This video is part of the 2020 Sentara Cardiac Grand Rounds, "Heart in a Box: The Future is Now," originally broadcast September 15, 2020. Dr. Jonathan Philpott describes the process of heart recovery and reanimation attempts from Donation After Circulatory Death (DCD) and how this is unique from other heart donation types.
So my part of the talk I love this kind of do, and I have tow Thank Dr Barron. He's done a tremendous amount of the academic groundwork here, but I kind of wanted Thio use my time to set the stage to talk about what to expect. What you individually want to see, kind of how this is going to roll out. And I wanted to emphasize some of the things that I thought were super important that I've now learned maybe aren't and some other things that I didn't even think we're even a consideration and now I think are very important. So the title of my talk, his expectations I don't know if many people have seen this movie Moneyball, but if you haven't, it's a fascinating movie, and it and it very much relates to what we're talking about here. We had a Moneyball event that happened, Um, last year. I think right around December. What did they do when they do? December 4? Yeah, December the fourth. So Duke did the first one of these December the fourth, and it splashed into the news and we were all sitting down there. Were like, Yeah, that's great and I said, Stop the meeting. This is like Moneyball. And if you'll remember in Moneyball, what happens is Brad Pitt here is playing the general manager. I think of one of the California teams, and he doesn't have any money, so he can't recruit good players. So he hires this mathematician who looks at bad players that have one unique skill and they're cheap, and he's able to field a near world Siri's winning team by buying cheap, bad players. Everybody else's discarded and everybody makes fun of him and half his team quits and so forth. And at the end of that, though, all of a sudden he's invited to go to Boston, where the Boston Red Sox owner sits him down and says, Listen, the first one through the door is always bloody. Anybody who's not tearing their team down right now are gonna be dinosaurs. And we had this conversation actually in the room, and at that point we were like the trials closed. It's just super high profile centers. There's no way we're gonna be able to get into this. We made some phone calls, and lo and behold, they were like two or three slots left, and the reason they were opening up was because of Cove it coveted. Shut down some of the centers in the Northeast and suddenly we had this window and we made the case and administration jumped right on, and we got it. So what is O. C. S. O. C. S is a Lincoln Dorf heart. Remember back when you were probably in college and they would take the heart out, put it on a little pump. It's It's been around for ages and ages and ages. It's just that nobody's ever tried to do it with a human heart. But it's basically just a classic prep that you would see in any biological lab where you take the heart out and you put it on a pump and it has a little oxygenate er, and you give it drugs and so forth and test it. We do it over and over to you all the time. Mouse hearts, rabbits, hearts, pig hearts. That lab over there is doing language, or perhaps all the time, analyzing different things to do. But for us, it's not just laying Dorf. This is disruptive. It is going to change transplantation for hearts. Fundamentally, you saw the England slide that Dr Baron put up 50% of their hearts. Now we're coming from D C D. So let's just start with basics. Why is it important to us? Why is it important to Sentara? Well, because it's the access. This is the doorway to the future of heart transplantation. And right now there's gonna be 25 sites in the United States that have it, and you can Onley have it if you're using it for this trial right now. But that doorway is big. And on the other side of that, it's not just D. C D. It's also marginal hearts, our hearts that are very far away that you otherwise would not be able to get. So as they submit this to the FDA, there's several applications that are going through. So it's not just D. C. D. And when the FDA approves it, if you've got the technology, you're way ahead of the game and you could start transplanting. If we didn't get it, we would have been completely left behind, and at the time we made the application, Duke had it. But that was pretty much it we got the last slide, the last slot. But of all things, M c. V also slept in. So if we hadn't have gotten it, we would have been a tremendous disadvantage. So let me move on to the next question. Um, personally, why should it be important to you? Why is it important to me? It vastly opens up your access to donors. And that means that this concept for your patient can I get a heart, you know? Think about that for a second. Can I? Ok, I'm listed. It's like all these huge hurdles. They have to get over right? Can I? My heart's dying. I'm not gonna live, can I? Can I get listed for transplant? You know, that's kind of like winning the lottery. Okay? Yes, you can. But does that mean I'm going to get a heart? All these patients that come through that get evaluated. They're so excited when they're listed for transplant. And unless you're dying, you're kind of stuck in these doldrums, his purgatory and the patients on the list. A lot of people in this room or coordinators, and they know this. But for the vast majority of the audience, you don't know this. The people on the list are largely depressed. They in their mind they're all excited that they got listed for transplants. But most of them do not believe there ever gonna get heart. So dcd means hope. Now, Dr Barron talked about this a little bit. Um, donation after brain death. This is what we were limited to. And if you kind of think of a giant pie, I'm doing this for the WebEx audience. And the pie is all donations. The little tiny piece, the sliver that we had is a little tiny bit of the whole picture. The brain death little tiny slice that we have access to is tiny compared to the d. C D pool. So what this means is suddenly now we have access to the big group, the big group of donors that are out there, and I'm showing now just a quick overview of a tiny shot of our wait list Excel file. And you can see there's about as of this reporting about 30 people that were on it, I've blacked out their names. But what I want you to focus on is this little cut that I'm showing now, which is the number that they're listed at, and right next to it you can see the box, and it's most of them. Most of those boxes air blue, and it has a number in it and it's four. There's a There's a six, there's a seven, but for all these patients on our list, you can see there you knows classifications for transplant. It's kind of high again, Dr Baron said. There's six or seven classifications. The seventh one is that you're kind of inactivated, so there's really six. And if you look at this, if we zoom in on it a little bit better, what you see is that all of our patients on the list are listed as four's. There's a couple of there's a six. There's a seven down there, but almost everybody's of four. This is the doldrum. The reason you don't see ones, twos or threes is because they get transplanted. Now look to the far right by each one of these patients that big number 1364 thes air days on the list. If you look carefully, there's six of them that have over 1000 days on the list. It's over three years when you come down to the patient number 14 that's half the list, guys. That's one year on the list. They don't think they're going to get transplanted. They get listed a couple of months ago by they're all excited. They're waiting for the phone to ring. The phone doesn't ring. So what does this mean for you As a physician? It means that for your patients now there's hope. Once we perfect this will have an option that we should be able toe be able to deliver that these patients that are not one twos or threes. They're 45 and six and they're stuck on the list. And one of our goals is to take this list and crush it. Thio transplant these patients and get the people that were waiting hearts. So does some general concepts about the D. C D process. Dr. Baron has talked about this, but again, the patient is dying and we don't accelerate that we don't have anything to do with it. The family withdraws support, the patient dies, the patient is pronounced, and then there is a time period that goes by Beyond that And at that point, even after their pronounced in the standoff period happens, then a signal is given to the teams and we come in, get the organs and reanimated. It's not new. It's been done for kidneys, liver, lungs. Uh, the heart was the last one that's out there and again. The term that I want you to think about is reanimation. And this isn't something that you haven't seen. Believe it or not, how many of you all have been two codes where it's 30 minutes and all of a sudden you get rust, so you got to think about it Kind of like that. It's a code just for the heart. And like any code, you could go to some people a 30 minutes or 35 minutes and get them back, and you can go to some people, and after 15 minutes, they're not gonna come back. So there's a gamble here with these hearts. You don't know out of the gate how they're going to respond. You may be able to take this heart out and put it on the pump in 45 minutes and it comes back and it looks great. You could take it out in 10 or 15 minutes and put it on the pump, and it looks terrible. It's just like any code. So just to kind of break it down, heart reanimation is probably best thought of just like you're doing a code blue for the heart. And because of that, there's this important window that Dr Baron talked about. If you have a patient, that's coding and you get him back in two minutes. It's very different than the patient that you get back in 45 minutes, and the same thing applies here in the trial. They noticed that I think it was about 45 minutes or so. The heart quality really started to drop off. So what they've done is they've set in the trial here 30 minutes, and the way it happens is the patient starts to die, and in the process is there. Blood pressure falls and their SATs drop. They're still dying, but at a certain point when their systolic blood pressure is less than 50 are the peripheral saturation are under 70% the clock begins, and they need at that point to go ahead and pass away, and then you need to be able to go through the standoff period and then suddenly Russian, get the prime for the pump and get the heart out or get it flushed, actually, just to start the flush within 30 minutes. The price. So D. C. D. Howe almost titled this slide, the good, the bad and the ugly. So the good is it opens up the pool of donors. Um, the bad is this variability in the hearts that you're going to take or not take that's new with brain death. There are times where we fly out and look at the heart and then turn it down. But that it's super rare, maybe less than 2% of the time. With these, it's a little bit of a gamble. We just don't know what we're going to get, and they're gonna be hearts that we bring back and decided not to re implant. So you need to be prepared for that. We may disrupt the O. R schedule and go out and bring a heart back and look at it and the team's gonna look at it, and we're gonna make a decision not to use it. There are times where we're gonna fly out, and that clock is gonna get to 22 minutes and the patient has not expired and we're gonna walk because there's no way that then suddenly we could get through the standoff period and everything else and get that heart out and be within the 30 minute period. And this is the saddest part. There are a ton of donors, but the young donors, the one that you really want This is the one that takes typically longer to die. So they're gonna be times where we get really excited about a young donor and the clock starts and we run out of time before we could get the heart. There is definitely a manpower need on these. It's very different than brain death with a brain death donor right now. Usually it's just the surgeon that flies out. Although we're in the process of getting an assistant with us to go a swell, which would be kind of just standard of care, but with a d c D heart. What I'm about to show you is it's very labor intensive. Not necessarily for the surgeon. As much as it is gonna be part of the profusion ist and we're not on an island with ease. When we go and we get these hearts were in near constant communication with the Trans Medic folks. They have specialists that are on the line with us. They're getting video feeds when we can get it to them off the machine and the console and so forth. And in the next generation, you know, they transmitted. Folks don't just do hearts. They do liver and lung and so forth. And and the other generations they've already moved to an iPad that has WiFi on it. And as they're harvesting those, the team back in and over is constantly looking at the data and giving feedback that's about to happen for this is well, but in the interim, what this means is that when we fly longer, we have to have aircraft that have WiFi, which we have access to. We just used one a couple of days ago. Um, but it's different, very different than when we send a team for just a brain death donation. Workflow. What will this mean? Kind of looking at your workflow patterns. When the program rolls out, its gonna be slept similar to when we get a brain death donor, there's gonna be just the same kind of process where we say we're gonna fly a team out. But it's gonna be a little bit bigger because we're gonna have to send one of four profusion ist that have kind of begun to master this and and time all the profusion it's will be able to do it. But as you'll see in a second, it's pretty labor intensive the delays maybe a little bit longer, but it's gonna be quite consistent with what you've already been used to when we get a transplant call with. One difference is that the element of we may bring the heart back and then not use it. So I would just ask you when you're taking care of those patients and the donor call comes through just to re, we'll all be reiterating it, but it will be important for everybody. Say yeah, way Don't know yet. We'll have to get the heart back and look at it, so that's important for you to know the initiation. We've been through this a little bit, but I wanted to stress the blood recovery so the patient dies, the standoff period happens. And then, um, in this kind of brutal way, people get into the operating room, get the chest open, and then immediately we have to get about 1215 100 ccs of blood out. It's not getting the heart out that's difficult. It's actually getting the blood because the patient has died and there's no pumping, there's no circulation. So trying to drain it and get the right volume is actually the hardest part of the learning curve. And I put this up kind of show one of the perceptions that I had coming on, you know, the workflow for getting the heart out. It's with brain death. It's just the surgeons. But here it's surgeons and profusion working together and on the left side of the screen you can see the surgeon challenge, which is to get the blood and get the heart out. But on the right side of the screen, I've got about eight or nine things there on. I wanted to stress that because one of the things we learned in and over is that there is a tremendous degree of stress on our profusion ist to get this pump loaded primed all the infusion pumps running. The infusion pumps programmed the infusion pumps and lines d aired the proper medications given into the pump, all the alerts and warnings cleared to receive the heart. It is a tremendous job that the profusion team has to go through.
