Slides of the short presentation held in Brussel during the 2015 consensus conference on Thoracic Donors.

1. Report of the survey
C. Amarelli

2. Consensus Conference Report
Maximizing Use of Organs Recovered From the Cadaver Donor: Cardiac
Recommendations
March 28-29, 2001 Crystal 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
Endpoint
Evaluate the local policies on Brain Death Diagnosis and Management
15 years after Cristal City.

5. 44/68 64%
462/1044 44%
73/409 17%
10/453 2,2 %

6. Possible causes of such a low extraction of heart donors:
• PERCEIVED INCREASE OF PGF RATES IN THE LAST DECADE (role of changing 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

7. Target
• 27 European experts in Thoracic Transplant and Donor Management.
Survey Structure
• 20 Questions
 4 On Brain Death Definition
 4 on DCD
 3 on Organ Procurement
 1 on policies to increase thoracic organ donors
 5 on current management of organ donors
 3 on new strategies for organ preservation

8. Results: Brain Death Definition

9. Results: Brain Death Definition

10. Results: Brain Death Definition

11. Results: Brain Death Definition

12. Results: Brain Death Definition
• Brain death definition should be standardized to shorten the time for diagnosis
• 65% diagnosis require multiple testing time to confirm BD diagnosis
• 30% fear the hemodynamic and metabolic effect due to apnea testing in BD patients
• 83,3% consider 4V-Cerebral angiography a reliable test for a rapid diagnosis of BD.

13. Results: DCD

14. Results: DCD

15. Results: DCD

16. Results: DCD

17. Results: DCD

18. Results: DCD
• 55% of centers don’t have experience in DCD also in a high selected panel of experts
• DCD donation experience in heart transplantation derive from Lung Transplant DCD
• DCD donation regards prevalently DCD Maastricht III patients
• 80% of centers doing DCD work in countries where the no-touch period is 5 minute
• Ethical issues with 5-minute no touch period.

19. Results: DCD

20. Results: Organ assessment

23. 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
• Scouting Program

24. Results: Organ assessment
Manageable with Ex-Vivo perfusion.
Proper ventilation in the donor.

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

26. Results: Organ assessment
Manageable with Ex-Vivo perfusion.
Facilities for Coronary Angiograms.
Donor Score 0%

27. Results: Organ assessment
• Coronary Angiogram Available 31%
• Transesophageal Echo 31%
• Donor Score 7%

28. Results: Organ assessment
Manageable with Ex-Vivo perfusion
Manageable with Advanced Monitoring

29. Results: policies to increase thoracic organ donors

30. Results: current management of organ donors
Results: current management of organ donors

31. Results: current management of organ donors
Results: current management of organ donors

32. Results: current management of organ donors
• The large majority of heart donors and about 50% of lung donors are perceived as
marginal donors.
• The large majority of Lung donor reject factors are manageable with proper ventilation
and ex-vivo lung perfusion
• The large majority of Heart donors reject factors are manageable with an advanced
monitoring, facilities for coronary angiograms and possibly with ex-vivo perfusion
• Pulmonary catheters, coronary angiogram and transesophageal echo are not commonly
available (31.25%)
• Donor score despite large literature play little role.

33. Results: current management of organ donors
• Scouting policies and Assessment of donor done by the procurement agencies are
seen as interesting perspective to increase thoracic donors
• Despite considered one of the most common factors for reject donors (43,75%)
vasocostrictor are the most commonly used drugs in thoracic donors (87,5%)
• Hormon Replacement therapy is used only in 50% of patients
• Protective ventilation parameters are used in 20%, higher PEEP in 46,67%.

34. Results: current management of organ donors

35. Results: current management of organ donors
SOLUTION LUNG
Perfadex 71,4%
Papworth 7,1%
Celsior 7,1%
Homemade 14,2
SOLUTION HEART
St. Thomas 38,4%
Custodiol 30,7%
Celsior 15,4%
UW 7,7 %

36. Results: current management of organ donors

37. Results: new strategies of organ preservation
% center involved in
ex-vivo perfusion
% of cases in center performing
ex-vivo perfusion
Heart 25% 60 %
Lung 53,3% 6,6 %

38. Results: new strategies of organ preservation
Heart
OCS Transmedics 75 %
Local 25 %
Lung
OCS Transmedics 50 %
Vivoline 25 %
Toronto protocol 12,5%

39. Results: new strategies of organ preservation
Heart
37° C 50 %
35° C 25 %
15° C 25 %
Lung
37° C 50 %
36° C 25 %
35° C 12,5%

40. Results: new strategies of organ preservation

41. Results: new strategies of organ preservation
• Preconditioning stategies are rarely adopted (18,75%)
• Despite tolerating long maximum cold ischemic time (251 min for Heart - 456
min for Lung) cold organ storage solutions remains largely conservative (lack of
evidence for more expensive solutions?)
• In Heart Transplant OCS Transmedics is rarely replaced from local protocols
• In Lung Transplants OCS and Vivoline are the most adopted systems
• Normothermic perfusion is commonly used (all about 1 center) for Heart and
always used for Lung despite new evidences on hypothermic beneficial effect.

42. Conclusions
• Brain Death Definition should be more homogeneous in Europe and tests with
high predictive capacity (4-V cerebral angiography) could help to shorten the
time required to declare BD in cases in which rush and procure is indicated.
• Ethical issues for definition of cardiac death in the setting of DCD donors joke a
pivotal role to warrant an expansion of this new frontier in thoracic organ
transplantation
• Donors with higher age require more data to extract more donors from the pool
and to better assess organ function: facilities for TEE and Coronary Angiogram
are desirable

43. Conclusions
• A large number of lung donors could be best managed by proper ventilation
and ex-vivo machine perfusion
• A large number of hearts donors could be best managed by advanced
monitoring
• Programs of Scouting and Assessment and management of the donor done by
procurement agencies are viewed with interest by a panel of european experts
• Hormone replacement therapy and weaning of vasocostrictors guided by
hemodinamic monitoring appear appealing

44. Conclusions
• Data on efficacy of preconditioning strategies and on “gold standard” organ
preservation with cold saline storage solutions appear needed to have a control
arm in comparison with ex-vivo machine perfusion.
• Also in an highly specialized panel of experts ex-vivo heart perfusion is still
underused in centers without experience in ex-vivo lung perfusion.
• Temperature for ex-vivo perfusion is one of the first issues to addresses
• Limitations
• few partecipants
• highly specialized partecipants not reflecting the real-world practice