This video is part of the 2020 Sentara Cardiac Grand Rounds, "Heart in a Box: The Future is Now," originally broadcast September 15, 2020. David Baran, MD, FACC, FSCAI, FHFSA, identifies the advantages and disadvantages of the OCS Heart monitoring system for donor hearts.
Dr. Baran explains the OCS device is designed to keep a donor heart at a human-like, metabolically active state which allows physicians to utilize their medical judgement to assess a potentially suitable heart’s condition and viability.
Dr. Jonathan Philpott, Transplant Surgical Director at Sentara, also reviews heart reanimation outcomes of transplants with donation after circulatory death (DCD) compared to donation after brain death (DBD).
the advantage is that I'm not a surgeon, but my surgical colleagues tell me it's relatively straightforward, Dr Phil, probably able to show us today images of what this looks like putting this heart from somebody who's died onto this machine. You're able to moderate. You actually even able to do a corner angiogram. Uh, if you want on these donors, the disadvantages air cost, everything has a cost. This certainly has a financial cost is well, if you wait too long, you can't go 24 hours. Like with kidneys, you can't put them on a plane. Eventually, the heart does become a de minus. You can see with visual monitoring how the heart's doing, but it's not the same as being in a human body, and we only have it the moment. Crude biomarkers such as lactate Well, does it work? Bottom line Jack Article from the same group in Australia now looking at this, your Kaplan Meier curve. The blue is donation after circulatory determination, death actually better than the brain dead donors. Certainly not statistically different on this was a total of 22 D C. D hearts, compared against 90 for brain dead donors as Before we brought this technology to Sentara, it was really a monumental team effort. Uh, we reach out to a variety of centers overseas that really led the way. And doing this is Vpon Mata, uh made a over in England Ashley and published a very nice experience about how you started D. C D program. A couple of things are relevant. The overall improvement in volume in transplants was about 25% in their experience, and when you look carefully, see some of the patients did not expire. You took them in operating room, but patients stayed in a marginal blood pressure state, and some of the organs were not able to be used because you can't go hours waiting for a patient to expire. Because then that high poxy mia and ischemia leads to the organ not being useful. And not all the organs that they retrieved necessarily look good on pump. Yet this is a window into the future and Papworth in England, where there's a tremendous disparity between the need for donors and the availability they've had. Incredible results. We spoke to those folks is well saying that if you confined D C D donors the results are equivalent and worldwide. In Manchester, they've done 10 D c d hearts in two years. As of yesterday in the United States and the heart of the boss trial, 82 hearts have been done same and Papworth 78 Australia has been very busy. We are witnessing what is the future? In five or 10 years, everyone will be doing this. But for now, we're unbelievably privileged with supportive administration, cardiothoracic surgery and all of the team to be able to bring this to Sentara. The consensus of the centers that I spoke to is that that D. C D is likely to increase. Everybody recognizes this that in England, for example, half of their transplant volume comes this way. And Australia, 30% Belgium, 20 some odd percent because with special with drug use and other things, more and more donors experience almost death than not dying of trauma. Seatbelt laws do save lives, but people will still do unfortunate things to themselves that leads them to be in a state where D C D is in fact, one of the remaining ways you can procure organs, primary graft, dysfunction where initially the heart could be slow to wake up and require ECMO about 25% of the time. And so we go into this process with odds. What open with an experienced team that understands how to manage these patients, even if they're initially a bit sluggish. They're all young hearts, and it's really got catapulted with the release of this information from Duke last year, where Duke actually did the first United States D C D heart transplant on our team. Looking, said Bob, look at this December 3rd, 2019 almost 51 years to the day since Christian Bernard's transplant, how do we get involved in this? And thus began a race that is culminated now in the ability to do D. C transplants here it's Antara eso for my favorite cartoon from growing up. Would you wanna be the first man on the moon? Lina says. I'm not that brave. Well, we're not the first. So this is the trial that we're gonna be in and look at the company that we're gonna keep yell Tampa General Emery, Mass. General Duke, I believe since the slide Cleveland Clinic, Stanford and Cedars have been added. This is a trial where patients are asked to randomize with randomize between D. C de possible in a 3 to 1 fashion to standard of care or bag of ice. Uh, in fact, in this trial, the D C D arm is enrolled so quickly because there's been so money available dcd hearts that otherwise being buried and lost that now this is trial is gonna be done in the next few weeks. The recipients are basically all primary transplants above the age of 18 not multi organs. In terms of size, of the trial will be 90 D C D hearts and the primary endpoint is non inferiority. You wanna make sure that we can replicate what was done in Australian everywhere else, that the patients don't have a survival disadvantage, and we're not the first to continue the cartoon, Lana says. I'm not even sure I'd like to be the second, and the third man would have quite a bit of responsibility to and so forth. And it ends by saying your brother is the only person I know who wants to be the 43rd man on the moon. But we won't be the 43rd, but we won't be the first. What we worry about is likely what we're not gonna find. You know, we all thought growing up in the the seventies, the quicksand was gonna be a much bigger problem than it really turned out to be on. We recognize that everything we're doing now is gonna be pioneering work. And we may discover new lessons. But we'll save a lot of patients along the way who otherwise would not get a transplant so we can worry and say, G, I'm scared of the future. Or we can acknowledge that our colleagues in other countries have really gone ahead of us and really proven that this works. We have patients every year that air dying without the ability to receive transplants, we can. And we must push forward to bring those patients the life saving gift. And now I have true privilege of my working with my colleague Dr Jonathan Philpott in a surgical team. Um, none of this would be possible without the amazing teamwork between us. Yes, Lauren, um, for what they're calling a vegetative state. What is, I guess what is the explicit criteria? Like, how does the family decide that their loved ones in a persistent vegetative state and we're not gonna witness anymore. It's a great question, and that's up to the team that's taken care of that donor. So by definition, brain death is very clear. We've all been in the situation. Our family is very upset. They said, No, no, don't stop the ventilator. But patient has a death certificate, not the case in D. C. D. And so it is up to the opinion of the neurologist on these are patients by and large, that if you just supported them, might just live in this awful netherworld for various periods of time until eventually they succumb. So the transplant team has zero involvement on that side, for the ethical reasons has to be families that decide that this is no way to live, and they literally will withdraw the ventilator. They will withdraw support. E think that's a That's a good question, and I'm going to get into that just a little bit here as well. But the key and I kind of had to wrestle with this personally a little bit. The key is that they're dying and they're going to die, and we don't have anything to do with that and you got to think about it like just in your forget all this for a second. Just think about it. Like in your daily routine. There are people that are not brain dead that are gonna die. And the family makes the decision. They say, what would they have wanted? And they say Everybody comes to the consensus they wouldn't wanna live on like this. And they withdraw and or make them comfort care. And the patient goes on to die. The key word here. Like when I first started going with this, I was all focused on D C D. Get off of that. The key word here is reanimation. That's the Touchstone. The patient is gone, the they have died. The key here is Can you get in and pull something out that is dead basically and reanimated
