W. Steves Ring

Consensus Conference Report Maximizing Use of Organs Recovered From the Cadaver Donor: Cardiac Recommendations: March 28–29, 2001, Crystal City, Va

The shortage of available donor hearts continues to limit cardiac transplantation. For this reason, strict criteria have limited the number of patients placed on the US waiting list to ≈6000 to 8000 per year. Because the number of available donor hearts has not increased beyond ≈2500 per year, the transplant waiting list mortality rate remains substantial. Suboptimal and variable utilization of donor hearts has compounded the problem in the United States. In 1999, the average donor yield from 55 US regions was 39%, ranging from 19% to 62%. This report provides the detailed cardiac recommendations from the conference on “Maximizing Use of Organs Recovered From the Cadaver Donor” held March 28 to 29, 2001, in Crystal City, Va. The specific objective of the report is to provide recommendations to improve the evaluation and successful utilization of potential cardiac donors. The report describes the accuracy of current techniques such as echocardiography in the assessment of donor heart function before recove...The shortage of available donor hearts continues to limit cardiac transplantation. For this reason, strict criteria have limited the number of patients placed on the US waiting list to 6000 to 8000 per year. Because the number of available donor hearts has not increased beyond 2500 per year, the transplant waiting list mortality rate remains substantial. Suboptimal and variable utilization of donor hearts has compounded the problem in the United States. In 1999, the average donor yield from 55 US regions was 39%, ranging from 19% to 62%. This report provides the detailed cardiac recommendations from the conference on “Maximizing Use of Organs Recovered From the Cadaver Donor” held March 28 to 29, 2001, in Crystal City, Va. The specific objective of the report is to provide recommendations to improve the evaluation and successful utilization of potential cardiac donors. The report describes the accuracy of current techniques such as echocardiography in the assessment of donor heart function before recovery and the impact of these data on donor yield. The rationale for and specific details of a donor-management pathway that uses pulmonary artery catheterization and hormonal resuscitation are provided. Administrative recommendations such as enhanced communication strategies among transplant centers and organ-procurement organizations, financial incentives for organ recovery, and expansion of donor database fields for research are also described. (Circulation. 2002;106:836-841.)

Congenital Heart Surgery Nomenclature and Database Project: aortic aneurysm, sinus of valsalva aneurysm, and aortic dissection

The extant nomenclature for aortic aneurysms, sinus of valsalva aneurysms, and aortic dissections is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. Classification was based on morphology, histology, anatomic location, etiology, and acuity. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing that would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Consensus Conference Report

The shortage of available donor hearts continues to limit cardiac transplantation. For this reason, strict criteria have limited the number of patients placed on the US waiting list to ≈6000 to 8000 per year. Because the number of available donor hearts has not increased beyond ≈2500 per year, the transplant waiting list mortality rate remains substantial. Suboptimal and variable utilization of donor hearts has compounded the problem in the United States. In 1999, the average donor yield from 55 US regions was 39%, ranging from 19% to 62%. This report provides the detailed cardiac recommendations from the conference on “Maximizing Use of Organs Recovered From the Cadaver Donor” held March 28 to 29, 2001, in Crystal City, Va. The specific objective of the report is to provide recommendations to improve the evaluation and successful utilization of potential cardiac donors. The report describes the accuracy of current techniques such as echocardiography in the assessment of donor heart function before recove...The shortage of available donor hearts continues to limit cardiac transplantation. For this reason, strict criteria have limited the number of patients placed on the US waiting list to 6000 to 8000 per year. Because the number of available donor hearts has not increased beyond 2500 per year, the transplant waiting list mortality rate remains substantial. Suboptimal and variable utilization of donor hearts has compounded the problem in the United States. In 1999, the average donor yield from 55 US regions was 39%, ranging from 19% to 62%. This report provides the detailed cardiac recommendations from the conference on “Maximizing Use of Organs Recovered From the Cadaver Donor” held March 28 to 29, 2001, in Crystal City, Va. The specific objective of the report is to provide recommendations to improve the evaluation and successful utilization of potential cardiac donors. The report describes the accuracy of current techniques such as echocardiography in the assessment of donor heart function before recovery and the impact of these data on donor yield. The rationale for and specific details of a donor-management pathway that uses pulmonary artery catheterization and hormonal resuscitation are provided. Administrative recommendations such as enhanced communication strategies among transplant centers and organ-procurement organizations, financial incentives for organ recovery, and expansion of donor database fields for research are also described. (Circulation. 2002;106:836-841.)

The Society of Thoracic Surgeons National Congenital Heart Surgery Database Report: analysis of the first harvest (1994-1997).

This analysis summarizes the first report of the Society of Thoracic Surgeons National Congenital Heart Surgery Database Committee in association with Summit Medical Systems. Twenty-four centers joined the program at various dates of entry resulting in 18,894 enrolled patient records. This report compiled the relevant clinical features of 18 congenital heart categories over a 4-year period (1994-1997), which included 8,149 patient records. The data analyses are largely descriptive in character. Missing data points were described and not omitted in the analysis. Statistical analysis was not performed due to missing data points in some categories. Certain trends, however, could be identified and are discussed. The first Society of Thoracic Surgeons National Congenital Heart Surgery Database Report has succeeded in establishing a finite record that can be improved to establish universal national and international utility, risk stratification, and scholarly outcome analyses.

Thoracic organ transplantation in the United States, 1994-2003

Using OPTN/SRTR data, this article reviews the state of thoracic organ transplantation in 2003 and the previous decade. Time spent on the heart waiting list has increased significantly over the last decade. The percentage of patients awaiting heart transplantation for >2 years increased from 23% in 1994 to 49% by 2003. However, there has been a general decline in heart waiting list death rates over the decade. In 2003, the lung transplant waiting list reached a record high of 3,836 registrants, up slightly from 2002 and more than threefold since 1994. One‐year patient survival for those receiving lungs in 2002 was 82%, a statistically significant improvement from 2001 (78%). The number of patients awaiting a heart‐lung transplant, declining since 1998, reached 189 in 2003. Adjusted patient survival for heart‐lung recipients is consistently worse than the corresponding rate for isolated lung recipients, primarily due to worse outcomes for heart‐lung recipients with congenital heart disease. A new lung allocation system, approved in June 2004, derives from the survival benefit of transplantation with consideration of urgency based on waiting list survival, instead of being based solely on waiting time. A goal of the policy is to minimize deaths on the waiting list.

Perfusion Preservation versus Static Preservation for Cardiac Transplantation: Effects on Myocardial Function and Metabolism

INTRODUCTION Continuous perfusion of donor hearts for transplantation has received increasing interest, but the effects on cellular metabolism, myocyte necrosis, and myocardial edema are not well defined. METHODS Pig hearts were instrumented with sonomicrometry crystals and left ventricular catheters. Left ventricular function was quantified by the pre-load-recruitable stroke work (PRSW) relationship. Hearts were arrested with Celsior solution with 5.5 mM 13C-glucose added, and removed and stored in cold solution (n = 4) or placed in a device providing continuous perfusion of this solution at 10 ml/100 g/min (n = 4). After 4 hours of storage, left atrial samples were frozen, extracted, and analyzed by magnetic resonance spectroscopy. Hearts were then transplanted into recipient pigs and reperfused for 6 hours, with function measured hourly. At the end of the experiment, left ventricular water content and serum creatine kinase-MB isoenzyme levels were measured. RESULTS Baseline left ventricular function was similar in both groups. During reperfusion, the volume-axis intercept of the PRSW relationship was significantly lower in hearts stored with continuous perfusion (p < 0.05), suggesting reduced contractile impairment. Magnetic resonance spectroscopy revealed a decrease in tissue lactate in hearts that received continuous perfusion. Serum creatine kinase-MB isoenzyme levels were higher hearts that had static storage (30.8 +/- 9.0 vs 13.2 +/- 2.7 ng/ml; p < 0.05). Left ventricular water content was similar in both groups (0.797 +/- 0.012 vs 0.796 +/- 0.014; p = 0.45). CONCLUSIONS Donor hearts sustain less functional impairment after storage with continuous perfusion. This technique reduces tissue lactate accumulation and myocardial necrosis without increasing myocardial edema and appears promising as a method to improve results of cardiac transplantation.

Echocardiographic versus cardiac catheterization diagnosis of infants with congenital heart disease requiring cardiac surgery

The success of noninvasive preoperative evaluation of infants with congenital heart disease using cardiac ultrasound depends not only on diagnostic accuracy, but also on risk of morbidity and mortality as compared with infants who undergo cardiac catheterization. Fifty-six infants (age 10 weeks or younger) with coarctation of the aorta (n = 16), coarctation with ventricular septal defect (n = 12), valvar aortic stenosis (n = 10) or total anomalous pulmonary venous connection (n = 18) were examined. Thirty-one underwent noninvasive preoperative assessment and 25 underwent evaluation including cardiac catheterization. Age, level and duration of support, pH, renal function, mortality, complications of cardiac catheterization and errors of diagnosis were compared. Significant differences between the 2 groups were more frequent preoperative use of prostaglandin E1 and shorter hospital stay in the noninvasively evaluated coarctation group. Of the infants with coarctation and ventricular septal defect, 1 who had cardiac catheterization required renal transplantation and 1 evaluated noninvasively required surgery at age 3 months for mitral stenosis not discovered on preoperative evaluation. One noninvasively evaluated infant with total anomalous pulmonary venous connection had a stenotic communication between the pulmonary venous confluence and the left atrium not detected by ultrasound. Surgery was successful in the latter 2 infants. Noninvasive preoperative diagnosis of some infants with congenital heart disease can be performed without increasing the risk of operative morbidity and mortality. Eliminating cardiac catheterization reduces hospital costs, decreases total numbers of catheterizations performed and influences the structure of training programs.

Heterogeneous myocardial catecholamine concentrations in patients with congestive heart failure.

Left ventricular catecholamine and plasma norepinephrine levels were assayed in 39 patients undergoing cardiac transplantation to test the hypothesis that in congestive heart failure (CHF) the normally high concentration of myocardial norepinephrine is depleted while dopamine is increased because dopamine conversion to norepinephrine is the rate-limiting step in norepinephrine synthesis. Plasma norepinephrine was elevated in all patients (average 741 +/- 472 micrograms/ml), but myocardial norepinephrine was variable, ranging from 79 to 2,127 ng/g (average 512 +/- 392). Myocardial dopamine also varied considerably (range 0 to 713 ng/g, average 143 +/- 150). Nineteen patients had the expected pattern of low cardiac norepinephrine and elevated dopamine levels. However, myocardial catecholamine levels were normal (high norepinephrine, low dopamine) in 7 patients; both norepinephrine and dopamine were low in 6 patients; and norepinephrine levels were preserved but dopamine high in 7 patients. Cardiac norepinephrine level correlated only weakly with peripheral vascular resistance (r = 0.39, p less than 0.05), and examination of multiple other variables failed to reveal likely causes of the differences in cardiac norepinephrine and dopamine between patients. Thus, myocardial norepinephrine is not uniformly reduced in patients with severe CHF, and further attempts to delineate the factors regulating myocardial catecholamine concentration and adrenergic function in such patients are needed.

Antibodies against donor human leukocyte antigens and the outcome of cardiac allografts in adults and children.

Background. Mismatched histocompatibility antigens between donor organ and host stimulate the immune response that causes allograft rejection. Antibodies against human leukocyte antigen (HLA) are known to appear in the serum of heart transplant recipients. Methods. We have tested stored sera with HLA bound to polystyrene microbeads in a retrospective analysis of heart recipients transplanted in our center to better understand the impact of antibodies against HLA on the posttransplant course. Our analysis included two groups of patients: 113 adults and 31 children who received consecutive heart transplants performed between 1996 and 2003. Results. Presence of HLA antibodies, especially when donor-specific, as determined with single HLA class I or class II beads, was associated with more frequent occurrence of acute rejection, development of transplant-related coronary artery disease and decreased graft survival. Recipients having antibodies only to HLA not in the transplant and those without any HLA antibodies had similar outcomes, suggesting that antibodies against antigens not present on the donor organ did not harm the graft. Conclusion. The results showed that presence of antibodies against HLA of the donor correlated with graft loss and suggested that testing for these antibodies may help in the management of heart transplant patients.

15- to 30-Year Follow-up of Patients Undergoing Repair of Ruptured Congenital Aneurysms of the Sinus of Valsalva

Rupture of a congenital aneurysm of the sinus of Valsalva is a rare congenital cardiac malformation. Between 1956 and 1971, we operated on 14 patients aged 9 to 36 years (median, 20 years) for repair of a ruptured aneurysm of the sinus of Valsalva, and have followed each patient to the present. Two operative and 4 late deaths occurred, 3 following a second cardiac operation and the other from dysrhythmia. Late complications have included development of complete heart block in 2 patients (necessitating permanent pacemaker insertion 11 and 24 years after initial repair), progression of aortic regurgitation in 2 (necessitating valve replacement 9 and 13 years after initial repair), and endocarditis in 1 patient 20 years after repair. Four of the 8 remaining long-term survivors (followed for 15 to 30 years [mean, 23.6 years]) are in New York Heart Association (NYHA) Class I, and the other 4 are in NYHA Class II. Three of the 5 patients with suture closure (no pledgets or adjacent ventricular septal defect repair) of the ruptured aneurysm of the sinus of Valsalva sustained recurrent rupture and required repeat closure. Whether the lack of prosthetic material to bolster the repair or inadequate resection of redundant aneurysmal fibrous tissue was responsible for these recurrences cannot be stated. Operative management of patients with ruptured congenital aneurysms of the sinus of Valsalva is discussed.