Getting out of the box: the future of the UK donation after circulatory determination of death heart programme.

Heart failure imposes a significant burden on all health care systems and has a 5-year mortality of 50%. Heart transplantation and ventricular assist device (VAD) implantation are the definitive therapies for end stage heart disease, although transplantation appears to offer superior long-term survival and quality of life over VAD implantation. Transplantation is limited by a shortage in donor hearts, resulting in considerable waiting list mortality. Donation after circulatory determination of death (DCD) offers a significant uplift in the number of donors for heart transplantation. The outcomes both from the UK and internationally have been exciting, with outcomes at least as good as conventional donation after brain death (DBD) transplantation. Currently, DCD hearts are reperfused using ex-situ machine perfusion (ESMP). Whilst ESMP has enabled the development of DCD transplantation, it comes at significant cost, with the per run cost of approximately GBP £90,000. In-situ perfusion of the heart, otherwise known as thoraco-abdominal normothermic regional perfusion (taNRP) is cheaper, but there are ethical concerns regarding the potential to restore cerebral perfusion in the donor. We must determine whether there is any cerebral circulation during in-situ perfusion of the heart to ensure that it does not invalidate the diagnosis of death and potentially violate the dead donor rule. Besides this, there is a need for a randomised controlled trial to definitively determine whether taNRP offers any clinical advantages over ex-situ machine perfusion. This viewpoint article explores these issues in more detail.

Quantifying increased lateral column instability in Adult Acquired Flatfoot Deformity (AAFD).

AAFD comprises ligamentous failure and tendon overload, mainly focused on the symptomatic posterior tibial tendon and the spring ligament. Increased lateral column (LC) instability arising in AAFD is not defined or quantified. This study aims to quantify the increased LC motion in unilateral symptomatic planus feet, using the contralateral unaffected asymptomatic foot as an internal control. In this case matched analysis, 15 patients with unilateral stage 2 AAFD foot and an unaffected contralateral foot were included. Lateral foot translation was measured as a guide to spring ligament competency. Medial and LC dorsal sagittal instability were assessed by direct measurement of dorsal 1st and 4th/5th metatarsal head motion and further video analysis. The mean increase in dorsal LC sagittal motion (between affected vs unaffected foot) was 5.6 mm (95% CI [4.63-6.55], p < 0.001). The mean increase in the lateral translation score was 42.8 mm (95% CI [37.48-48.03], p < 0.001). The mean increase in medial column dorsal sagittal motion was 6.8 mm (95% CI [5.7-7.8], p < 0.001). Video analysis also showed a statistically significant increase in LC dorsal sagittal motion between affected and unaffected sides (p < 0.001). This is the first study that quantifies a statistically significant increased LC dorsal motion in feet with AAFD. Understanding its pathogenesis and its link to talonavicular/spring ligament laxity improves foot assessment and may allow the development of future preventative treatment strategies.

Differential contribution of lateral plantar foot ligaments to lateral column stability - A cadaver based sectioning analysis.

Lateral column (LC) instability occurs in adult acquired flatfoot deformity (AAFD). Differential ligament contribution to LC stability is unknown. The primary aim was to quantify this by using cadaver sectioning of lateral plantar ligaments. We also determined the relative contribution of each ligament to dorsal translation of the metatarsal head in the sagittal plane. 17 below-knee cadaveric specimens, preserved by vascular embalming method, were dissected to expose plantar fascia, long/short plantar ligaments (L/SPL), calcaneocuboid (CC) capsule and inferior 4th/5th tarsometatarsal (TMT) capsule. Dorsal forces of 0 N, 20 N and 40 N were applied to the plantar 5th metatarsal head after sequential ligament sectioning in different orders. Pins provided linear axes on each bone, allowing relative angular bone displacements to be calculated. Photography and ImageJ processing software were then used for analysis. The LPL (and CC capsule) had the greatest contribution to metatarsal head motion (107 mm) after isolated sectioning. In the absence of other ligaments, sectioning these resulted in significantly increased hindfoot-forefoot angulation (p ≤ 0.0003). Isolated TMT capsule sectioning demonstrated significant angular displacement even when other ligaments remained intact (with intact L/SPL, p = 0.0005). CC joint instability required both LPL and capsular sectioning for significant angulation to occur, whilst TMT joint stability was largely dependent on its capsule. The relative contribution of static restraints to the lateral arch has not yet been quantified. This study provides useful information on relative ligament contribution to both CC and TMT joint stability, which may in turn improve understanding of surgical interventions used to restore arch stability.