Mark Cunningham, MD

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Strategies to Improve Heart DonationA Cardiac
Transplant Surgeons Perspective

• Mark Cunningham, MD
• Assistant Professor of Cardiothoracic Surgery
• Keck School of Medicine
• University of Southern California

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Strategies to Improve Heart Donation

• Challenges in donor management for cardiac
  donation
• Monitoring and intervention
• Conventional acceptance criteria
• On the horizon

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Strategies to Improve Heart Donation

• Variables for the heart transplant surgeon to
  consider at 2 AM
• Donor medical history
• Donor/recipient size
• Hemodynamic parameters
• Catecholamine requirements
• ECG, ECHO, and angiogram results
• Troponin, CK levels
• Visual inspection, ischemic time

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Strategies to Improve Heart Donation

• Direct cardiac trauma will reduce the likelihood
  of successful cardiac donation.
• Herniation or progression to brain death impairs
  cardiac function necessitating donor
  resuscitation. Donor assessments done during this
  phase will be misleadingly
• poor and reassessment should occur.

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Strategies to Improve Heart Donation

• Myocardial dysfunction following brain death

Sympathetic Surge
Hormone Depletion
Hormone Depletion

• Myocardial necrosis secondary to catecholamines

• Low circulating levels of thyroid and cortisol
  impair function

• Decreased coronary perfusion pressure
  precipitates ischemia impairing myocardial
  function

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Temporal Changes in LV Systolic Function in Heart
Donors Serial Echocardiography

• Retrospective review of all donors with ejection
  fractions lt 50 or regional wall abnormalities on
  initial echo that underwent serial echo (n16)
• 13/16 initial EF lt 50 improvement in 12/16 with
  average EF 41 ? 56
• Medical management
• Guidelines mandate hemodynamic monitoring
• Inotropes (15/16 received dopamine)
• CVP goal 5-8 mmHg
• Prior to 1st echo correct ? volume status,
  acidosis, hypoxia, hypercarbia, electrolyte
  abnormalities and anemia
• 75 received corticosteroids
• NONE received thyroid hormone
• Responders 12/16 ? transplanted with 92
  survival at 16 months

Zaroff J Heart Lung Txp 2003 22383-388
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Donor Cardiac Troponin Levels

• Anderson 19941 Retrospective
• cTn-T correlated with post txp adrenaline use
• Not associated with early allograft failure
• Grant 19942 Retrospective Pediatric
• cTn-I significantly associated with graft failure
• Riou 19953 Retrospective
• cTn-T significantly correlated with severe ? LVEF
• CPK-MB not useful
• Vijay 19984 Retrospective
• cTn-T higher levels developed episodes of high
  grade rejection
• Potapov 20015
• cTnI and cTnT elevations correlated with impaired
  graft function
• CPK-MB not useful

1. Anderson transplantation 1994 581056-1057
4. Vijay Ann Thoracic Surg 1998
661934-1939 2. Grant Circulation 1994
962618-2612 5.
Potapov Transplantation 2001 711394-1400 3.
Riou Circulation 1995 92409-414
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Strategies to Improve Heart Donation

• Thoracic organs due require management to be
  optimized and stay optimized for donation.
  Hearts will need to be resuscitated and lungs
  managed to have optimal outcomes. The echo is
  only a snapshot of the function at a specific
  moment in time. Where a PA catheter will trend
  progress over time and guide therapy.

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Crystal City 2002
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Crystal City 2002
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Donor Hormonal Therapy (Human)T3- Cortisol-
Insulin
Hormone (n21)
Standard (n26)

• Unsuitable Donor 20
  0
• Dopamine ug/Kg/min 14 ? 19
  27 ? 13
• CV Fxn ?
  ? 2x Cardiac output
• EKG abnormal Persisted
  Improved
• MAP ?
  56mmHg ?86mmHg (? 53)
• CVP ?
  11mmHg ? 7mmHg (? 35)
• HR ?
  67 ? 91 (? 35)
• HCO3 Required ? 100
  ? 95
• Lactate NR
  5.1 ? 2.4 (? 52)
• Temp ?
  330 ? 360

Novitzky Transplantation 1987 43852-854
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Hormonal Resuscitation Cardiac Outcomes
3 Hormonal Resuscitation
Non-3 Hormonal Resuscitation

• 46 reduced odds of death with 30 days
• 48 reduced odds of early dysfunction
• Steroids alone or steroids plus triiodothyronine
  or L-thyroxine significantly reduced prolonged
  graft function

Rosendale Transplantation, 2003 75 482-487
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Hormonal Resuscitation Cardiac
Drugs Combinations
Drugs
a3HR, three-drug hormonal resuscitation T3,
triiodothyronine T4, L-thyroxine.
Rosendale Transplantation 2003751336-1341
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Kaplan-Meier Survival Curves for Three-drug
Hormonal Resuscitation (3HR) Donor Hearts versus
Non-3HR Donor Hearts
Rosendale Transplantation 2003751336-1341
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Strategies to Improve Heart Donation

• Crystal City modifications of existing heart
  donor criteria
• Age Donors gt 55 may be used selectively, though
  coexisting LVH and longer ischemic times may
  increase recipient mortality risks
• Size Despite an increased risk associated with
  small donors, a normal sized adult male (70kg)
  donor is suitable for most recipients
• LVH Mild LVH (wall thickness 13mm by
  echocardiography and no LVH by ECG criteria)
  does not preclude recovery, particularly with
  shorter ischemic times

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Strategies to Improve Heart Donation

• Crystal City modifications of existing heart
  donor criteria
• Valvular lesions
• Certain lesions, such as mild or moderate
  mitral or tricuspid regurgitation, or a normally
  functioning bicuspid aortic valve may be
  amenable to bench repair, prior to
  transplantation
• Congenital lesions
• Certain lesions, such as a secundum type ASD,
  may be amenable to bench repair
• Coronary angiography
• a. Male donor age 3545years and female donor
  age 3550years perform angiography if there
  is a history of cocaine use or3 risk factors
  for CAD
• b. Male donor age 4655years and female donor
  age 5155years angiography recommended
• c. Age 55 years angiography strongly
  recommended
• CAD Donor hearts with mild coronary artery
  disease should be considered for
  recipients with relatively urgent need

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Strategies to Improve Heart Donation

• Non invasive cardiac monitoring (Lidco)
• DCD heart donation