Annals of cardiothoracic surgery最新文献

Background: Controlled donation after circulatory death (cDCD) allografts made up a small fraction of donor hearts available for transplant, however it is estimated this could increase to 30% in future years. The purpose of this systematic review and meta-analysis was to describe the largest and most up-to-date short- and long-term survival outcomes for cDCD cardiac transplantation.

Methods: Three electronic databases were selected to complete the initial literature search from inception of records until February 2024. Primary outcomes were short-term survival at 12 months, as well as long-term time-to-event survival data. These data were calculated using aggregated Kaplan-Meier curves according to established methods. The secondary outcomes were acute rejection and primary graft dysfunction.

Results: Following the PRISMA screening protocol, ten studies were included for analysis, eight of which were published in the last 12 months. A pooled cohort of 1,219 donor/recipient pairs were analyzed, of which all had graphical extraction of individual patient data to reveal an aggregated Kaplan-Meier curve. The survival estimates at 1, 3 and 5 years for the pooled cDCD cohort were 92.4%, 85.3% and 85.3%, respectively. In-hospital mortality rates were low at just 2.5%.

Conclusions: While only making up a small percentage of current heart transplant figures, cDCD allografts may not only significantly reduce waitlist times, but could also increase the donor pool, and improve survivability over current procurement techniques. Ultimately, cDCD allografts show promise in offering an effective and favorable procurement source for cardiac transplantation worldwide.

Background: Donation after circulatory death (DCD) donation is becoming more and more popular worldwide. However, in this setting of donation, heart graft suffers from the ischemic injury related with the cardiac arrest. In Italy, the declaration of death with cardiac parameters requires the registration of electrocardiograph for twenty minutes resulting in a very prolonged grafts' warm ischemia time. The aim of this study is to present the Italian preliminary experience on heart transplantation (HTx) from controlled DCD (cDCD) donors.

Methods: Despite a very long period of warm ischemic time (WIT) expected, in April 2023, a DCD heart program was started in Italy and in May 2023 the first DCD heart transplant was performed. In the present paper, preliminary results of the national program are analyzed.

Results: Since May 2023 until December 2024, 40 DCD heart transplants were performed in Italy. Donors' characteristics were the followings: 31 male, nine female, mean age of 46.6±14.7 years. Causes of death were: 19 trauma, eight cerebral bleeding, four post-anoxia coma, nine others. Three donors showed mild coronary artery disease at angiography. Mean WIT was 43.2±10.8 minutes. Thoraco-abdominal normothermic regional perfusion (T-A NRP) was used in all cases. Recipients' characteristics were the followings: 33 males, seven females, mean age 59.1±12.3 years, 16 re-operations (REDO), 18 on an urgent list. Eight (21%) patients required post-transplant extracorporeal membrane oxygenation (ECMO), four (50%) of whom were successfully weaned. Thirty-day mortality was 10%. Median duration of post-transplant mechanical ventilation, intensive care unit stay and hospital stay was 45 hours, six days and 28 days respectively. At discharge, mean ejection fraction (EF) was 57.8%±10% and tricuspid annular plane systolic excursion (TAPSE) 18.2±3.1 mm, without any significant valvular disfunction.

Conclusions: Italian preliminary results suggest that DCD heart transplantation can be successful despite a very long WIT and marginal donors' characteristics. A larger experience and data about medium and long-term results are mandatory to better confirm the short-term findings.

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.