Annals of cardiothoracic surgery最新文献

Background: In the United Kingdom (UK), the adoption of donation after circulatory determination of death (DCD) has boosted transplantation rates by 20%. However, about 100 patients per year on the waitlist still do not receive a transplant due to low transplantation rates. Current reports review rates of utilisation after offer acceptance but fail to report the offer acceptance rate and the reasons for offer declines. We have therefore analysed the reasons why heart offers were declined over the past 16 years.

Methods: A retrospective analysis was conducted on the primary reasons for the decline of heart offers between 1^st January 2008 and 31^st December 2022. Reasons were obtained directly from the National Health Service Blood and Transplant Registry and categorised into five groups: 'donor-related', 'organ-related', 'recipient-related', 'logistical' and 'other'. These categories were then analysed.

Results: During this period, 2,673 heart offers were accepted for transplantation. Comparatively, 6,310 offers were declined, most commonly due to poor function (35.8%) and 'donor past medical history (PMH)' (20.4%), together accounting for 56% of all declined heart offers. The largest category was 'organ-related' reasons (47.6%), and the smallest group was 'logistical' reasons (1.0%). Recipient-related factors accounted for only 7.8% of declined offers.

Conclusions: Donor heart function and PMH are the most common reasons for declining heart offers, with non-clinical factors also contributing to offer declines. Greater acceptance rates can be achieved with greater logistical support for the UK heart transplantation networks and the implementation of more robust and objective assessment methods for offered hearts, including biomarkers and coronary angiography, particularly in DCD donation.

For most of the last almost 60 years of heart transplantation, static ice storage has been the dominant means of organ preservation. This method has allowed about 4 hours of relatively safe cold ischemic time, after which the risk of graft dysfunction increases exponentially. This limitation governed our allocation system and limited our ability to explore remote and extended criteria donors. Static-controlled hypothermia was recently introduced into clinical practice, and accumulating data demonstrate superior results with preservation when compared to ice storage. This has allowed centers to increasingly consider remote and extended criteria donors. Herein, we review the available data within the Global Utilization and Registry Database for Improved Heart Preservation (GUARDIAN-Heart Registry), supporting the expanding use of controlled, static preservation.

Background: Heart failure remains a significant cause of morbidity and mortality internationally. With significant disparities in supply and demand for donor organs and recipients, there has been a growing need to expand the donor pool. Donation after circulatory death (DCD) heart transplantation offers such a method, with ex-situ machine perfusion (ESMP) and thoracoabdominal normothermic reperfusion (NRP) offering two potential methods of procuring DCD organs. This systematic review and meta-analysis aims to evaluate the current literature and compare DCD with donation after brain death (DBD) as well as DCD methods of transplantation.

Methods: A systematic literature review was performed according to PRISMA guidelines. Primary outcomes were 30-day, 6- and 12-month survival, as well as primary graft dysfunction (PGD) and acute rejection. Secondary outcomes were length of stay (LOS), intensive care unit (ICU) LOS and temporary dialysis. Weighted averages were utilised to summarise data with funnel plots utilised for comparisons. Reconstructed Kaplan-Meier curves were utilised to evaluate mid-term survival.

Results: A total of 10 studies were included evaluating 923 DCD recipients and 7,236 DBD recipients. Survival for DCD and DBD patients at 6 months was 93% and 91% respectively [odds ratio (OR), 1.5; 95% confidence interval (CI): 1.0-2.2; P<0.05] and at 12 months 93% and 91% for DCD and DBD respectively (OR 0.77, 95% CI: 0.1-5.3, P=0.8). Acute rejection was 15% and 19% in DCD and DBD patients respectively (OR, 1.0; 95% CI: 0.6-1.8; P=0.9). Thirty-day survival was similar between NRP (96.9%) and direct procurement and perfusion (DPP) (97%) (OR, 0.8; 95% CI: 0.2-3.9; P=0.8). PGD was higher in DCD (17%) compared with DBD (8%) patients (OR, 1.9; 95% CI: 0.98-3.7; P=0.06) whilst PGD for DPP and NRP was 21% and 14% respectively.

Conclusions: DCD may offer comparable outcomes to DBD in short and mid-term outcomes, although PGD remains a concern. Further comparative research is required to delineate the role of both techniques in the current transplant landscape.

Background: Normothermic ex situ heart perfusion (ESHP) has increased the donor pool with hearts donated after circulatory death (DCD), but functional assessment during ESHP using lactate trends is suboptimal. This study presents the clinical use of high-resolution cardiac mapping to assess electrical function of human DCD hearts on ESHP, where low-voltage-areas might be indicative of myocardial injury.

Methods: Hearts were procured following circulatory arrest of the donor and restarted on normothermic ESHP. DCD hearts were transported to the recipient hospital and lactate concentrations were regularly measured in the perfusate. High-resolution epicardial mapping of the left (LV) and right ventricle (RV) was performed with a 192-electrode array during normothermic ESHP prior to transplantation. Unipolar potential voltages and slopes, conduction velocity and the amount of low-voltage potentials and conduction block were calculated from these recordings.

Results: Electrical mapping was performed on ten DCD hearts transported on ESHP with sequential cardiac transplantation, showing safety and feasibility of the technique. Median potential voltage of the LV and RV was 15.7 mV (14.0-17.4 mV) and 11.3 mV (8.3-11.9 mV) respectively, and low-voltage potentials were minimally present. In comparison, the electrical function of one rejected heart with increasing lactate trend did not differ from the transplanted hearts.

Conclusions: High-resolution electrical mapping of DCD hearts on ESHP may serve as novel additional diagnostic tool for assessing graft function, especially in marginal donors.

Background: Although it has been widely recognized that heart transplantation (HT) following donation after circulatory death (DCD) can be a successful strategy to expand the donor pool, its clinical outcomes compared to donation after brain death (DBD) are still the subject of intense investigation. We reviewed the clinical characteristics of HT after DCD from the three largest multicenter nationwide registries, highlighting technical aspects, donor and recipient selection, and early outcomes. Moreover, we performed a meta-analysis of survival outcomes of DCD vs. DBD using reconstructed individual patient time-to-event data.

Methods: The PubMed, Web of Science, and Scopus databases were searched in January 2024 to identify the most recent reports from three large multicenter nationwide registries (United States, United Kingdom, and Australia) of HT after DCD. Clinical characteristics were summarized using descriptive statistics, and survival curves were reconstructed for DBD using individual patient time-to-event data. The pooled hazard ratio (HR) with confidence interval (CI) was calculated via Cox regression.

Results: A total of 646 DCD HT patients and 7,253 DBD controls were included in this review. In the majority of cases, donors were young males. The mean age of recipients ranged from 48 to 57 years, and the majority were males with idiopathic dilated cardiomyopathy. Up to 40% of patients required postoperative mechanical circulatory support with extracorporeal membrane oxygenation (ECMO). The meta-analysis estimated a pooled 1-year survival of 91.1% (95% CI: 88.6-93.7%) and 90.1% (95% CI: 89.4-90.8%) for DCD and DBD patients, respectively (P=0.91), with a pooled HR of 0.88 (95% CI: 0.65-1.20).

Conclusions: Although the generally more favorable clinical profile of DCD donors and recipients may constitute a potential selection bias, our meta-analysis documented similar early and medium-term survival outcomes for DCD and DBD HT.

In the last decade, heart transplants using allografts from adult donors after circulatory death, in a controlled setting, controlled donation after circulatory death (cDCD) have been rapidly adopted and widely performed. The selection of retrieval methods has largely been determined by state or institutional guidelines concerning permissible postmortem procedures. A significant majority of cDCD heart recoveries have employed direct procurement and perfusion (DPP) followed by normothermic machine perfusion (NMP) for graft preservation. Another established method involves the thoracoabdominal normothermic regional perfusion (taNRP), which is then followed by either NMP or static cold storage. Processing, management and surgical techniques of heart allograft procurement after cDCD are herein described and discussed.