Donation After Circulatory Death (DCD) Heart Transplantation in Australia: a solution to the donor shortage?

Dr Sarah Scheuer, Dr Hong Chee Chew, Professor Peter Macdonald, Assoc Prof Kumud Dhital

On Behalf of St Vincent’s Hospital DCD Heart Transplant Group

Transplantation pathways

Donation after brain death (DBD)

Controlled death - minimal to no warm ischaemic time (WIT)

Donation after circulatory death (DCD)

Uncontrolled progression to asystole - variable WIT

Declaration of brain death

Preservation flush

ProcurementCold static

storage

Withdrawal of life

supportAsystole

Stand off period

Declaration of circulatory

death

Blood collection

Preservation flush

ProcurementNormothermic

machine reperfusion

WITCold ischaemic

time

Combined ischaemic time (CiT)

Overcoming the DCD heart barriers

Enhancing tolerance to warm ischemia with supplementation

GTN – nitric oxide donor

• Hing A J, et al. Combining Cariporide with Glyceryl Trinitrate

Optimizes Cardiac Preservation During Porcine Heart

Transplantation. American Journal of Transplantation. 2009; 9:

2048–2056

EPO – glycoprotein hormone, active in SAFE cardioprotective

pathway

• Watson AJ, et al. Enhanced preservation of the rat heart following

prolonged hypothermic ischemia with erythropoietin supplemented

Celsior solution. J Heart Lung Transplant. 2013; 32: 633–640

• DCD hearts are exposed to an

unavoidable warm ischaemic injury

• Ideal preservation modality

• Minimizes ischaemic injury

• Allow for organ resuscitation

• Facilitate viability assessment prior to

transplantation

Normothermic perfusion device

Current outcomes of the clinical DCD program

59 DCD retrievals

44 Hearts Retrieved

41 Clinical

28 Transplanted

13 Declined

11 Inadequate Recovery

2 OCS Failure3 Research

15 Did Not Progress (DNP)

Protocol modifications

• Commencement of WIT at systolic BP < 90 mmHg

• Extension of donor age to <55

• Addition of increased dose of methylprednisolone and regular albumin

to combat oedema whilst on the TransMedics

26 27

4238 37

4 2

7

7 8

0

10

20

30

40

50

60

Heart transplants per annum by donation pathway

DCD

DBD

2014 2015 2016 2017 2018

Current outcomes of the clinical DCD program

St Vincent’s Experience

Donor demographics

Male : Female 24 : 4

Average age 30 ± 8 (range 20 – 54)

Average weight 82 ± 15 kg

Vasopressor support 12 / 28 (43%)

Lungs used 19 / 28 (68%)

43%

14%

25%

11%

7%

Donor C.O.D for All Transplanted

TBI HBI Hanging ICH Other

Current outcomes of the clinical DCD program

Time on OCS (TransMedics) 285 min (mean, range 141 – 410)

Recipient Cross Clamp Time (min) 87 ± 33

Recipient Bypass Time (min) 190 ± 69

Mechanical Support

• ECMO

• IABP

43% (12/28)

*36% (10/28)

11% (3/28)

ICU Stay (days) 7 – median (mean 9 ± 7)

Hospital Stay (days) 24 – median (mean 28 ± 19)

LVEF - 1 week 67 ± 5%

Survival (Log Rank) 96% (vs. 87% DBD at 4 years)

No-ECMO ECMO P-value

Warm Ischaemic Time 23 ± 6 mins 23 ± 3 mins 0.32

Time to Asystole 11 ± 5 mins 9 ± 3 mins 0.08

Asystole – Cardioplegia 12 ± 2 mins 15 ± 3 mins 0.003

Cold Ischaemic Time 29 ± 5 mins 27 ± 6 mins 0.20

OCS 277 ± 70 mins 306 ± 60 mins 0.14

Conclusion

• DCD heart procurement is a feasible alternative to the traditional DBD pathway, with excellent results in patient cohort to date

• Combined approach, to both further improve ischaemic tolerance and minimise asystole-plegia time required to reduce high early ECMO rates

• High staff requirements and cost may be prohibitive in some centres

Clinical studies

Heart and Lung Clinic

• Dr Mark Connellan

• Dr Alasdair Watson

• Dr Emily Granger

• Prof Chris Hayward

• A/Prof Andrew Jabbour

• Dr Paul Jansz

• Prof Anne Keogh

• A/Prof Eugene Kotlyar

• Dr Phillip Spratt

Pre-clinical studies

Victor Chang Cardiac Research Institute – Transplant laboratory

• Dr Ling Gao

• Dr Hong Chee Chew

• Dr Arjun Iyer

• Dr Jeanette Villaneuva

• Aoife Doyle

• Dr Mark Hicks

Perfusionists

• Mr Claudio Soto

• Mr Adam Roshan

Transplant Coordinators

ICU

• Dr Priya Nair