MSGID: 1:317/3 6413ecf6   
   PID: hpt/lnx 1.9.0-cur 2019-01-08   
   TID: hpt/lnx 1.9.0-cur 2019-01-08   
    Maintaining heart function in donors declared 'dead by circulatory   
   criteria' could improve access to heart transplantation    
      
     Date:   
         March 16, 2023   
     Source:   
         University of Cambridge   
     Summary:   
         More donated hearts could be suitable for transplantation if they   
         are kept functioning within the body for a short time following   
         the death of the donor, new research has concluded.   
      
      
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   FULL STORY   
   ==========================================================================   
   More donated hearts could be suitable for transplantation if they are   
   kept functioning within the body for a short time following the death   
   of the donor, new research has concluded.   
      
      
   ==========================================================================   
   The organs are kept functioning by restarting local circulation to the   
   heart, lungs and abdominal organs -- but, crucially, not to the brain   
   -- of patients whose hearts have stopped beating for five minutes or   
   longer and have been declared dead by circulatory criteria (donation   
   after circulatory death, or DCD).   
      
   It is hoped that this technique could increase the number of usable   
   donated hearts by as much as 30% in the future, helping address the   
   shortage of transplant organs. In 2021, 8,409 heart transplants were   
   reported to the Global Observatory on Donation and Transplantation (GODT)   
   by 54 countries. This activity is in contrast with the 21,935 patients   
   who were on a heart waiting list during the year 2021, of whom 1,511 died   
   while waiting and many others became too sick to receive a transplant.   
      
   John Louca, a final year medical student at Gonville & Caius College,   
   University of Cambridge, and the study's first author, said: "Heart   
   transplants are the last bastion for patients with end-stage heart   
   failure. They are successful -- patients who receive a transplant live   
   on average a further 13 to 16 years. The biggest problem they face   
   is actually getting access to a donated heart: many patients will die   
   before an organ becomes available. That's why we urgently need to find   
   ways to increase the suitability of donor organs."  Though the first   
   heart transplant performed at the Groote Schuur Hospital in Cape Town   
   (South Africa) in 1967 was obtained from a DCD donor, this technique   
   was abandoned and replaced by heart transplants obtained from donors   
   confirmed dead using neurological criteria (donation after brain death,   
   or DBD) -- in other words, their brain has stopped functioning entirely.   
      
   Until recently, heart transplants worldwide were still performed only   
   with organs obtained from DBD donors. However, in recent years, heart   
   transplants from DCD donors have become a clinical reality worldwide   
   thanks to years of research carried out in Cambridge.   
      
   DCD is the donation of organs by patients who tragically have a   
   non-survivable illness. These patients are typically unconscious   
   in intensive care in hospital and dependent on ventilation. Detailed   
   discussions between doctors, specialist nurses and the patient's family   
   take place and if the family agree to organ donation, the process starts.   
      
   After treatment is withdrawn, the heart stops beating and it begins   
   to sustain damage to its tissues. After 30 minutes, it is thought that   
   this damage becomes irreversible and the heart unusable. To prevent this   
   damage, at the time of death these non-beating hearts are transferred   
   to a portable machine known as the Organ Care System (OCS) where the   
   organ is perfused with oxygenated blood and assessed to see whether it   
   is suitable for transplantation.   
      
   This technique was pioneered by Royal Papworth Hospital NHS Foundation   
   Trust in Cambridge, whose transplant team carried out the first DCD   
   heart transplant in Europe in 2015. Royal Papworth has since become the   
   largest and most experienced DCD heart transplant centre in the world.   
      
   DCD heart transplantation started simultaneously in Australia, followed   
   by Belgium, The Netherlands, Spain and USA. According to the GODT,   
   295 DCD heart transplants were performed in these six countries in 2021.   
      
   Organ Care Systems are expensive, costing around US$400,000 per   
   machine plus an additional $75,000 for consumables for each perfused   
   organ. An alternative, and much more cost-effective approach, is known   
   as thoraco-abdominal normothermic reperfusion (taNRP). This involves   
   perfusing the organ in situ in the donor's body and is estimated to cost   
   around $3,000. Its use was first reported in 2016 by a team at Royal   
   Papworth Hospital.   
      
   In a study published in eClinical Medicine, an international team of   
   clinical scientists and heart specialists from 15 major transplant   
   centres worldwide, including the UK, Spain, the USA and Belgium, looked   
   at clinical outcomes of 157 DCD donor hearts recovered and transplanted   
   from donors undergoing taNRP.   
      
   They compared these with the outcomes from 673 DBD heart transplants,   
   which represents the 'gold-standard'.   
      
   The team found that overall, the use of taNRP increased the donor pool   
   significantly, increasing the number of heart transplantations performed   
   by 23%.   
      
   Mr Stephen Large, Consultant Cardiothoracic Surgeon at Royal Papworth   
   Hospital and chief investigator, said: "Withdrawing life support from   
   a patient is a difficult decision for both the families and medical   
   staff involved and we have a duty to honour the wishes of the donor as   
   best we can. At present, one in ten retrieved hearts is turned down,   
   but restoring function of the heart in situ could help us ensure more   
   donor hearts find a recipient."  Survival rates were comparable between   
   DCD and DBD heart transplantation, with 97% of patients surviving for   
   more than 30 days following taNRP DCD heart transplant, 93% for more   
   than a year and 84% of patients still alive after five years.   
      
   Professor Filip Rega, Head of Clinic at the Department of Cardiac Surgery,   
   UZ Leuven, Belgium, said: "This promising new approach will allow us   
   to offer heart transplantation, a last resort treatment, to many more   
   patients in need of a new heart."  The researchers say that some of the   
   benefits from taNRP are likely thanks to the reduced amount of time the   
   heart was not receiving oxygenated blood, known as its warm ischaemic   
   time, when compared to direct procurement (that is, when the heart is   
   removed immediately for transplant, and perfused outside the body). The   
   median average time was 16.7 minutes, significantly less than the 30   
   minutes associated with permanent damage to the heart cells.   
      
   An added benefit to this approach is that it allows medical teams to   
   simultaneously preserve several organs, such as the liver, pancreas and   
   kidneys, without the need of several organ-specific external machine   
   perfusion devices. This decreases complexity and costs.   
      
   Professor Ashish Shah, Head of the Department of Cardiac Surgery   
   at Vanderbilt University Hospitals, Nashville, USA, said: "Heart   
   transplantation has been and always will be a uniquely international   
   effort. The current study is another example of effective international   
   collaboration and opens a new frontier, not just in transplantation,   
   but in our basic understanding of how all hearts can be rescued."   
   Dr Beatriz Domi'nguez-Gil, Director General of the National Organisation   
   of Transplantation in Spain, said: "The results of this collaborative   
   study bring hope to thousands of patients in need for a heart transplant   
   every year throughout the world. Its findings reveal that DCD heart   
   transplantation based on taNRP can lead to results at least similar to   
   the gold standard and increase hearts available for transplantation in   
   a manner that contributes to the sustainability of health-care systems."   
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   ==========================================================================   
   Story Source: Materials provided by University_of_Cambridge. The original   
   text of this story is licensed under a Creative_Commons_License. Note:   
   Content may be edited for style and length.   
      
      
   ==========================================================================   
   Journal Reference:   
      1. John Louca, Marco O"chsner, Ashish Shah, Jordan Hoffman, Francisco   
         Gonza'lez Vilchez, Iris Garrido, Mario Royo-Villanova, Beatriz   
         Domi'nguez-Gil, Deane Smith, Leslie James, Nader Moazami, Filip   
         Rega, Janne Brouckaert, Johan Van Cleemput, Katrien Vandendriessche,   
         Vincent Tchana-Sato, Diawara Bandiougou, Marian Urban, Alex Manara,   
         Marius Berman, Simon Messer, Stephen Large, Nirav Patel, Rohan   
         Sanghera, Constantinos Kapetanos, Antonio Rubino, Sai Bhagra,   
         Luis-Alberto Martinez-Marin, Jordan Allen, Chindu John, Daniel   
         Normington, Steven Tsui, Aravinda Page, Vanessa Chow, William   
         McMaster, Alicia Pe'rez- Blanco, Elisabeth Torres, Jose' Cuenca,   
         Fernando Mosteiro, Marta Farrero, Elena Sandoval, Manuela Camino,   
         Juan Ja'urena, Fabrizio Sbraga, Eva Oliver, Antonio Quintana,   
         Vincente Morant, Belen Este'banez, A'lvaro Rocafort, Manuel Cobo,   
         Francisco Nistal, Manuel Go'mez-Bueno, Marina Pe'rez-Redondo, Arne   
         Neyrinck, Diethard Monbaliu, Laurens Ceulemans. The international   
         experience of in-situ recovery of the DCD heart: a multicentre   
         retrospective observational study. eClinicalMedicine, 2023; 58:   
         101887 DOI: 10.1016/j.eclinm.2023.101887   
   ==========================================================================   
      
   Link to news story:   
   https://www.sciencedaily.com/releases/2023/03/230316140928.htm   
      
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