Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 57
Filtrar
1.
Indian J Crit Care Med ; 26(4): 421-438, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35656056

RESUMO

Organ donation following circulatory determination of death (DCDD) has contributed significantly to the donor pool in several countries. In India, majority of deceased donations happen following brain death (BD). While existing legislation allows for DCDD, there have been only few reports of kidney transplantation following DCDD from India. This document, prepared by a multidisciplinary group of experts, reviews international best practices in DCDD and outlines the path for DCDD in India. Ethical, medical, legal, economic, procedural, and logistic challenges unique to India have been addressed. The practice of withdrawal of life-sustaining treatment (WLST) in India, laid down by the Supreme Court of India, is time-consuming, possible only in patients in a permanent vegetative state, and too cumbersome for day-to-day practice. In patients where continued medical care is futile, the procedure for WLST is described. In controlled DCDD (category-III), decision for WLST is independent of and delinked from the subsequent possibility of organ donation. Families that are inclined toward organ donation are explained the procedure including the timing and location of WLST, consent for antemortem measures, no-touch period, and the possibility of stand-down and return to the intensive care unit (ICU) without donation. In donation following neurologic determination of death (DNDD), if cardiac arrest occurs during the process of BD declaration, the protocol for DCDD category-IV has been described in detail. In DCDD category-V, organ donation may be possible following unsuccessful cardiopulmonary resuscitation of cardiac arrest in the ICU. An outline of organ-specific requisites for kidney, liver, heart, and lung transplantation following DCDD and techniques, such as normothermic regional perfusion (nRP) and ex vivo machine perfusion, has been provided. The outcomes of transplantation following DCDD are comparable to those following DBDD or living donor transplantation. Documents and checklists necessary for successful execution of DCDD in India are described. How to cite this article: Seth AK, Mohanka R, Navin S, Gokhale AGK, Sharma A, Kumar A, et al. Organ Donation after Circulatory Determination of Death in India: A Joint Position Paper. Indian J Crit Care Med 2022;26(4):421-438.

2.
Am J Transplant ; 21(2): 636-644, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32659872

RESUMO

A consensus conference on frailty in solid organ transplantation took place on February 11, 2018, to discuss the latest developments in frailty, adopt a standardized approach to assessment, and generate ideas for future research. The findings and consensus of the Frailty Heart Workgroup (American Society of Transplantation's Thoracic and Critical Care Community of Practice) are presented here. Frailty is defined as a clinically recognizable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with every day or acute stressors is compromised. Frailty is increasingly recognized as a distinct biologic entity that can adversely affect outcomes before and after heart transplantation. A greater proportion of patients referred for heart transplantation are older and have more complex comorbidities. However, outcomes data in the pretransplant setting, particularly for younger patients, are limited. Therefore, there is a need to develop objective frailty assessment tools for risk stratification in patients with advanced heart disease. These tools will help to determine appropriate recipient selection for advanced heart disease therapies including heart transplantation and mechanical circulatory support, improve overall outcomes, and help distinguish frailty phenotypes amenable to intervention.


Assuntos
Fragilidade , Transplante de Coração , Transplante de Órgãos , Consenso , Cuidados Críticos , Humanos
3.
Respirology ; 26(12): 1171-1180, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-34608706

RESUMO

BACKGROUND AND OBJECTIVE: Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious condition occurring in 2%-4% of patients after acute pulmonary embolism. Pulmonary endarterectomy (PEA) is a potential cure for technically operable disease. The epidemiology and long-term outcomes of CTEPH have not been previously described in Australia and New Zealand. METHODS: Data were extracted from the Pulmonary Hypertension Society of Australia and New Zealand (PHSANZ) registry for patients diagnosed with CTEPH between January 2004 and March 2020. Baseline characteristics, treatment strategies, outcome data and long-term survival are reported. RESULTS: A total of 386 patients were included with 146 (37.8%) undergoing PEA and 240 (62.2%) in the non-PEA group. PEA patients were younger (55 ± 16 vs. 62 ± 16 years, p < 0.001) with higher baseline 6-min walk distance (6MWD; 405 ± 122 vs. 323 ± 146 m, p = 0.021), whilst both groups had similar baseline pulmonary haemodynamics. Pulmonary hypertension-specific therapy was used in 54% of patients post-PEA and 88% in the non-PEA group. The 1-, 3- and 5-year survival rates were 93%, 87% and 84% for the PEA group compared to 86%, 73% and 62%, respectively, for the non-PEA group (p < 0.001). Multivariate survival analysis showed baseline 6MWD was an independent predictor of survival in both operated and medically managed patients. CONCLUSION: In this first multicentre report of CTEPH in Australia and New Zealand, long-term survival is comparable to that in other contemporary CTEPH registries. However, PEA was only performed in a minority of CTEPH patients (37.8%) and significantly less than overseas reports. Greater awareness of PEA and improved patient access to experienced CTEPH centres are important priorities.


Assuntos
Hipertensão Pulmonar , Embolia Pulmonar , Doença Crônica , Endarterectomia , Humanos , Hipertensão Pulmonar/epidemiologia , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/terapia , Nova Zelândia/epidemiologia , Artéria Pulmonar , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/terapia , Sistema de Registros , Resultado do Tratamento
4.
Curr Opin Organ Transplant ; 25(3): 241-247, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32374575

RESUMO

PURPOSE OF REVIEW: Increasing number of patients with end-stage heart failure and those with improved survivorship from selective utilization of implantable mechanical circulatory support devices have added further burden and complexity to the transplant waitlist and on the rate-limiting availability of donor hearts from the standard pathway of donation after brain death. Unlike this conventional route, the increasing clinical use of donation after circulatory death (DCD) donor hearts necessitates a closer understanding of the logistics involved in the DCD process as well as of the risks associated with the unique pathophysiological consequences in this setting. RECENT FINDINGS: Notwithstanding a higher incidence of delayed graft function, the clinical utilization of DCD hearts for cardiac transplantation over the past five years has demonstrated this to be a well-tolerated and strategic alternative with excellent medium-term clinical outcomes. SUMMARY: The uptake of DCD heart transplantation remains selective and currently confined to Australia, the United Kingdom, Belgium, and more recently the USA. A more significant adoption will only come about through: a concerted effort to resolve the ethical and clinical controversies; a better understanding of postconditioning strategies; continued resolve to reduce the obligatory period of warm ischemia; and from better extracorporeal platforms that permit functional viability assessment of the DCD donor heart.


Assuntos
Morte Encefálica/fisiopatologia , Transplante de Coração/métodos , Doadores de Tecidos/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
5.
Intern Med J ; 47(10): 1202-1205, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28994259

RESUMO

In this 'paired' case report, we describe two heart transplants performed 3 days apart at our centre. Both cases involved very prolonged transportation time of the donor heart. In one case, the donor heart was transported in an ice chest, while in the other case the organ was transported using a normothermic ex vivo perfusion (NEVP) system. The additional retrieval costs incurred by the use NEVP were more than offset by the reduction in subsequent inpatient costs.


Assuntos
Cardiomiopatias/cirurgia , Transplante de Coração/métodos , Tempo para o Tratamento , Sobrevivência de Tecidos/fisiologia , Doadores não Relacionados , Adolescente , Idoso , Cardiomiopatias/diagnóstico , Transplante de Coração/normas , Humanos , Masculino , Tempo para o Tratamento/normas
6.
Curr Opin Organ Transplant ; 22(3): 189-197, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28379853

RESUMO

PURPOSE OF REVIEW: Despite continued expansion in the use of extended-criteria donor hearts following donation after brain death, there remains an unacceptable discrepancy between the supply of suitable donor hearts and the demand from increasing recipient numbers on transplant wait lists. Until recently, the additional approach of utilizing organs following donation after circulatory death (DCD) had not been possible for clinical heart transplantation in the modern era. This review describes relevant advances in translational research and provides an update on the favourable adoption of this donation pathway for clinical heart transplantation. RECENT FINDINGS: The use of an ex-situ transportable cardiac perfusion platform together with modified cardioplegia, supplemented with postconditioning agents, has allowed three centres to report successful transplantation of distantly procured human DCD hearts. This has been achieved by utilizing either a method of direct procurement and ex-situ perfusion on the device or through an initial in-situ reanimation with extracorporeal normothermic regional perfusion prior to ex-situ perfusion. SUMMARY: DCD heart transplantation is feasible with excellent early outcomes. In the face of continued and significant donor organ shortage and inevitable wait list attrition, the rejection of suitable DCD hearts, in jurisdictions permitting this donation pathway, is increasingly difficult to justify.


Assuntos
Transplante de Coração/métodos , Obtenção de Tecidos e Órgãos/métodos , Doação Dirigida de Tecido , Humanos , Doadores de Tecidos
7.
Lancet ; 385(9987): 2585-91, 2015 Jun 27.
Artigo em Inglês | MEDLINE | ID: mdl-25888085

RESUMO

BACKGROUND: Orthotopic heart transplantation is the gold-standard long-term treatment for medically refractive end-stage heart failure. However, suitable cardiac donors are scarce. Although donation after circulatory death has been used for kidney, liver, and lung transplantation, it is not used for heart transplantation. We report a case series of heart transplantations from donors after circulatory death. METHODS: The recipients were patients at St Vincent's Hospital, Sydney, Australia. They received Maastricht category III controlled hearts donated after circulatory death from people younger than 40 years and with a maximum warm ischaemic time of 30 min. We retrieved four hearts through initial myocardial protection with supplemented cardioplegia and transferred to an Organ Care System (Transmedics) for preservation, resuscitation, and transportation to the recipient hospital. FINDINGS: Three recipients (two men, one woman; mean age 52 years) with low transpulmonary gradients (<8 mm Hg) and without previous cardiac surgery received the transplants. Donor heart warm ischaemic times were 28 min, 25 min, and 22 min, with ex-vivo Organ Care System perfusion times of 257 min, 260 min, and 245 min. Arteriovenous lactate values at the start of perfusion were 8·3-8·1 mmol/L for patient 1, 6·79-6·48 mmol/L for patient 2, and 7·6-7·4 mmol/L for patient 3. End of perfusion lactate values were 3·6-3·6 mmol/L, 2·8-2·3 mmol/L, and 2·69-2·54 mmol/L, respectively, showing favourable lactate uptake. Two patients needed temporary mechanical support. All three recipients had normal cardiac function within a week of transplantation and are making a good recovery at 176, 91, and 77 days after transplantation. INTERPRETATION: Strict limitations on donor eligibility, optimised myocardial protection, and use of a portable ex-vivo organ perfusion platform can enable successful, distantly procured orthotopic transplantation of hearts donated after circulatory death. FUNDING: NHMRC, John T Reid Charitable Trust, EVOS Trust Fund, Harry Windsor Trust Fund.


Assuntos
Displasia Arritmogênica Ventricular Direita/terapia , Cardiomiopatia Dilatada/terapia , Transplante de Coração/métodos , Miocardite/terapia , Preservação de Órgãos/métodos , Doadores de Tecidos/classificação , Obtenção de Tecidos e Órgãos/métodos , Adulto , Displasia Arritmogênica Ventricular Direita/fisiopatologia , Biópsia , Cardiomiopatia Dilatada/fisiopatologia , Feminino , Parada Cardíaca Induzida , Humanos , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Choque/patologia , Resultado do Tratamento , Viroses/terapia , Isquemia Quente
8.
Curr Opin Organ Transplant ; 21(3): 336-42, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26967996

RESUMO

PURPOSE OF REVIEW: Cold static storage is a time-tested and simple method of preserving hearts retrieved from optimal donors after brain death (DBD). The increasing gap between supply and demand for donor organs together with changing donor and recipient characteristics have led to renewed interest in the use of machine perfusion to increase both the quality and quantity of donor hearts for transplantation. RECENT FINDINGS: Two major approaches to machine perfusion of donor hearts have been investigated - hypothermic (HMP) and normothermic machine perfusion (NMP). Recent preclinical studies with HMP confirm that it provides superior donor heart preservation to cold static storage. HMP systems have been developed for human heart preservation but have yet to be tested clinically. In contrast, NMP has undergone extensive clinical evaluation in human heart transplantation, including optimal and higher risk DBD donors. In addition, NMP has enabled distant procurement and successful transplantation of hearts retrieved from human donation after circulatory death donors. SUMMARY: Initial clinical experience suggests that NMP of donor hearts retrieved from higher risk DBD and donation after circulatory death donors enables well tolerated ex-vivo reanimation, preservation, and assessment of these organs. In particular, this technology allows successful utilization of extended-criteria donor hearts that would otherwise be discarded.


Assuntos
Criopreservação/métodos , Circulação Extracorpórea/métodos , Transplante de Coração/métodos , Coração/fisiopatologia , Preservação de Órgãos/métodos , Perfusão/métodos , Humanos
9.
Pacing Clin Electrophysiol ; 38(8): 925-33, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25940215

RESUMO

BACKGROUND: Both implantable cardioverter defibrillators (ICDs) and left ventricular assist devices (LVADs) have a positive impact on survival in the heart failure population. We sought to determine whether these positive effects on survival are additive or whether LVAD therapy supersedes ICD therapy. METHOD: We analyzed survival data of patients implanted with nonpulsatile LVADs between October 2004 and March 2013. Survival in patients with ICDs (n = 64) was compared to those without ICDs (n = 36). Patients exited the study at the time of heart transplantation or death. RESULTS: A total of 100 patients underwent LVAD implantation during this time. Patients had a mean follow-up time of 364 ± 295 days. Death occurred in 15 (38%) patients in the no ICD group versus 18 (30%) in the ICD group. Univariate analysis demonstrated a marginal early survival benefit at up to 1 year post-LVAD implant in the ICD cohort; however, at time points greater than 1 year there was no statistically significant benefit in ICD therapy in LVAD patients (P = 0.56). Multivariate analysis did not show any significant predictor of survival. There were no patients who died of sudden cardiac death. There was no significant difference in the time to heart transplantation (443 days ± 251 no ICD vs 372 days ± 277 ICD, P = 0.37). CONCLUSION: The benefit of ICD therapy in the setting of continuous flow LVAD therapy is uncertain. Although prolonged ventricular arrhythmias (VAs) may potentially impact on patient survival, LVAD therapy is beneficial in prevention of sudden cardiac death due to VAs.


Assuntos
Desfibriladores Implantáveis , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Coração Auxiliar , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida
10.
Heart Lung Circ ; 23(9): 841-6, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24751512

RESUMO

BACKGROUND: With improved life expectancy more octogenarians now present with aortic valve disease. Cardiac surgery in this group of patients has previously been considered high risk due to co-morbidities and challenges of rehabilitation. This study seeks to challenge the concept of octogenarian cardiac surgery "unsuitability" by analysing operative outcomes and long term survival following aortic valve replacement. METHODS: Eighty-seven consecutive patients undergoing aortic valve replacement between 2000 and 2009 at St Vincent's Hospital were retrospectively identified. Statistical analysis was performed using SPSS (version 15 and 19). RESULTS: The average age was 82.7 ± 2.4 years. The mean logistic EuroSCORE was 18.86 ± 14.11. Post-operatively, four patients required insertion of a permanent pacemaker (4.6%) and five patients had a myocardial infarction (5.8%). In-hospital mortality was 3.4%. Follow-up was 93.1% complete. One-year survival was 92.9%, three-year survival was 86.7% and five-year survival was 75.0%. At follow-up 98.1% of patients were New York Heart Association (NYHA) Class I or II. CONCLUSIONS: Results were excellent despite reasonable co-morbidities and Euroscore risk. Survival was impressive and the NYHA class reflected the success of the surgery in relieving the pathological aortic valve process. Patient age should not be the primary exclusion for cardiac surgery for aortic valve disease.


Assuntos
Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Bioprótese , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Idoso de 80 Anos ou mais , Cuidados Críticos , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Estudos Retrospectivos , Índice de Gravidade de Doença , Esternotomia/mortalidade , Taxa de Sobrevida
11.
Heart Lung Circ ; 23(8): 703-10, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24709393

RESUMO

BACKGROUND: Improved survival of heart transplant (HTx) recipients and increased acceptance of higher risk donors allows development of late pathology. However, there are few data to guide surgical options. We evaluated short-term outcomes and mortality to guide pre-operative assessment, planning, and post-operative care. METHODS: Single centre, retrospective review of 912 patients who underwent HTx from February 1984 - June 2012, identified 22 patients who underwent subsequent cardiac surgery. Data are presented as median (IQR). RESULTS: Indications for surgery were coronary allograft vasculopathy (CAV) (n=10), valvular disease (n=6), infection (n=3), ascending aortic aneurysm (n=1), and constrictive pericarditis (n=2). There was one intraoperative death (myocardial infarction). Hospital stay was 10 (8-21) days. Four patients (18%) returned to theatre for complications. After cardiac surgery, survival at one, five and 10 years was 91±6%, 79±10% and 59±15% with a follow-up of 4.6 (1.7-10.2) years. High pre-operative creatinine was a univariate risk factor for mortality, HR=1.028, (95%CI 1.00-1.056; p=0.05). A time dependent Cox proportional hazards model of the risk of cardiac surgery post-HTx showed no significant hazard; HR=0.87 (95%CI 0.37-2.00; p=0.74). CONCLUSIONS: Our experience shows cardiac surgery post-HTx is associated with low mortality, and confirms that cardiac surgery is appropriate for selected HTx recipients.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Cardiopatias , Transplante de Coração , Adulto , Intervalo Livre de Doença , Feminino , Seguimentos , Cardiopatias/etiologia , Cardiopatias/mortalidade , Cardiopatias/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida
12.
Heart Lung Circ ; 23(10): 963-9, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24973864

RESUMO

BACKGROUND: New generation continuous-flow left ventricular assist devices (LVADs) utilise centrifugal pumps. Data concerning their effect on patient haemodynamics, ventricular function and tissue perfusion is limited. We aimed to document these parameters following HeartWare centrifugal continuous-flow LVAD (HVAD) implantation and to assess the impact of post-operative right heart failure (RHF). METHODS: We reviewed 53 consecutive patients (mean age 49.5 ± 14.1 yrs) with HVAD implanted in the left ventricle, at St. Vincent's Hospital, Sydney, between January 2007 and August 2012. Available paired right heart catheterisation (n=35) and echocardiography (n=39) data was reviewed to assess response of invasive haemodynamics and ventricular function to LVAD support. RESULTS: A total of 28 patients (53%) were implanted from interim mechanical circulatory support. Seventeen patients (32%) required short-term post-implant veno-pulmonary artery extracorporeal membrane oxygenation. At 100 ± 61 days post-implant, mean pulmonary artery pressure and mean pulmonary capillary wedge pressure decreased from 38.8 ± 7.7 to 22.9 ± 7.7 mmHg and 28.3 ± 6.4 to 13.4 ± 5.4 mmHg respectively (p<0.001). LV end diastolic diameter decreased from 71.3 ± 12.7 to 61.1 ± 13.7 mm and LV end-systolic diameter from 62.7 ± 12.3 to 53.9 ± 14.4mm (p<0.001). Aortic regurgitation remained trivial. Serum sodium increased from 133.3 ± 5.7 to 139.3 ± 2.8 mmol/L and creatinine decreased from 109.1 ± 42.5 to 74.3 ± 26.2 µmol/L (p<0.001). Across the entire cohort, the six-month survival/transplant rate was significantly lower for RHF patients (72.2%, n=18) compared to those without (96.9%, n=35, p=0.01). CONCLUSIONS: HVAD support improves haemodynamics, LV dimensions and renal function. Following implantation with a centrifugal continuous-flow LVAD, RHF remains a significant risk with a tendency to worse outcomes in the short to medium term.


Assuntos
Insuficiência Cardíaca/cirurgia , Ventrículos do Coração/fisiopatologia , Coração Auxiliar , Hemodinâmica , Disfunção Ventricular Esquerda/cirurgia , Adulto , Pressão Arterial , Cateterismo Cardíaco , Creatinina/sangue , Ecocardiografia , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/fisiopatologia , Ventrículos do Coração/diagnóstico por imagem , Humanos , Hipertrofia Ventricular Esquerda/complicações , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Pressão Propulsora Pulmonar , Sódio/sangue , Taxa de Sobrevida , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Direita/complicações , Disfunção Ventricular Direita/fisiopatologia
13.
J Card Fail ; 19(3): 169-75, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23482077

RESUMO

OBJECTIVE: Studies have shown that pump output by continuous-flow left ventricular assist devices (LVADs) increases with graded exercise testing. However, data on pump behavior during activities of daily living and sleep, where cardiac output requirements vary markedly, are lacking. We sought to determine pump parameters and activity levels in stable patients receiving outpatient LVAD therapy. METHODS AND RESULTS: Eleven outpatients (mean age 51 ± 14 years, 9 male) with centrifugal continuous-flow LVADs underwent monitoring of LVAD flow, heart rate (HR), energy expenditure, and physical activity over 1 week in an outpatient setting. Physical activity was recorded with the use of a combined pedometer, accelerometer, and calorimeter Sensewear armband. Pump, HR, and physical activity parameters were time matched for correlation analysis. Outpatients had an average pump flow of 5.67 ± 1.27 L/min and engaged predominately in low levels of physical activity (mean daily step count 3,249/day). Across the entire cohort, pump flow exhibited strong univariate relationships with patients' energy expenditure (r = 0.73), step count (r = 0.69), HR (r = 0.73), sleep (r = -0.89), and skin temperature (r = -0.85; P < .0001 for all). Multivariate analysis suggested that pump output was predominantly affected by recumbent position, energy expenditure and skin temperature (r(2) = 0.84; P < .0001). Pump flow and power consumption were significantly lower during sleep than during wake periods (5.48 ± 1.31 L/min vs 5.80 ± 1.26 L/min; P < .001). CONCLUSIONS: Pump output from continuous-flow LVADs is adaptive to changes in activities of daily living. Circadian variation in pump flow is mostly explained by recumbency and activity levels. Despite adequate pump flow, many LVAD patients continue to live sedentary lifestyles.


Assuntos
Atividades Cotidianas , Assistência Ambulatorial/métodos , Coração Auxiliar , Atividade Motora/fisiologia , Função Ventricular Esquerda/fisiologia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais
14.
Artif Organs ; 37(3): 313-8, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23373528

RESUMO

The current recommended anticoagulation regimen during continuous flow centrifugal left ventricular device support is a combination of antiplatelet therapy as well as oral anticoagulation. Despite this, pump thrombosis occurs in rare situations. We report the risk factors and nonsurgical management and outcomes of five patients implanted with continuous flow centrifugal left ventricular assist devices who displayed clinical, hemodynamic, and laboratory features of intrapump thrombosis. This information may support the use of intravenous thrombolytics for suspected pump thrombus in these newer generation devices.


Assuntos
Fibrinolíticos/administração & dosagem , Insuficiência Cardíaca/terapia , Coração Auxiliar/efeitos adversos , Terapia Trombolítica , Trombose/tratamento farmacológico , Função Ventricular Esquerda , Adulto , Anticoagulantes/uso terapêutico , Evolução Fatal , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Transplante de Coração , Hemodinâmica , Hemólise , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/uso terapêutico , Desenho de Prótese , Falha de Prótese , Fatores de Risco , Trombose/sangue , Trombose/diagnóstico , Trombose/etiologia , Fatores de Tempo , Resultado do Tratamento
15.
Heart Lung Circ ; 22(11): 952-4, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23506725

RESUMO

LVADs are increasingly being used to support patients with end stage heart failure. As such, the traditional definition of death, the absence of a pulse, requires re-examination as it is no longer clinically relevant. We present two contrasting cases of "death" on LVAD support and present some ethical issues surrounding the end of life on LVAD support.


Assuntos
Cardiomegalia , Coração Auxiliar , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
16.
Transplantation ; 107(2): 361-371, 2023 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-36044329

RESUMO

Heart transplantation from donation after circulatory death (DCD) donors has the potential to substantially increase overall heart transplant activity. The aim of this report is to review the first 8 y of our clinical heart transplant program at St Vincent's Hospital Sydney, to describe how our program has evolved and to report the impact that changes to our retrieval protocols have had on posttransplant outcomes. Since 2014, we have performed 74 DCD heart transplants from DCD donors utilizing a direct procurement protocol followed by normothermic machine perfusion. Changes to our retrieval protocol have resulted in a higher retrieval rate from DCD donors and fewer rejections of DCD hearts during normothermic machine perfusion. Compared with our previously reported early experience in the first 23 transplants, we have observed a significant reduction in the incidence of severe primary graft dysfunction from 35% (8/23) to 8% (4/51) in the subsequent 51 transplant recipients ( P < 0.01). The only withdrawal time interval significantly associated with severe primary graft dysfunction was the asystolic warm ischemic time: 15 (12-17) versus 13 (11-14) min ( P < 0.05). One- and 5-y survival of DCD heart transplant recipients was 94% and 88%, comparable to that of a contemporary cohort of donation after brain death recipients: 87 and 81% ( P -value was not significant). In conclusion, heart transplantation from DCD donors has become a major contributor to our overall transplant activity accounting for almost 30% of all transplants performed by our program in the last 2 y, with similar DCD and donation after brain death outcomes.


Assuntos
Transplante de Coração , Disfunção Primária do Enxerto , Obtenção de Tecidos e Órgãos , Humanos , Morte Encefálica , Doadores de Tecidos , Transplante de Coração/efeitos adversos , Transplante de Coração/métodos , Sobrevivência de Enxerto , Estudos Retrospectivos , Morte
17.
Transplant Direct ; 7(6): e699, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34036169

RESUMO

Hearts from older donors or procured via donation after circulatory death (DCD) can alleviate transplant waitlist; however, these hearts are particularly vulnerable to injury caused by warm ischemic times (WITs) inherent to DCD. This study investigates how the combination of increasing donor age and pharmacologic supplementation affects the ischemic tolerance and functional recovery of DCD hearts and how age impacts cardiac mitochondrial respiratory capacity and oxidative phosphorylation. METHODS: Wistar rats (12-, 18-, and 24-mo-old) were subjected to DCD with 20-min fixed WIT. Hearts were procured, instrumented onto a Langendorff perfusion circuit, flushed with Celsior preservation solution with or without supplementation (glyceryl trinitrate [GTN]/erythropoietin [EPO]/zoniporide [Z]) and perfused (Krebs-Henseleit buffer, 37°C Langendorff 30-min, working 30-min). Cardiac functional recovery of aortic flow (AF), coronary flow (CF), cardiac output (CO), and lactate dehydrogenase release were measured. Native heart tissue (3-, 12-, and 24-mo) were assessed for mitochondrial respiratory capacity. RESULTS: Unsupplemented 18- and 24-month DCD hearts showed a 6-fold decrease in AF recovery relative to unsupplemented 12-month DCD hearts. GTN/EPO/Z supplementation significantly increased AF and CO recovery of 18-month DCD hearts to levels comparable to supplemented 12-month hearts; however, GTN/EPO/Z did not improve 24-month DCD heart recovery. Compared to 12-month heart tissue, 24-month hearts exhibited significantly impaired mitochondrial oxygen flux at complex I, II, and uncoupled maximal respiration stage. CONCLUSIONS: Reduced ischemic tolerance after DCD was associated with increasing age. Pharmacologic supplementation improves functional recovery of rat DCD hearts but only up to age 18 months, possibly attributed to a decline in mitochondrial respiratory capacity with increasing age.

18.
Intensive Care Med ; 47(3): 265-281, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33635355

RESUMO

A decision to withdraw life-sustaining treatment (WLST) is derived by a conclusion that further treatment will not enable a patient to survive or will not produce a functional outcome with acceptable quality of life that the patient and the treating team regard as beneficial. Although many hospitalized patients die under such circumstances, controlled donation after the circulatory determination of death (cDCDD) programs have been developed only in a reduced number of countries. This International Collaborative Statement aims at expanding cDCDD in the world to help countries progress towards self-sufficiency in transplantation and offer more patients the opportunity of organ donation. The Statement addresses three fundamental aspects of the cDCDD pathway. First, it describes the process of determining a prognosis that justifies the WLST, a decision that should be prior to and independent of any consideration of organ donation and in which transplant professionals must not participate. Second, the Statement establishes the permanent cessation of circulation to the brain as the standard to determine death by circulatory criteria. Death may be declared after an elapsed observation period of 5 min without circulation to the brain, which confirms that the absence of circulation to the brain is permanent. Finally, the Statement highlights the value of perfusion repair for increasing the success of cDCDD organ transplantation. cDCDD protocols may utilize either in situ or ex situ perfusion consistent with the practice of each country. Methods to accomplish the in situ normothermic reperfusion of organs must preclude the restoration of brain perfusion to not invalidate the determination of death.


Assuntos
Transplante de Órgãos , Obtenção de Tecidos e Órgãos , Morte , Humanos , Qualidade de Vida , Doadores de Tecidos
20.
Indian J Thorac Cardiovasc Surg ; 36(Suppl 2): 224-232, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33061207

RESUMO

PURPOSE: There is increasing clinical utilization of hearts from the donation after circulatory death (DCD) pathway with the aim of expanding the donor pool and mitigating the ever-present discrepancy between the inadequate availability of good quality donor hearts and the rising number of patients with end-stage heart failure. METHODS: This article reviews the rationale, practice, logistical factors, and 5-year experience of DCD heart transplantation at St Vincent's Hospital, Sydney. FINDINGS: Between July 2014 and July 2019, 69 DCD donor retrievals were undertaken resulting in 49 hearts being instrumented on an ex situ normothermic cardiac perfusion device. Seventeen (35%) of these hearts were declined and the remaining 32 (65%) were used for orthotopic DCD heart transplantation. At 5 years of follow-up, the 1-, 3-, and 5-year survival was 96%, 94%, and 94% for DCD hearts compared with 89%, 83%, and 82% respectively for donation after brain death (DBD) hearts (n.s). The immediate post-implant requirement for temporary extra-corporeal membrane oxygenation (ECMO) support for delayed graft function was 31% with no difference in rejection rates when compared with the contemporaneous cohort of patients transplanted with standard criteria DBD hearts. SUMMARY: DCD heart transplantation has become routine and incorporated into standard clinical practice by a handful of pioneering clinical transplant centres. The Australian experience demonstrates that excellent medium-term outcomes are achievable from the use of DCD hearts. These outcomes are consistent across the other centres and consequently favour a more rapid and wider uptake of heart transplantation using DCD donor hearts, which would otherwise be discarded.

SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA