics of patients with preeclampsia and eclampsia in a tertiary teaching hospital in India

The aim of our study was to identify preoperative risk factors affecting overall survival after cardiac retransplantation (ReTX) in a contemporary era.The United Network for Organ Sharing database was used to identify patients undergoing ReTX between 1995 and 2012. Of the total 28,464 primary transplants performed, 987 (3.5%) were retransplants. The primary outcome investigated was overall survival. The influence of preoperative donor and recipient characteristics on survival were then tested with univariate logistic regression and multivariate Cox regression models.Of 987 patients who underwent ReTX, median survival was 9 years. Estimated survival at 1, 3, 5, 10, and 15 years following retransplant was 80% (95% confidence interval [CI], 78%-83%), 70% (95% CI, 67%-73%), 64% (95% CI, 61%-67%), 47% (95% CI, 43%-51%), and 30% (95% CI, 25%-37%), respectively. Clinical predictors of survival using multivariable analysis included donor age (relative risk [RR], 1.14; P = .004), ischemic time > 4 hours (RR, 1.48; P = .004); preoperative support with extracorporeal membrane oxygenator (RR, 3.91; P < .001), and the time between previous and current transplant (P = .004). Patients with ReTX have 1.27 times higher relative risk of death compared with patients undergoing primary transplant only (RR, 1.27; 95% CI, 1.13-1.42; P < .001).Patients who undergo cardiac ReTX can expect to have a 1-year survival less than a patient undergoing primary transplant with an acceptable median overall survival. Both donor and recipient preoperative factors contribute to overall survival following cardiac ReTx. Donor characteristics include age of the donor and ischemic time. Recipient factors include the need for extracorporeal membrane oxygenator and the number of days between the first and second transplant. Optimal survival following cardiac ReTX can best be predicted by choosing patients who are farther out from their initial transplant, not dependent upon preoperative extracorporeal support, and by choosing donor hearts younger in age and those likely to have shorter ischemic times.

6030Effects of adjunctive treatment with low-dose alteplase during primary percutaneous coronary intervention according to ischaemic time

Abstract Background Microvascular obstruction affects half of patients with acute ST-segment elevation myocardial infarction and confers an adverse prognosis. Purpose We aimed to determine whether the efficacy and safety of a therapeutic strategy involving low-dose intra-coronary alteplase infused early after coronary reperfusion associates with ischaemic time. Methods We conducted a prospective, multicentre, parallel group, 1:1:1 randomised, dose-ranging trial in patients undergoing primary percutaneous coronary intervention. Ischaemic time, defined as the time from symptom onset to coronary reperfusion, was a pre-specified sub-group of interest. Between March 17, 2016, and December 21, 2017, 440 patients presenting at 11 hospitals in the UK were enrolled with follow up to 3 months. Patients with acute myocardial infarction due to occlusion of a major coronary artery presenting ≤6 hours from symptom onset were randomly assigned to treatment with placebo, alteplase 10mg or alteplase 20mg. The primary outcome was the amount of microvascular obstruction disclosed by cardiac magnetic resonance imaging at 2–7 days. Secondary outcomes included infarct size, myocardial haemorrhage, left ventricular ejection fraction, and troponin T area-under-the curve. Results 440 patients were randomized (figure), the primary endpoint was achieved in 396 (90%), seventeen (3.9%) withdrew and all other patients were followed up to 3 months. In the primary analysis, the amount of microvascular obstruction did not differ between the groups. Their ischaemic times were: ≤2 hours, n=98; ≥2–&lt;4 hours, n=215; and ≥4–6 hours, n=83. In patients with an ischaemic time ≥4 hours, treatment with alteplase (10 mg, n=26; 20 mg, n=30) was associated with a dose dependent increase in the amount (mean) of microvascular obstruction (% left ventricular mass) compared to placebo (n=27) 1.14 vs. 3.11 vs. 5.20; mean difference on square root scale 0.81 (95% CI 0.21, 1.42), p=0.009. The interaction test between ischaemic time and treatment (active vs. placebo) was not statistically significant p=0.06, however when the interaction was assessed for a trend across treatment groups this did reach statistical significance, p=0.018. Furthermore, a higher proportion of patients presenting ≥4–6 hours treated with 20 mg of alteplase had myocardial haemorrhage (59.3%) compared to the placebo group (28.0%), odds ratio 3.81 (95% CI 1.19, 12.25), p=0.025. The amount of haemorrhage was also greater; estimated mean difference 3.49 (95% CI 1.22, 5.75), p=0.0026. No between-treatment group differences for myocardial haemorrhage were observed in patients presenting with shorter ischaemic times. Study flow diagram Conclusions In patients presenting with an ischaemic time ≥4 hours, adjunctive treatment with low-dose intra-coronary alteplase during primary PCI was associated with increases in microvascular obstruction and myocardial haemorrhage. The mechanism may involve haemorrhagic transformation within the infarct core. Acknowledgement/Funding NIHR EME programme (reference: 12/170/45); British Heart Foundation (BHF reference FS/16/74/32573)

P2707Invasive coronary physiology during primary percutaneous coronary intervention in patients treated with intracoronary alteplase or placebo: the double-blind T-TIME physiology substudy

Abstract Background Impaired microcirculatory reperfusion worsens prognosis post-primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). Intracoronary (IC) alteplase targets persisting thrombus post-reperfusion &amp; distal embolisation. In the T-TIME trial microvascular obstruction on cardiac magnetic resonance (CMR) did not differ with IC alteplase vs placebo. Purpose To prospectively determine if index of microcirculatory resistance (IMR) is lower &amp; coronary flow reserve (CFR) or resistive reserve ratio (RRR) are higher (improved) with IC alteplase, &amp; to provide mechanistic insights. Methods A pre-planned substudy of the main protocol. From 2016–2017, STEMI patients from 3 UK hospitals ≤6 hrs ischaemic time were randomised in a 1:1:1 dose-ranging, double-blind design. Following standard care reperfusion, alteplase (10 or 20mg) or placebo was infused over 5–10 mins proximal to the culprit lesion pre-stenting. IMR (primary outcome), CFR &amp; RRR (secondary outcomes) were measured in the culprit artery post-PCI. Physiology results were obscured from clinicians acquiring the data, to maintain blinding. CMR was performed 2 days &amp; 3 months post-STEMI. Subgroup analyses were prespecified including by ischaemic time (&lt;2 hours, 2–4 hrs, &gt;4 hrs) &amp; IMR threshold &gt;32. Results In 144 patients (mean age 59 yrs, 80% male), IMR, CFR or RRR post-PCI did not differ with alteplase vs placebo (Table). Patients with ischaemic time &lt;2 hrs had a dose related increase in CFR (placebo 1.2 [IQR 1.1–1.7], alteplase 10mg 1.4 [IQR 1.0–1.8], alteplase 20mg 2.0 [IQR 1.8–2.3] p=0.01 for interaction) &amp; RRR (placebo 1.5 [IQR 1.3–1.9], alteplase 10mg 1.6 [1.1–2.2], alteplase 20mg 2.2 [2.0–2.6], p=0.03 for interaction). In subjects with post-PCI IMR&gt;32, % ST-resolution at 60 mins was worse with alteplase 10mg vs placebo (23.1±53.9 vs 50.9±31.5) &amp; in those with IMR≤32% ST-resolution at 60 mins was better with alteplase 20mg vs placebo (68.0±30.7 vs 39.1±43.2), p=0.002 for interaction. The CMR findings in the substudy &amp; overall trial populations were consistent. Main results Placebo Alteplase 10mg Alteplase 20mg (n=53) (n=41) (n=50) IMR, median (IQR) 33.0 (17.0–57.0) 22.0 (17.0–42.0) 37.0 (20.0–57.8) p=0.15 p=0.78 CFR, median (IQR) 1.3 (1.1–1.8) 1.4 (1.1–1.9) 1.5 (1.1–2.0) p=0.92 p=0.74 RRR, median (IQR) 1.6 (1.3–2.2) 1.6 (1.4–2.6) 1.8 (1.3–2.4) p=0.69 p=0.81 P-values for comparison of alteplase with placebo. Conclusions In acute STEMI with ischaemic time ≤6 hrs, IMR, CFR or RRR post-PCI did not differ with alteplase vs placebo. In those with shorter ischaemic times (&lt;2 hrs) CFR &amp; RRR, but not IMR, were improved with alteplase. We observed interactions between alteplase dose, ischaemic time &amp; mechanisms of effect. Acknowledgement/Funding Dr Maznyczka is funded by a fellowship from the British Heart Foundation (FS/16/74/32573). T-TIME was funded by grant 12/170/4 from NIHR-EME

Indian Subcontinent's First Bilateral Supracondylar Level Upper Limb Transplantation.

Introduction This is the first case of supracondylar level transplant from the Indian subcontinent, performed for a bilateral below elbow amputee. It has a completely different set of challenges for the transplant team, with a relatively shorter ischemia time window. The technical considerations for the same have been discussed in detail in this article. Materials and Methods The patient was a 19-year-old female who lost her both upper limbs at proximal forearm level due to severe crush injury following a road traffic accident. Insufficient bone length on either side necessitated a supracondylar level transplant. The preoperative workup included detailed clinical evaluation, biochemical, and psychological evaluation. The donor was a young brain-dead, male patient from a hospital, 30 minutes away. The donor and recipient preparations in this case were unique. The recipient’s own elbow flexors and extensors were used while the elbow joint was from the donor. The specific challenges we faced during this procedure have been described in detail. Results The transplantation has been a complete technical success, with the patient rehabilitated back to her independent life style. This article describes only the technical considerations. The functional recovery aspect is part of an another soon to be published manuscript. Conclusion Supracondylar level arm-transplant requires a highly coordinated team effort with precise preoperative planning, along with meticulous attention to detail to achieve a successful outcome. In properly selected patients, it could be a life-changing procedure, worth all the effort.

Fast prostate retrieval in robot-assisted laparoscopic prostatectomy for next-generation biobanking.

Robotic-assisted laparoscopic radical prostatectomy (RALP) has become the most widespread treatment for organ-confined prostate cancer. Here, we describe a fast specimen retrieval technique for RALP to obtain high-quality tissue specimen with minimal warm ischemia time for next-generation biobanking. Here, we show that using fast retrieval technique, short warm ischemia times can be achieved while not increasing the surgical time. Patients undergoing RALP with written informed consent participated in Helsinki Urological Bank study. Previously operated RALP patients and those, who were not willing to participate in the study, served as a control group. The study consisted of 1685 patients, 684 in fast retrieval and 1001 in control group. We developed a novel fast retrieval technique in which fascia is opened for camera port according to the prostate size and a running suture is placed and tightened against the camera port in the beginning of the operation. Immediately after prostate is freed from attachments, suture is loosened and the prostate is extirpated inside the endoscopic bag through the camera port fascial opening, then the fascial suture is again tightened against the camera port and the RALP procedure is completed. The mean warm ischemia times in fast retrieval group were 20min 18s and 22min 30s, respectively, in patients without and with lymphadenectomy. The mean console and surgery times with and without lymphadenectomy were similar in both groups. There were no technique-related complications associated with Fast Retrieval procedure. Tissue integrity test results for the RNA and DNA quality showed good quality for the specimen. Fast retrieval technique can easily and safely be utilized to maximize usefulness of RALP tissue specimen in downstream biobank applications.

Prehospital ECG transmission results in shorter door-to-wire time for STEMI patients in a remote mountainous region

BackgroundPre-hospital triage with ECG-transmission may reduce time to reperfusion in patients with ST-elevation acute myocardial infarction (STEMI). Less, however, is known on potential benefit of ECG-transmission triage in mountain areas, with complex orography. MethodsPatients admitted for STEMI and primary coronary angioplasty (pPCI) in a mountain area served by a single cathlab and triaged with ECG-transmission were enrolled in the study and compared with controls: patients' demographics and time to coronary wire were recorded. ResultsForty-seven consecutive patients were enrolled in the study: 23 patients following ECG transmission and 24 STEMI patients who presented directly to the Emergency Department. At multivariable regression analysis, pre-hospital ECG-transmission electrocardiogram was an independent predictor of shorter time-to-wire (beta −0.34, p < 0.05). In case of transport times >30 min, ECG-transmission triage achieved time-to-wire times 20% shorter. Excluding unreducible transport time, avoidable delay was reduced by 38% in the whole population, by 48% in case of peripheral areas (transport time > 30 min from cathlab) and elderly (>80 years) patients (p < 0.05 in all cases). ConclusionsPre-hospital triage with ECG-transmission is associated with shorter ischemic time even in mountain areas with a complex orography profile. The benefit is greater in elderly patients and remote areas.

Sequential Single Lung Transplant (SLT) with or without Ex-Vivo Lung Perfusion Maximizes on Donor to Transplant Conversion Rates

Purpose A double lung donor may be split, with a single lung transplanted sequentially into two different recipients by one team. This minimizes utilization of hospital staff resources, day time theater access and supports donor to transplant conversion rates. This is a retrospective institutional review of the first 12 cases assessing the impact of extended ischemic time (for the delayed second lung transplant recipient) on length of stay (LOS), intermediate term graft function and survival. Methods Twelve sequential single lung transplants were performed from 6 donors between August 2016 and September 2017. Basic data for donors and recipients including outcomes (ischemic time, ICU stay, total hospital stay, 30 day mortality, 12-month survival including pulmonary function tests (PFTs)) were recorded. Borderline lungs were implanted to the EVLP circuit and reperfused using acellular supplemented Steen Solution (Vitrolife, Goteborg, Sweden). Recipients were categorized into 2 groups: G1 for patients who received the 1st lung, hence having a shorter ischemic time (whether they had EVLP or not), G2 for patients who received the 2nd lung, hence a longer ischemic time. 3 patients received EVLP reconditioned lungs. Results Donor data (n = 6) were: age, 44.2 ± 8.33 years; female/male, 5:1; cause of death: intracranial haemorrhage 4(66.6%), hypoxic brain injury 1(16.6%) and traumatic brain injury 1(16.6%). Mean LAS Score was similar for both groups (44.9 G1 and 41.7 G2, p value=0.64). Mean ischemic time from donor cross clamp to reperfusion was 389 minutes for G1 and 708 minutes for G2. There was no significant difference in ICU stay: 14.7 days vs 6.0 days with a quicker discharge from ITU in the G2(p value=0.20). The mean Hospital LOS was 32.3 vs 20.3 days, (p value= 0.35) Mean FEV1 at 3 months in G1 was 2.4 L (79.7%) and in G2 was 2.0 L (68.4%) (p value=0.38). No all cause 30 day mortality in both groups. At 1-year 2 patients had died from an unexpected bradycardic cardiac arrest. Conclusion SLT if limited resources are available maximize on donor to transplant conversion rates. Donor ischemic lung time is not a deterrent in the era of EVLP. SLT into two recipients by a single theater service is feasible, cost-effective and safe.