Slides on the methodology of the consensus conference on Thoracic Donors.

1. Methodology
C. Amarelli

2. (Circulation. 1996;94:2883-2889.)
© 1996 American Heart Association, Inc.
Consensus Conference Report
Maximizing Use of Organs Recovered From the Cadaver Donor: Cardiac Recommendations
March 28-29, 2001Crystal City, VA
JG Zaroff, BR Rosengard, WF Armstrong, WD Babcock, A D’Alessandro, GW Dec,
NM Edwards, RS Higgins, V Jeevanandum, M Kauffman, JK Kirklin, SR Large, D
Marelli, TS Peterson, WS Ring, RC Robbins, SD Russell, DO Taylor, A Van Bakel, J
Wallwork, JB Young.
Circulation 2002;106:836

7. 44/68 64%
462/1044 44%
73/409 17%
10/453 2,2 %

9. Possible causes of so low extraction of heart donors:
• PERCEIVED INCREASE OF PGF RATES IN THE LAST DECADE (role of recipient profile)
• INCREASE OF THE HAZARD FOR PGF WITH THE INCREASE OF DONOR AGE
• IF LONG ISCHEMIC TIME ARE PROJECTED
• IF HIGH DOSAGE OF INOTROPES
• INADEQUATE AVAILABILITY OF DATA (ANGIOGRAPHY, FUNCTIONAL DATA ETC.)
• PERCEIVED CLINICAL STABILITY OF OUTPATIENT RECIPIENT
• PERCEIVED AVAILABILITY OF A SURGICAL BACKUP TO TRANSPLANT (MCS)
• NOT FOR ALL
• COMPLEX USE FOR BIVENTRICULAR FAILURE

17. Landscape and Landmarks
Potential Thoracic
Organ Donor
Early Donor
Management
Hemodinamic
assessment Effective
Thoracic Organ
Donor
Scouting

18. Landscape and Landmarks
RECIPIENT
CHARACTERISTICS
/ ALLOCATION
RULES
Early Donor
Management/
Hemodinamic
assessment/
SCOUTING
DONOR
PRESERVATION

19. Heart Donor Assessment
How:
• RISK FACTORS
• ECG
• Ecocardiography
• Stress Echocardiography
• ECO TE
• Angiography
• Biomarkers
• Other (CT scan etc.)
• Multiparametric Scores
When
?
Who:
• Local staff
• Donor Agencies

20. Lung Donor Assessment
How:
• RISK FACTORS
• Radiography
• Blood Gas Analysis
• CT Scan
• Broncoscopy
• Ecography
• Microbiology
• Other (CT scan etc.)
• Multiparametric Scores
When
?
Who:
• Local staff
• Donor Agencies

21. Dynamics changes of Thoracic organs
during donation process
• SYSTEMIC METABOLIC FAILURE
BRAIN DEATH
OXYGEN DELIVERY
OXYGEN CONSUMPTION
LACTATE
OXYGEN EXTRACTION

22. Donor Management
How:
• Swan-Ganz Catheter
• Other hemodinamic
monitoring devices
• Continuous TEE
• Bronchoscopy
When:
?
Role of Early
Management
Who:
• Local ICU staff
• Donor Agencies
• Scouting Programs

23. 1st TOP-Course
>ThoracicTransplantation<
•Adjust volume status: target CVP = 6-10 mmHg
•Correct acidosis:target pH = 7.4 – 7.45
•Correct hypoxemia: target p02 > 80 mmHg, sat >95%
•Correct anemia: target HCT > 30%; Hb > 10 g/dl
•Adjust inotropics to keep MAP > 60 mmHg
(dopamine/dobutamin < 10 µg/kg/min)
•Place PAC
•Adjust fluids, inotropes and pressors 15 min to
minimize use of alpha agonists and meet targets:
•MAP > 60 mmHg
•PCWP 8-12 mmHg
•C.I. > 2.4
•Dopamine or dobutamine < 10 µg/kg/min
•CVP 4-12 mmHg
•SVR 800 – 1200 dune/sec/cm-5
•T3: 4 µg bolus + infusion 3 µg/hour
•Vasopressin: 1 unit bolus + infusion at 0.5 – 4 units/hour
•methylprednisolone=: 15 mg/kg bolus
•Insulin: 1 unit/ hour minimum
•Rule out structural abnormalities
Crystal City Consensus circulation 2001

24. Inflammatory damage
Hyperdynamic storm
Endothelial activation
ICAM
VCAM
selectins
Neurogenic hypotension
Inflammatory cell infiltration
Pro-inflammatory cytokines (IL-6, TNF-@, IL-8)
TLR - complement
Early graft dysfunction Late graft dysfunctin
Kidney, Heart, Lung, (Liver)
ΔPERFUSION
RELEASE FROM BRAIN

25. DIRECT CARDIAC INJURY MODEL
Sympathetic discharge
CNS-injury
Systemic vascular resistance
α-adrenergic
“Primary cardiac injury”
Systemic vascular resistance
Myocardial oxygen demand
Coronary vasoconstriction/(reduced coronoary flow reserve)
Subendocardial ischemia
Structural damage
myocytolysis
contraction band necrosis (calcium overload) (VERAPAMIL)
edema formation
cell infiltration
ATP production (ATP depletion after ischemia)
mitochondrial injury-sarcomere injury
interstitial norepinephrine

26. LOAD-DEPENDENT CARDIAC
INJURY MODEL
Loss of vasomotor tone
vasomotor tone / AFTERLOAD
Coronary perfusionpreload
contractility
Frank Starling
Affinity of contractile proteins to Ca2+
Intracellular Ca2+ release
Stress activated Ca2+ channels
reduced oxygen supply
homeometric
autoregulation
“garden hose
effect”

27. DonorAssessment
At Harvesting Time
• Ischemic Time
• Age (in absence of coronaric lesions)
• Inotropic dosage
Are risk factors related to the actual gold
standard of myocardial preservation: Cold
Static Cardioplegic Solutions.

30. Donor Preservation
How:
• Cold Static
• Hypotermic Ex vivo
perfusion
• Normotermic Ex vivo
perfusion
When:
?
Physiopathology
of Brain Death
Who:
• Donor Agencies
• Transplant Centers

31. Methods
• Each of the partecipants to the Core Group should
purpose 2 choices for every task so to identify 2
responsibles for every task.
• Every task should be online on the dropbox open to
modifications by everyone (word revision mode) so the
responsibles of the tasks can accept or not modification
of each of the component of the consensus.
• Every task may be developed indipendently but
bibliographic service may be updated from every
partecipants at the best of his knowledge.

32. Draft of Tasks and Responsible Role
Tasks:
• Donor Assessment
• Donor Management
• Manage Modifiable Risk factors
• Donor Monitoring
• Brain Death Pathophysiology
and timing for harvesting
• Scouting Programs
• Organ Preservation (DBD/DCD)
• Donor Allocation Protocols
• Proposal of logistic models to
increase the rate of thoracic
Organs
• Specific Considerations about
pediatric transplantations
Who:
• Clinicians (cardiologist/pneumologists)
• Anesthesiologist
• Anesthesiologist/Surgeon
• Clinicians/Anesthesiologist
• Anesthesiologists
• Cardiologist/Anesthesiologist
• Surgeons/Anesthesiologist
• Procurement/Surgeons
• Procurement Agencies
• Surgeons