Normothermic Regional Perfusion in Controlled Donation After the Circulatory Determination of Death: Understanding Where the Benefit Lies.

Controlled donation after the circulatory determination of death (cDCDD) has emerged as a strategy to increase the availability of organs for clinical use. Traditionally, organs from cDCDD donors have been subject to standard rapid recovery (SRR) with poor posttransplant outcomes of abdominal organs, particularly the liver, and limited organ utilization. Normothermic regional perfusion (NRP), based on the use of extracorporeal membrane oxygenation devices, consists of the in situ perfusion of organs that will be subject to transplantation with oxygenated blood under normothermic conditions after the declaration of death and before organ recovery. NRP is a potential solution to address the limitations of traditional recovery methods. It has become normal practice in several European countries and has been recently introduced in the United States. The increased use of NRP in cDCDD has occurred as a result of a growing body of evidence on its association with improved posttransplant outcomes and organ utilization compared with SRR. However, the expansion of NRP is precluded by obstacles of an organizational, legal, and ethical nature. This article details the technique of both abdominal and thoracoabdominal NRP. Based on the available evidence, it describes its benefits in terms of posttransplant outcomes of abdominal and thoracic organs and organ utilization. It addresses cost-effectiveness aspects of NRP, as well as logistical and ethical obstacles that limit the implementation of this innovative preservation strategy.

Outcomes of liver transplantation with thoracoabdominal normothermic regional perfusion: a matched-controlled initial experience in Spain.

Thoracoabdominal (TA) normothermic regional perfusion (NRP) should allow the safe recovery of heart and liver grafts simultaneously in the context of controlled donation after circulatory death (cDCD). We present the initial results of cDCD liver transplantation with simultaneous liver and heart procurement in Spain until October 2021. Outcomes were compared with a matched cohort of cDCD with abdominal NRP (A-NRP) from participating institutions. Primary endpoints comprised early allograft dysfunction (EAD) or primary non-function (PNF), and the development of ischemic-type biliary lesions (ITBL). Six transplants were performed using cDCD with TA-NRP during the study period. Donors were significantly younger in the TA-NRP group than in the A-NRP group (median 45.6 years and 62.9 years respectively, p = 0.011), with a median functional warm ischemia time of 12.5 min in the study group and 13 min in the control group. Patient characteristics, procurement times, and surgical baseline characteristics did not differ significantly between groups. No patient in the study group developed EAD or PNF, and over a median follow-up of 9.8 months, none developed ITBL or graft loss. Extending A-NRP to TA-NRP for cardiac procurement may be technically challenging, but it is both feasible and safe, showing comparable postoperative outcomes to A-NRP.

Experiencia preliminar en una unidad de cuidados intensivos con Impella Recover®. Asistencia ventricular microaxial en pacientes con bajo gasto cardíaco / Preliminary experience in an intensive care unit with Impella Recover®. A new circulatory support system in patients with low cardiac output

El síndrome de bajo gasto cardíaco tras cardiotomía se caracteriza por una mala contractilidad ventricular izquierda que requiere el apoyo de altas dosis de fármacos vasoactivos, el uso de balón de contrapulsación y en ocasiones imposibilita la desconexión de la circulación extracorpórea. Presentamos 5 casos en los que se implantó un dispositivo de «reciente creación» en la asistencia ventricular izquierda: Impella Recover® (Impella CardioSystems AG, Aachen, Alemania), por shock cardiogénico al final de la intervención. De estos pacientes, 4 recuperaron la función cardíaca y la asistencia ventricular se pudo retirar tras un promedio de 70 ± 55h. En el quinto paciente, el dispositivo no mostró un resultado favorable y se evidenció insuficiencia ventricular derecha, por lo que fue necesario recurrir a una asistencia biventricular tipo Berlin Heart (AU)

The low cardiac output syndrome following cardiopulmonary bypass is characterized by poor left ventricular contractibility that requires the support of high doses of vasoactive drugs, intra-aortic balloon pump, and sometimes makes it impossible to disconnect the extracorporeal circulation. We report 5 cases in which a «recently created» device in left ventricular support was inserted, the Impella Recover® (Impella CardioSystems AG, Aachen, Germany) due to cardiogenic shock at the end of the surgery. Four of these patients recovered their heart function and the ventricular support could be removed after 70 ± 55h. In a fifth patient, the right ventricular failure warranted the use of Berlin Heart assist device (AU)