What are the barriers to wider use of organ perfusion?

Simple diagram with dotted line framing red circle with icon of human heart to represent organ perfusion


UNOS Chief Medical Officer David Klassen, M.D., discusses perfusion-driven advances and remaining challenges

Normothermic perfusion continues to show promise as an innovation that will help increase the number of donor organs available for transplant. With perfusion, circulation and normal body temperature and function are maintained for the organ, making it possible both to evaluate the organ and potentially to limit the impact of ischemic time. However, cost, technology and training considerations remain barriers to widespread implementation. UNOS Chief Medical Officer Dr. David Klassen discusses recent developments in the field.
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Explore issues in normothermic perfusion with a curated reading list

Q. Where is perfusion having the most impact right now in organ transplantation?

We’re seeing a steady increase in the number of organs being perfused. In 2022, more than 1,100 transplanted donor livers, hearts and lungs were perfused. Between 2018 and 2022, there was an almost five-fold increase in perfused livers transplanted, from fewer than 100 to nearly 500.

Perhaps the most important recent development is perfusion for DCD (donation after circulatory death) heart transplantation. Because the heart is particularly vulnerable to warm ischemic injury, increasing the number of successful DCD heart transplants was really dependent on perfusion technologies. A third of all donors are DCD donors, and potentially a significant number could be heart donors; one study estimated that widespread adoption of DCD heart transplant could lead to 300 more adult heart transplants annually.  UNOS data show that the number of DCD hearts perfused and transplanted has gone from 0 in 2018 to 199 in 2022.

photo Dr. David Klassen, UNOS Chief Medical Officer

“Perhaps the most important recent development is perfusion for DCD (donation after circulatory death) heart transplantation.”

David Klassen, M.D., Chief Medical Officer

Q. Are there other significant new developments?

In addition to ex-vivo machine perfusion, normothermic regional perfusion (NRP) for recovery of organs from DCD donors is now spreading fairly widely, and is also helping to increase the number of DCD hearts available for transplant. (See Normothermic Regional Perfusion: A reading list.) With NRP, cardiopulmonary bypass or ECMO is used to restore circulation and enable perfusion of DCD organs prior to recovery. Because these technologies are already in use in most ICUs, there is no new technology to acquire or learn to use, as there is with ex-vivo machines. Also with NRP, separate perfusion devices for each organ aren’t needed, as abdominal and thoracic organs can be perfused before recovery with this process.

Q. What barriers remain to greater use of perfusion?

At the present time cost remains the most significant limiting factor for either type of perfusion. It’s expensive, and questions have yet to be resolved about when it is most appropriate to use perfusion,  who pays for it, and how those costs are reimbursed.  Whether cost will limit the use of perfusion to larger and better-resourced transplant centers or OPOs remains to be seen.

Implementation of these technologies is also logistically complex.   It takes time and effort for new technologies and procedures like these to be widely incorporated.

Finally, more data are needed to firmly determine whether perfusion leads to better patient outcomes. Research so far indicates generally equal outcomes when compared with non-perfused organs.  Despite these questions perfusion is enabling increased use of expanded criteria and DCD organs, including those that previously might not have been considered viable for transplant.

A reading list

Understanding Normothermic Regional Perfusion (NRP)

Rather than perfusing donor organs by machine after recovery (“ex-vivo” perfusion), NRP uses extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass technology to restore circulation and perfuse DCD donor organs prior to recovery from the deceased donor. The advantages of NRP include the potential to reduce warm ischemia time for DCD donor organs and the ability to assess DCD hearts prior to recovery.

However, NRP is technically complex and requires rapid, coordinated execution by a skilled team. To ensure success with the procedure, the recovery team may need to bring all the necessary equipment and supplies, as well as its own perfusionists, which can add to the cost and other considerations of procurement.

In addition, questions have been raised even within the medical community about the ethics of a procedure that restores circulation in a deceased donor as well as about the transparency necessary for true informed consent from donor families.

This reading list provides an overview of NRP as well as discussions and recent perfusion news coverage.

Oct. 2022 | American Society of Anesthesiologists: “Statement on Controlled Organ Donation After Circulatory Death”

April 2021 | The American College of Physicians: “The American College of Physicians says organ procurement method raises significant ethical concerns”

Feb. 2020 | The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine: “Why DCD donors are dead” An ethical and philosophical analysis of NRP and DCD transplant.

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Another record year for heart transplants: Steep increases seen in DCD transplants in 2022

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A 68% increase in DCD heart transplants was part of a record-setting 2022

68% increase in DCD heart transplants in 2022

The 11th straight year of increases in heart transplants coincides with advancements in organ perfusion technology and DCD recovery practices.

In 2022, 42,888 organ transplants were performed in the United States, an increase of 3.7 percent over 2021 and a new annual overall record.*

While new records were also set for liver, kidney and lung transplants, heart transplants in particular experienced a steep increase, from both donation after brain death (DBD) donors, as well as donation after circulatory death (DCD) donors.

Heart transplants increased overall by 21.5 percent (4,169 in 2022)

DBD heart transplants increased 4.6 percent (3,822 in 2022)

DCD heart transplants increased 68 percent (347 in 2022)

Advances in technology and donor recovery practices contributing to increases

Rapidly-evolving perfusion technology is allowing more DCD hearts to be transplanted. Perfusion allows organs to remain viable for longer periods outside the body; this is important for organs such as hearts and lungs, which have shorter windows of time when compared to kidneys. 2022 saw a 95 percent increase in transplants of machine-perfused hearts.

Coinciding with these advances in technology, increasing recovery of DCD donors has been a key area of focus for the nation’s 56 organ procurement organizations (OPOs) for a number of years. A recent UNOS-led collaborative project helped OPOs share effective practices related to recovering DCD donors to increase transplant. Over the course of the national project, 75 percent of OPOs participated in one or both of the two cohorts, contributing to the overall increases in DCD donors recovered and DCD organs transplanted. A subsequent collaborative project is currently focused on increasing transplantation of DCD lungs, and more than 40 percent of the nation’s lung transplant programs are participating.  

A report from the National Academies of Sciences, Engineering and Medicine (NASEM) recommends taking collaborative improvement approaches as well as embracing innovative technologies to maximize organ use, in particular use of DCD organs.  

February is American Heart Month. Get resources, fact sheets and other information on the National Institutes of Health website.  

*According to the most recent data from the Organ Procurement and Transplantation Network (accessed Feb. 13, 2023)

In focus

February is American Heart Month

7 years of HOPE

7 years of HOPE

Implemented in 2015 , the HIV Organ Policy Equity (HOPE) Act has given more than 350 living with HIV an opportunity to receive a lifesaving transplant from an HIV-positive donor.

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Process Engineer

Job Title: Process Engineer

Summary:  The process engineer is responsible for the installation, qualification, operation, supervision of a biomedical device assembly facility clean room.  The role includes developing standard operating protocols, training materials, scheduling, and reporting activities for manufacturing within a regulatory controlled environment.  This includes operations of the facility, electrical, process equipment , HVAC, high performance air filtering, and cleaning.

The process engineer is responsible for handling multiple projects for the lifecycle of the controlled environment including commissioning  and qualifications activities to decommissioning.  He or she will be responsible for organizing, budgeting, scheduling, carrying out, instruction, and supervision of the project as directed by company leadership.

Company Overview: Hibernicor is an innovative medical device company that manufactures single use disposable containers which will be marketed for sale in the US and Europe.

Key Position Responsibilities:

The process engineer will be responsible for defining the critical quality attributes, and process parameters in the clean room including particulate levels, relative humidity, and temperature parameters in a GMP compliant manner. The engineer should define the clean room requirements in a user requirements document and solicit input from qualified vendors following established ISPE/ASTM methodologies and guidance.

The process engineer will perform and maintain a risk assessment for all the critical process parameters including quality assurance, quality control, commissioning, validation, manufacturing safety, automation, and project management.  This may include researching, developing and acting on plans  using in depth knowledge of ISO and 21 CFR Part 11 and other regulatory guidelines.

The process engineer will prepare commissioning and qualification protocols, standard operating procedures, and work instructions as needed for equipment and facility operations aligning with an overall master validation plan.  The engineer should be able to write the validation master plan, commissioning and validation documents for the clean room, HVAC systems, and equipment; specifically design qualification, installation qualification, operational qualification, and procedure qualification documents (DQ/IQ/OQ/PQ).  The engineer should be able to prepare checklist and complete inspections that includes both static and dynamic exhaustive testing of systems or major system components to support the qualification of equipment or system based upon manufactures acceptance test or user requirements specifications (FAT/SAT).

The process engineer must of have experience and understanding of clean room facility and requirements.  In addition the engineer must have knowledge of computer system validation requirement and preparation and execution of protocol related to computerized systems provided by vendors. The engineer will supervise with the help of contractors on daily basis with follow up and completion of qualifying activities and GMP documentation including: clean room fitment, filter, HVAC and software automation testing and audit trail verifications.

The process engineer will supervise progress of the commissioning and qualifying activities on a periodic basis and hold status meetings with the stakeholders.  The engineer will maintain alignment to the budgetary guidelines, quality and safety standards.  The engineer will need to maintain and update quality control documents in an existing electronic GMP compliant document management system.

The process engineer will need to manage multiple task to coordinate projects timelines and work collaboratively with vendors and stakeholders to mitigate risk, facilitate problem solving, and to reduce  or avoid delays.

Minimum employee qualifications:

Bachelor degree in engineering or science field
US citizen or permanent resident
A minimum of 3 years of professional experience leading, initiating and completing projects.
Experience with statistical data and an ability to effectively perform technical analysis
Experience making risk based decisions
Experience navigating and adhering to structured system requirements (i.e. Quality Management System)
Demonstrated effective communication of technical information, both verbally and in written reports
Ability and willingness to respond beyond normal business hours (including weekends).

Desired position skills in:

Working in a clean room environment and understanding facility infrastructure, as it relates to supporting a clean room.
Working knowledge of environmental standards (FDA 21 CFR Part 11, ISO 14644, ISO 14698, etc.)
Understanding  of bioburden, endotoxins, particulate, etc. and conducting statistical analysis thereof.

Reporting: The packaging engineer reports to the quality manager and company director.

Location: The location of the job is at the company offices either in the US. If travel may be necessary to accomplish the job responsibilities and is anticipated to be no more than 10% of the employment.

Type of Employment: The position is full time.

Salary Range & Benefits: The salary and benefits are commensurate with the applicant’s qualifications and experience.

How to Apply: Please submit a cover letter, resume and 3 references with contact information. We will respond to suitable candidates by email to setup an initial telephone interview.

Contact Information:

253 Ridge Drive
Jackson, MS 39216

UNOS CEO Brian Shepard to leave organization after a decade of service

United Network for Organ Sharing (UNOS) today announced that CEO Brian Shepard will depart the organization at the end of September, following the completion of his contract. Shepard’s 10-year tenure as UNOS CEO was marked by groundbreaking progress in the U.S. organ donation and transplantation system.

Maureen McBride, Ph.D., UNOS’ chief operating officer, will assume the role of interim CEO beginning Oct. 1 while UNOS conducts a national search for Shepard’s successor. McBride has been with the organization since 1995. She served as director of research until 2014, when she accepted her current role as COO.

Brian Shepard, CEO, United Network for Organ Sharing

A commitment to improving the system

During his tenure, Shepard presided over the adoption of innovative policies, lifesaving improvements and record increases in both organ donation and transplant, including 2021, when the national system conducted more than 41,000 transplants in a single year, a global record. These and other advancements have positioned UNOS to drive the next phase of system progress, from increasing equity in transplant to adopting cutting-edge technologies, to collaborative improvement, further strengthening the nation’s high performing system and saving more lives.

“As UNOS CEO, Brian was a constant and courageous advocate for increasing equity in our national donation and transplantation system,” said Jerry McCauley, M.D., vice-president of the UNOS Board of Directors and incoming president. “His leadership has resulted in marked improvements in access to transplant for patients of color and those who have been historically marginalized. I am proud to have worked alongside Brian as a member of the UNOS board and am excited to build upon the foundation he has laid to further advance our mission and save even more lives.”

“UNOS is the engine that powers the U.S. donation and transplant system, and we are so lucky to have had Brian Shepard in the driver’s seat for the past decade,” said Matthew Cooper, M.D., president of the UNOS Board of Directors. “During such a pivotal time in our community, Brian took UNOS to the next level, driving accomplishments and championing the work of so many. His is a legacy to be celebrated.”

Prioritizing patients, equity and innovation

Under Shepard’s leadership, UNOS undertook a series of efforts to increase equitable access to transplant, including adopting a new way to distribute donor organs that emphasizes patient need. These new polices have resulted in greater access for the sickest patients.

“These changes to organ distribution weren’t easy or always popular, and it was so important to have Brian centering these discussions,” said David Mulligan, M.D., immediate past president of the UNOS board. “Now that these policies are in place, we can see the positive impact they’re having on patients and families across the country.”

Additionally, Shepard was instrumental in the development of UNOS Labs, an innovation center dedicated to fostering new ideas and encouraging experimentation. Since its founding, UNOS Labs has developed transplant-focused predictive analytics to help doctors decide whether to accept an organ offer for their patient, a GPS tracker for organ shipments, an offer simulator to conduct behavioral science research to improve organ matching, and a high-quality medical image sharing platform.

“The UNOS team is the most incredibly talented and dedicated team I’ve ever had the honor of being a part of,” said Shepard. “I’ve always viewed my job as making their job easier; removing obstacles and watching them run. I’m so proud of what they’ve accomplished and of all of the ongoing efforts that will further improve donation and transplant in the U.S.”

A vision for the future of organ allocation

Over the last several years, Shepard has helped put into place a new allocation policy, called continuous distribution. This innovative approach dissolves rigid boundaries, and is structured so that no single attribute determines whether or not a patient receives a transplant. Importantly, continuous distribution is also designed to allow for more patient engagement in the decision-making process.

“As a three-decade heart transplant survivor who strongly advocates increased involvement for transplant patients in the policy development process, continuous distribution is a game changer,” said Jim Gleason, president of Transplant Recipients International Organization (TRIO). Gleason has engaged with UNOS for more than 25 years and is a two-term former UNOS Board member. “This effort is not only going to help guide patients to the information they need in their transplant journey, it will also give them an active contributor seat at the decision-making table.”

A lasting legacy

“From policymaking to technology, from system-wide improvements to one-on-one interactions, Brian’s leadership has left an indelible mark on UNOS and the wider donation and transplant community,” said Sue Dunn, former CEO of Donor Alliance and a former UNOS board president. “But for me, to see his ongoing commitment to honoring selfless donors, their courageous families, and recognizing the often-thankless work of our OPOs – that is a legacy be proud of.”

“We’ve come such a long way in the last decade,” said Shepard. “While I am honored that the Board asked me to continue to serve as CEO, I felt it was the right time to take the next step. I have worked with so many amazing and dedicated people over the years who made it possible to accomplish all that I originally set out to do as UNOS CEO. Now, as we embark on a new chapter with even more exciting opportunities, I know the UNOS team and the donation and transplant community are in good hands, and I’m excited about the future.”

United Network for Organ Sharing (UNOS) is the mission-driven non-profit serving as the nation’s transplant system under contract with the federal government. We lead the network of transplant hospitals, organ procurement organizations, and thousands of volunteers who are dedicated to honoring the gifts of life entrusted to us and to making lifesaving transplants possible for patients in need. Working together, we leverage data and advances in science and technology to continuously strengthen the system, increase the number of organs recovered and the number of transplants performed, and ensure patients across the nation have equitable access to transplant.

For media inquiries, contact or (804) 782-4730.

The post appeared first on UNOS.

[Approval] Ex situ heart perfusion: The past, the present, and the future

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J Heart Lung Transplant. 2021 Jan;40(1):69-86. doi: 10.1016/j.healun.2020.10.004. Epub 2020 Oct 14.


Despite the advancements in medical treatment, mechanical support, and stem cell therapy, heart transplantation remains the most effective treatment for selected patients with advanced heart failure. However, with an increase in heart failure prevalence worldwide, the gap between donor hearts and patients on the transplant waiting list keeps widening. Ex situ machine perfusion has played a key role in augmenting heart transplant activities in recent years by enabling the usage of donation after circulatory death hearts, allowing longer interval between procurement and implantation, and permitting the safe use of some extended-criteria donation after brainstem death hearts. This exciting field is at a hinge point, with 1 commercially available heart perfusion machine, which has been used in hundreds of heart transplantations, and a number of devices being tested in the pre-clinical and Phase 1 clinical trial stage. However, no consensus has been reached over the optimal preservation temperature, perfusate composition, and perfusion parameters. In addition, there is a lack of objective measurement for allograft quality and viability. This review aims to comprehensively summarize the lessons about ex situ heart perfusion as a platform to preserve, assess, and repair donor hearts, which we have learned from the pre-clinical studies and clinical applications, and explore its exciting potential of revolutionizing heart transplantation.

PMID:33162304 | DOI:10.1016/j.healun.2020.10.004

[Approval] Clinical transplantation using negative pressure ventilation ex situ lung perfusion with extended criteria donor lungs

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Nat Commun. 2020 Nov 13;11(1):5765. doi: 10.1038/s41467-020-19581-4.


Lung transplantation remains the best treatment option for end-stage lung disease; however, is limited by a shortage of donor grafts. Ex situ lung perfusion, also known as ex vivo lung perfusion, has been shown to allow for the safe evaluation and reconditioning of extended criteria donor lungs, increasing donor utilization. Negative pressure ventilation ex situ lung perfusion has been shown, preclinically, to result in less ventilator-induced lung injury than positive pressure ventilation. Here we demonstrate that, in a single-arm interventional study ( number NCT03293043) of 12 extended criteria donor human lungs, negative pressure ventilation ex situ lung perfusion allows for preservation and evaluation of donor lungs with all grafts and patients surviving to 30 days and recovered to discharge from hospital. This trial also demonstrates that ex situ lung perfusion is safe and feasible with no patients demonstrating primary graft dysfunction scores grade 3 at 72 h or requiring post-operative extracorporeal membrane oxygenation.

PMID:33188221 | PMC:PMC7666579 | DOI:10.1038/s41467-020-19581-4

[Approval] Combined Assessment of Functional and Metabolic Performance of Human Donor Hearts: Possible Application in Donation After Circulatory Death

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Transplantation. 2021 Jul 1;105(7):1510-1515. doi: 10.1097/TP.0000000000003531.


BACKGROUND: Donation after circulatory death (DCD) represents an increasing source of organs. However, evaluating the suitability of DCD hearts for transplantation represents a challenge. Contractile function is the ultimate determinant of recovery. We developed a novel technique in an ex vivo rig for the measurement of contractility using intraventricular balloons. We compared this technique with the measurement of lactate metabolism, the current gold standard.

METHODS: Human DCD (n = 6) and donation after brain death (n = 6) hearts were preserved by perfusion with a cold oxygenated crystalloid solution for 4 h, transferred to a blood perfusion rig at 37 °C where balloons were inserted into the left (LV) and right (RV) ventricles to measure developed pressure (DP = systolic minus diastolic). Perfusate lactate levels were measured for metabolic assessment. Concordance between LVDP and lactate was assessed during 4 h using cutoffs for LVDP of 70 mm Hg and for lactate of 10 mmol/L.

RESULTS: Measurements of contractile function (LVDP) and metabolism (lactate levels) were deemed concordant in 7 hearts with either a high LVDP (mean 100 mm Hg) with low lactate (mean 6.7 mmol/L)) or a low LVDP (15 mm Hg) with high lactate (mean 17.3 mmol/). In the remaining 5 hearts, measurements were deemed discordant: 4 hearts had high LVDP (mean 124 mm Hg), despite high lactate levels 17.3 mmol/L) and 1 had low LVDP (54 mm Hg) but low lactate (6.9 mmol/L).

CONCLUSIONS: The intraventricular balloon technique provides useful information regarding contractile recovery of donor hearts that if combined with lactate metabolism has potential application for the evaluation of DCD and marginal donation after brain death hearts before transplant.

PMID:33196627 | DOI:10.1097/TP.0000000000003531

[Approval] Myocardial Substrate Oxidation and Tricarboxylic Acid Cycle Intermediates During Hypothermic Machine Perfusion

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J Surg Res. 2021 Mar;259:242-252. doi: 10.1016/j.jss.2020.09.040. Epub 2020 Nov 26.


BACKGROUND: The optimal substrate for hypothermic machine perfusion preservation of donor hearts is unknown. Fatty acids, acetate, and ketones are preferred substrates of the heart during normothermic perfusion, but cannot replete the tricarboxylic acid (TCA) cycle directly. Propionate, an anaplerotic substrate, can replenish TCA cycle intermediates and may affect cardiac metabolism. The purpose of this study was to determine myocardial substrate preferences during hypothermic machine perfusion and to assess if an anaplerotic substrate was required to maintain the TCA cycle intermediate pool in perfused hearts.

METHODS: Groups of rat hearts were perfused with carbon-13 (13C)-labeled substrates (acetate, β-hydroxybutyrate, octanoate, with and without propionate) at low and high concentrations. TCA cycle intermediate concentrations, substrate selection, and TCA cycle flux were determined by gas chromatography/mass spectroscopy and 13C magnetic resonance spectroscopy.

RESULTS: Acetate and octanoate were preferentially oxidized, whereas β-hydroxybutyrate was a minor substrate. TCA cycle intermediate concentrations except fumarate were higher in substrate-containing perfusion groups compared with either the no-substrate perfusion group or the no-ischemia control group.

CONCLUSIONS: The presence of an exogenous, oxidizable substrate is required to support metabolism in the cold perfused heart. An anaplerotic substrate is not essential to maintain the TCA cycle intermediate pool and support oxidative metabolism under these conditions.

PMID:33250204 | DOI:10.1016/j.jss.2020.09.040

[Approval] Apoptotic Markers in Donor Hearts After Brain Death vs Circulatory Death

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Transplant Proc. 2021 Mar;53(2):612-619. doi: 10.1016/j.transproceed.2020.10.001. Epub 2020 Dec 2.


BACKGROUND: Use of donation after circulatory death (DCD) hearts is becoming more prevalent in cardiac transplantation. However, there is no standardized approach to myocardial preservation, and little data exists on ultrastructural changes in DCD hearts. We have previously identified increased proapoptotic and proinflammatory activity in brain dead donor (BDD) hearts that subsequently exhibit primary graft failure and lower levels in DCD left atrial tissue. This study further investigates these markers and correlates them with cardiac function in DCD hearts.

METHODS: This prospective study used donor hearts deemed unsuitable for transplant after gaining institutional ethics approval; 11 human hearts were obtained from 5 DCD donors and 6 BDDs. All hearts were preserved by continuous microperfusion for 4 hours with a cold crystalloid solution and then were evaluated on a blood perfusion bench rig. After 4 hours perfusion and working assessment, tissues from all cardiac chambers were stored for later messenger RNA (mRNA) analysis for proapoptotic and proinflammatory markers.

RESULTS: Significantly raised levels of caspase-1, BNIP3, and NADPH oxidase mRNA expression were identified in cardiac chambers from BDD hearts compared to DCD hearts, and these differences were exaggerated in older donors. In the pooled analysis, lower expression of caspase-1, NF-κB1, and BNIP3 mRNA correlated with developed pressure at 1 hour after reperfusion in the right ventricle, but not the left.

CONCLUSION: Compared to BDD hearts, DCD hearts exhibit less stimulation of proapoptotic cascades and reactive oxygen species, potentially reducing their susceptibility to ischemic reperfusion injury.

PMID:33279259 | DOI:10.1016/j.transproceed.2020.10.001

[Approval] Spanish experience with heart transplants from controlled donation after the circulatory determination of death using thoraco-abdominal normothermic regional perfusion and cold storage

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Am J Transplant. 2021 Apr;21(4):1597-1602. doi: 10.1111/ajt.16446. Epub 2021 Jan 2.


Heart transplantation from controlled donation after the circulatory determination of death (cDCDD) may help to increase the availability of hearts for transplantation. During 2020, four heart transplants were performed at three different Spanish hospitals based on the use of thoraco-abdominal normothermic regional perfusion (TA-NRP) followed by cold storage (CS). All donors were young adults <45 years. The functional warms ischemic time ranged from 8 to 16 minutes. In all cases, the heart recovered sinus rhythm within 1 minute of TA-NRP. TA-NRP was weaned off or decreased <1L within 25 minutes. No recipient required mechanical support after transplantation and all were immediately extubated and discharged home (median hospital stay: 21 days) with an excellent outcome. Four livers, eight kidneys, and two pancreata were also recovered and transplanted. All abdominal grafts recipients experienced an excellent outcome. The use of TA-NRP makes heart transplantation feasible and allows assessing heart function before organ procurement without any negative impact on the preservation of abdominal organs. The use of TA-NRP in cDCDD heart donors in conjunction with cold storage following retrieval can eliminate the need to use ex situ machine perfusion devices, making cDCDD heart transplantation economically possible in other countries.

PMID:33319435 | DOI:10.1111/ajt.16446