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Donation hearts turn better with a new method after the cycle death

Donation hearts turn better with a new method after the cycle death

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The controversial TANRP protocol shortens the ischemic time for donations after the cycle and improves the results.

Using transplanted hearts, which are preserved after the circulatory death by normothermal regional perfusion (TANRP), after an observation analysis leads to better clinical results than the use of those who have been called up by direct procurement and perfusion (DPP).

A year after the transplantation, patients with the heart called with the TANRP approach showed a less heavy primary graft function disorder and acute cellular rejection (ACR) than the patients taken with DPP, but there was no difference in the mortality between the two techniques, the investigators reported in one in a study Published this week In JACC: heart failure.

The data led by John Louca, MB BCHIR (University of Cambridge, England), say that the data in a larger randomized study require confirmation, but can carry out such a study or even expand the use of TANRP could prove to be a challenge.

“While Tanrp shows after the death of the death of the death of the heart transplantation in the circulatory potential, his widespread assumption is limited by a combination of logistical questions and ethical concerns regarding the violation of the dead donor rule by restarting cerebral perfusion,” they write. “There is a moratorium for technology in Belgium and Great Britain and [it] is prohibited in Australia, Canada and in many parts of the United States. “

The TANRP technology was increasingly used to reduce the ischemic insult that occurs between the interruption of life-supporting treatment and the confirmation of the cycle death. It contains the restoration of the circulation in the body of the donor after the death dying has been explained what concerns about whether it has violated the “dead donor rule”, which must meet the donor at the time of the organ procurement.

Radha Gopalan, MD (Banner – University Medical Center Phoenix, AZ), director of advanced heart failure, transplantation and mechanical assist devices in its center, described the observation study as “informative but not final”. While there may be difficulties to bring a randomized comparison between TANRP and DPP on the market, the observation data helps in this regard, he noticed.

“This study suggests that there is no difference in mortality,” Gopalan told TCTMD. “A year and a 3-year survival is comparable between the two, which is currently a good thing. It means that we can go to every patient and say:” We will randomize them in order to get the organs in one way or other? There is no difference in survival. “This enables us to have this conversation with the patient because it is a very difficult thing to do in a heart transplant [setting]. “”

Comparison of Tanrp with DPP

According to some estimates, the expansion of the organs donated after the cycle increased the donor pool by up to 30%.

However, a restriction of the use of these organs is the resulting ischemia, which can lead to irreversible organ damage. At Tanrp, the heart is perfected in situ before it is restored and then is preserved after explantation either with ex -situ -perfect or static cold storage. At DPP, on the other hand, the heart includes immediately after the circulation and preserves it from the donor to recipient with machine perfusion during transport.

With DPP after the death of the circulation, remove the transplant team to suitable organs that have suffered a longer period of ischemia. Ashish Correa, MBBS (the Mount Sinai Hospital, New York, NY), an advanced heart failure and transplantary, told TCTMD. Since the organ is adopted from the donor to an extracorporal perfusion machine, there are other ischemia.

“It is technically challenging and complex to set [the organ] On these external perfusion devices, “said Correa.” It is also expensive. ”

There is currently a lack of data in which TANRP and DPP heart results were compared, which meant that the investigators collected data from 20 transplantation centers in Belgium, Spain, Great Britain and the United States.

What is most important for our patients are you alive? Ashish Correa

Between 2023 and 2024 there were 504 transplants with hearts after confirmation of the circulatory death: 223 were received with TANRP and 281 with DPP. There was no difference in the donor size, weight, age, gender or sexual transplants between the groups. In addition, a similar number of liver and lungs per donor were called up in the TANRP and DPP groups, although more kidneys were accessed with DPP.

The DPP group had a significantly shorter functional, warm ischemic period, which is defined as a time from systolic blood pressure from donors to cold paraplegia than the TANRP group (Median 13 compared to 15 minutes; P = 0.005). However, the functional total ischemic period, which was defined as the time from the systolic blood pressure from donors to reperfusion, was significantly shorter with TANRP (median 15 compared to 39 minutes; P <0.001). There was also a significantly shorter ex -Superfusion time with TANRP donation hearts.

There was no difference in the survival of the recipient after the transplant after 30 days, 1 year, 3 years or over the entire examination period (median times of transplantation to the censorship date were 1,069 and 744 days in the DPP or TANRP arms). Similarly, in the COX modeling with mixed effects, no procurement method was associated with a better survival over the other.

The primary graft function was in patients with hearts who were procured via DPP (19.2% compared to 7.6%; P <0.001). In a logistical regression model, procurement via TANRP was connected to a lower use of mechanical circulatory support after the transplant (or 0.32; 95% CI 0.18-0.59). A total of 25.3% of the patients in the DPP group had an ACR episode that was treated in the first year after the transplantation compared to 13.0% in the TANRP group (P <0.001). The risk of a rejection-free survival for death was better with Tanrp (HR 0.45; 95% CI 0.30-0.69).

A less primary graft function with TANRP makes “intuitive sensible” because the DPP method is associated with longer ischemic times, said Correa. Like Gopalan, he sees the lack of a survival advantage with both approaches as good news.

“What is most important for our patients are you alive?” Correa said TCTMD. “There seems to be no difference due to every technology.”

Advantages with TANRP

Correa not only said that the ischemic time was shortened with TANRP, but also other advantages to get the heart in this way.

“If you have revived the organs, you have to assess an assessment of whether you are viable by just looking at the machine,” he said. “This is a more difficult way to make an evaluation, while with the Normothermic regional perfusion of Thoracoabdominal how the organs cut out in a much more natural state. The heart is appropriately loaded, and you can see how it might be in the recipient.”

There are also blood and imaging tests that can be carried out with TANRP that cannot be carried out as soon as the heart is placed on the organ care system. When the donor is located near the recipient hospital, the TANRP approach enables the hospitals to transport the relaxed hearts with static cold preservation.

Gopalan said his hospital procured his heart with Tanrp after the death of the circulation, but he does not believe that the retrospective analysis will change the procurement procedure for heart transplantation in those who use the donor hearts after the circulation. Among the 20 that are included in the study, all different options have to carry out heart transplants and to look after the heart in the follow -up examination. Protocols and guidelines on immunosuppression or biopsy, for example, differ, he said. This could lead to potentially confused results.

“If you combine several centers, you have to take [the results] With a grain of salt, “said Gopalan.” Nevertheless, it shows important points. Am I impressed by the newspaper? Yes. Will it change the practice? Not yet.”

Correa pointed out that more recipient patients in the DPP group needed inotropic support, which may have contributed to a higher risk of a primary graft function disorder. The DPP group also had long maintenance times, he noticed. For this reason, a randomized study would be justified, although it would require a large number, a challenge in the transplant and the nationwide consensus on the ethics of Tanrp, he said.

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