history of cardiac transplant, dr christian bernard, Groote schuur hospital,denise darvall, louis washansky, donor surgery, preservation solutions for harvested organs, organ transport systems
2. Trivia
• Dr Christiaan Barnard performed the first
human-to-human heart transplant at the
Groote Schuur Hospital in Cape Town on 3rd
December 1967
• The recipient was Louis Washkansky, a 53-
year-old ex-boxer with end-stage ischaemic
cardiomyopathy. He lived for 18 days.
13. Donor Management
• Plays a crucial role in defining results
• Number of organs transplanted per donor is
not an ideal endpoint
• Graft Function & survival are better indicators
• Achievement of Donor Management
Goals(DMG’s) is associated with better
outcomes
15. Outcomes
• Meeting DMGs prior to organ recovery with
ECDs is associated with achieving 3 or more
organs transplanted per donor
The impact of meeting donor management goals on the number
of organs transplanted per expanded criteria donor: a
prospective study from the UNOS Region 5 Donor Management
Goals Workgroup. Patel MS1, Zatarain J2, De La Cruz S2..JAMA
Surg. 2014 Sep;149(9):969-75
17. General considerations
• Most donors used for procuring multiple organs
• Prepared from head to mid thigh
• Central venous line
• Arterial line for invasive blood pressure
monitoring
18. Operative Steps
• Supine position
• Midline incision from Jugular notch to pubis
• Harvest of other organs started
• Median sternotomy
• Pericardiotomy and pericardial stay sutures taken
• Heart examined for:
- Cardiac injuries - Arteriosclerotic disease
- Congenital anomalies - Acquired heart disease
19.
20. Operative Steps
• Ascending aorta dissected up to Brachiocephalic
take off
• Superior vena cava completely dissected
• Purse string placed on Ascending aorta
• Heparin administered (200 U/kg)
• Cardioplegia cannula inserted
21.
22.
23. Operative Steps
• Cardioplegic solution infused by gravity
• SVC clamped and divided
• Right/left superior pulmonary vein partially
divided
• IVC divided leaving a part in continuity with liver
• Multiple ejections allowed and cross clamp
applied proximal to Brachiocephalic
24.
25. Operative Steps
• 1-2 ltr of cardioplegia solution infused
• Cold ice slush poured
• Coronary sinus effluent allowed to escape
through IVC
• Right superior and inferior pulmonary veins
divided
• Heart retracted superiorly and to the right
26. Operative Steps
• Left superior and inferior pulmonary veins
divided
• Aorta divided distal to Brachiochephalic
• Right and left Pulmonary arteries divided near
pericardial reflections
• Connective tissue behind the Left atrium divided
last
27.
28.
29. Operative steps
• Heart is removed from the body and immersed in cold
preservation solution
• The right & left pulmonary veins are joined by incision
• Left atrium is opened posteriorly between the
pulmonary veins
• Aorta is separated from the pulmonary trunk
• Pulmonary trunk is opened at its bifurcation to
preserve maximum circumference
30.
31. Operative Steps
• Cardiac chambers are thoroughly irrigated
with cold isotonic solution and inspected
• The organ is placed in triple sterile plastic
bags filled with preservation solution
• Transferred to an ice chest for transport
37. Co-ordination
• Operating room nursing staff
• Discussion regarding all planned interventions
• Status of recipients
• Recipients undergoing redo surgery
38. Logistics
• Involvement of Government and civic machinery
• Reliable transport options
• Provisioning of “Green Corridors”
• New legislation:
– Drone 2.0 proposal
40. Hypothermia
• 12 fold decrease in metabolic activity when
temp reduced from 37 to 4 degrees Celsius
• 5-10% metabolic activity still persists
41. Hypothermia
• Deleterious effects:
- Na+/K+ATPase alterations
- ATP depletion
- Dysregulation of Ca2+ homeostasis
- Mitochondrial perturbations
- Xanthine oxidase accumulation
- Increased levels of reactive oxygen species (ROS)
• Therefore the need for preservation solutions
42. Preservation solutions
• Genesis & evolution:
- Euro Collins (EC) solution was designed in the 1960s
and considered the preservation
- Revolutionized by the introduction of University of
Wisconsin (UW) solution in 1988
- High viscosity
- Less vicious alternatives: Celsior (CEL) and Histidine-
tryptophan-ketoglutarate (HTK)
- Plegisol from St. Thomas solution
- Papworth solution was centered on the inclusion of
donor blood in its composition
46. Preservation solutions for cardiac and pulmonary donor grafts: a review of the
current literature
Nicholas Latchana,1 Joshua R. Peck,2 Bryan Whitson, J Thorac Dis. 2014 Aug; 6(8):
1143–1149
47. Transportation Devices
• Traditional method: Ice Box/ picnic cooler
- Insulated box with ice and 3 plastic bags
- Preservation solution & saline poured
- Temp between 4-8 degrees celsius
- Unregulated temparature settings
- Static perfusion
- Preservation time up to 04 hours
- Precludes long distance transport
- Antique
- Simple and cheap
48. Transportation Devices
• Studies and debates:
Methods: Human hearts from brain dead donors rejected for
transplantation were preserved for 12 hours in University of Wisconsin
Machine Perfusion Solution by one of 3 techniques: 1. Static hypothermic
storage (n=6) 2. Antegrade perfusion (AP, n=8) or 3. Retrograde perfusion
(RP, n=7). Lactate accumulation in the preservation solution were
measured. Myocardial water content was measured at end-experiment
Results: Lactate/alanine ratios were lowest in RP hearts (suggesting ongoing
oxidative metabolism) and were highest in static hearts (consistent with
anaerobic metabolism). A trend towards greater myocardial water content
was observed in RP hearts
49. Transportation devices
Conclusion : Machine perfusion by either AP or RP technique can support
myocardial metabolism of human hearts over long intervals.
RP may be superior to AP for maintaining indices of myocardial oxidative
metabolism but may increase myocardial edema.
Metabolic Characteristics of Human Hearts Preserved For 12
Hours By Static
Storage, Antegrade Perfusion Or Retrograde Coronary Sinus
Perfusion
Matthias Peltz1, Michael L. Cobert1, Matthew E. Merritt2.
Scientific Meeting: 91st American Association of Thoracic
Surgery Annual Meeting (AATS) 2011
50. Transportation Devices
• Newer vistas:
1. SherpaPak CTS:
- The Paragonix Sherpa Pak™ device may decrease cold injury
of donor organs by maintaining the temperature consistently
between 4°C and 8°C and therefore may decrease primary
graft failure after organ transplantation
Innovative cold storage of donor organs using the Paragonix Sherpa Pak ™ devices
S.G Michel,1,2 G.M LaMuraglia II,1 M.L.L Madariaga. Heart Lung Vessel. 2015; 7(3): 246–255
54. Transportation Devices
4. TransMedics- OCS Heart:
- The Organ Care System maintains donor hearts in a near
physiologic beating state outside of the human body.
- The heart is supplied with warm oxygenated blood that is
supplemented with nutrients and electrolytes that have the
potential to maximize benefits and protect the heart from
damage.
- Commercially available in UK and Australia
- Undergoing PROCEED II trial in USA
-