Deane E. Smith

NYU Langone Health

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Donation after circulatory death heart transplantation using normothermic regional perfusion:The NYU Protocol

JTCVS Techniques (2022)

Les James V. Reed LaSala F.J. Hill Jennie Ngai Alex Reyentovich

This study aimed to evaluate the impact of cardiopulmonary bypass for thoraco-abdominal normothermic regional perfusion on the metabolic milieu of donation after cardiac death organ donors before transplantation.Local donation after cardiac death donor offers are assessed for suitability and willingness to participate. Withdrawal of life-sustaining therapy is performed in the operating room. After declaration of circulatory death and a 5-minute observation period, the cardiac team performs a median sternotomy, ligation of the aortic arch vessels, and initiation of thoraco-abdominal normothermic regional perfusion via central cardiopulmonary bypass at 37 °C. Three sodium chloride zero balance ultrafiltration bags containing 50 mEq sodium bicarbonate and 0.5 g calcium carbonate are infused. Arterial blood gas measurements are obtained every 15 minutes after every zero balance ultrafiltration bag is infused, and blood is transfused as needed to maintain hemoglobin greater than 8 mg/dL. Cardiopulmonary bypass is weaned with concurrent hemodynamic and transesophageal echocardiogram evaluation of the donor heart. The remainder of the procurement, including the abdominal organs, proceeds in a similar controlled fashion as is performed for a standard donation after brain death donor.Between January 2020 and May 2022, 18 donation after cardiac death transplants using the thoraco-abdominal normothermic regional perfusion protocol were performed at our institution. The median donor age was 42.5 years (range, 20-51 years), and 88.9% (16/18) were male. The mean total donor cardiopulmonary bypass time was 88.8 ± 51.8 minutes. At the beginning of cardiopulmonary bypass, the average donor lactate was 9.4 ± 1.5 mmol/L compared with an average final lactate of 5.3 ± 2.7 mmol/L (P<.0001). The average beginning potassium was 6.5 ± 1.8 mmol/L compared with an average end potassium of 4.2 ± 0.4 mmol/L (P<.0001) . The average beginning hemoglobin was 6.8 ± 0.7 g/dL, and the average end hemoglobin was 8.2 ± 1.3 g/dL (P<.001) . On average, donation after cardiac death donors received transfusions of 2.3 ± 1.5 units of packed red blood cells. Of the 18 donors who underwent normothermic regional perfusion, all hearts were deemed suitable for recovery and successfully transplanted, a yield of 100%. Other organs successfully recovered and transplanted include kidneys (80.6% yield), livers (66.7% yield), and bilateral lungs (27.8% yield).The use of cardiopulmonary bypass for thoraco-abdominal normothermic regional perfusion is a burgeoning option for improving the quality of organs from donation after cardiac death donors. Meticulous intraoperative management of donation after cardiac death donors with a specific focus on improving their metabolic milieu may lead to improved graft function in transplant recipients.

10.1016/j.xjtc.2022.11.014

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Citations (16)

A Simple Prioritization Change to Lung Transplant Allocation May Result in Improved Outcomes

The Annals of Thoracic Surgery (2020)

Stephanie H. Chang Luis F. Angel Deane E. Smith Julius A. Carillo D. Rudym

Prioritization

10.1016/j.athoracsur.2020.05.108

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Citations (3)

Cold Static Storage Combined with Intraoperative Cardioplegia Protection Strategy Yields Low Primary Graft Dysfunction

The Journal of Heart and Lung Transplantation (2024)

Morna J. Dorsey L James S. Chen Michael Allison S. Shrivastava

10.1016/j.healun.2024.02.870

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Citations (0)

Antithrombotic management for Impella^® temporary ventricular assist devices: An analysis of an academic health-system experience

The International Journal of Artificial Organs (2022)

Olivia Iskaros Tania Ahuja Serena Arnouk Bridget Toy Tyler Lewis

The use of acute mechanical circulatory support (MCS) has increased over the last decade. For patients with left-ventricular failure, an Impella® (Abiomed, Danvers, MA) may be used to improve cardiac output. The purpose of this study is to describe Impella® anticoagulation patterns and evaluate the safety and effectiveness of our protocol. This is a retrospective review of all adult patients who required at least 24 h of Impella® support and received a heparin-based purge solution. In total, 109 patients were included in the final analysis. The most common indication for Impella® device insertion was cardiogenic shock (76%) with the remaining patients receiving a device for a high-risk procedures; typically coronary artery bypass grafting or percutaneous coronary intervention. A total of 9 thrombotic events occurred among 8 (7%) patients and 50 bleeding events occurred among 43 (39%) patients, with the most common classification being BARC 3a (60%). A univariate analysis revealed that patients were more likely to bleed if they were less than 65 years old, had an indication of cardiogenic shock for Impella®, inserted the device peripherally, were on dual antiplatelet therapy, or had an intra-aortic balloon pump prior to Impella® insertion, the latter of which was confirmed with a multivariate analysis (OR 2.5 [1.072-5.830]; p = 0.034). For those monitored by anti-Xa, the presence of two or more values greater than 0.40 IU/mL was a risk factor for bleeding (p = 0.037). Our study identifies risk factors for bleeding in patients receiving temporary MCS with an Impella®.

Impella

Bleed

10.1177/03913988221082686

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Citations (1)

Missed Opportunities in Identifying Cardiomyopathy Etiology Prior to Advanced Heart Failure Therapy

Journal of Cardiac Failure (2019)

Norman Aiad Boyangzi Li Navneet Narula C. Gidea Stuart D. Katz

Etiology

10.1016/j.cardfail.2019.07.205

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Citations (0)

P91: ECMO Education Initiative for Advanced Practice Providers.

ASAIO Journal (2023)

Erica Duff Emily G. Kelley Bridget Toy Ronald Goldenberg Anthony Lubinsky

Study: Our Adult ECMO program is supported by a rounding model where an ECMO Specialist is in house 24/7 and available to be called for bedside support. We are able to utilize this rounding model due to the high level of expertise from our multidisciplinary critical care teams. This expertise is maintained through a robust nursing competency program, as well as a credentialing process and accredited continuing medical education (CME) course for physicians. However, a gap in initial and ongoing competency was identified for Advanced Practice Providers (APP). Prior to 2021, a total of 19 APPs had received some form of initial ECMO education with no ongoing recompetency training. Our APPs serve as frontline providers and first responders in ECMO emergencies. Therefore, we aimed to develop an education program, including didactic and hands-on training, which provides them with necessary competencies in managing patients on ECMO support. Methods: Our team introduced the APP Adult ECMO Education Initiative in April 2021. The initiation of this program included the development of the Education & Training Policy for Multidisciplinary Critical Care Team, a policy outlining the educational requirements for RNs and APPs who care for patients requiring ECMO, the creation of the Adult ECMO APP Emergency In-Service and the creation of the Adult ECMO APP Initial Training Course. Additionally, our existing Adult ECMO Management CME Course was adjusted to better meet the competency needs of both APPs and physicians managing ECMO patients. Post-initiative, three institutional ECMO education options were available to APPs (Figure 1). Additionally, the newly created policy mandated initial and annual competency training for any APP who cares for a patient on ECMO. Results: 25 APPs attended at least one of our institution's three ECMO education courses in Fiscal Year (FY) 2021, 33 APPs in FY 2022 and 31 APPs in FY 2023 (as of January 2023). This is compared to 15 or less in previous fiscal years (Figure 2). Post-test scores for our CME Course consistently show an increase in knowledge with an average score increase of 25 points, compared to the pre-test score, in the last three course offerings. For FY 2022, our ECMO survival rates included an 84% survival of ECMO with a 75% survival to discharge, compared to 78% survival of ECMO and 70% survival to discharge in FY 2021. In FY 2022, 54% of patients had zero ELSO-defined complications, compared to 47% in FY 2021 and 38% in FY 2020. Summary: Development and implementation of a structured training program for APPs has enabled our ECMO Program to improve upon our high-quality care by increasing APP's proficiency in ECMO management.

Credentialing

Best practice

Multidisciplinary team

10.1097/01.mat.0000944184.38073.6c

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Citations (0)

Commentary: Direct cardiac compression device for biventricular support: If we put lipstick on a pig, is it still a pig?

Journal of Thoracic and Cardiovascular Surgery (2021)

Nader Moazami Deane E. Smith

Lipstick

10.1016/j.jtcvs.2021.12.006

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Clinical and Financial Implications of 2 Treatment Strategies for Donor-derived Hepatitis C Infections

Transplantation Direct (2021)

Zoe A. Stewart Jeffrey Stern Nicole Ali Harmit Kalia Karen Khalil

Transplanting hepatitis C viremic donor organs into hepatitis C virus (HCV)-negative recipients is becoming increasingly common; however, practices for posttransplant direct-acting antiviral (DAA) treatment vary widely. Protracted insurance authorization processes for DAA therapy often lead to treatment delays.At our institution, 2 strategies for providing DAA therapy to HCV- recipients of HCV+ transplants have been used. For thoracic organ recipients, an institution-subsidized course of initial therapy was provided to ensure an early treatment initiation date. For abdominal organ recipients, insurance approval for DAA coverage was sought once viremia developed, and treatment was initiated only once the insurance-authorized supply of drug was received. To evaluate the clinical impact of these 2 strategies, we retrospectively collected data pertaining to the timing of DAA initiation, duration of recipient viremia, and monetary costs incurred by patients and the institution for patients managed under these 2 DAA coverage strategies.One hundred fifty-two transplants were performed using HCV viremic donor organs. Eighty-nine patients received DAA treatment without subsidy, and 62 received DAA treatment with subsidy. One patient who never developed viremia posttransplant received no treatment. Subsidizing the initial course enabled earlier treatment initiation (median, 4 d [interquartile range (IQR), 2-7] vs 10 [IQR, 8-13]; P < 0.001) and shorter duration of viremia (median, 16 d [IQR, 12-29] vs 36 [IQR, 30-47]; P < 0.001). Institutional costs averaged $9173 per subsidized patient and $168 per nonsubsidized patient. Three needlestick exposures occurred in caregivers of viremic patients.Recipients and their caregivers stand to benefit from earlier DAA treatment initiation; however, institutional costs to subsidize DAA therapy before insurance authorization are substantial. Insurance authorization processes for DAAs should be revised to accommodate this unique patient group.

Viremia

Interquartile range

Hepatitis C

Reimbursement

10.1097/txd.0000000000001222

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Citations (9)

Pulmonary Pathology of End-Stage COVID-19 Disease in Explanted Lungs and Outcomes After Lung Transplantation

American Journal of Clinical Pathology (2021)

Abdallah Flaifel Benjamin Kwok Jane P. Ko Stephanie H. Chang Deane E. Smith

Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may develop end-stage lung disease requiring lung transplantation. We report the clinical course, pulmonary pathology with radiographic correlation, and outcomes after lung transplantation in three patients who developed chronic respiratory failure due to postacute sequelae of SARS-CoV-2 infection.

Diffuse alveolar damage

10.1093/ajcp/aqab208

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Citations (18)

Commentary: Recognition is the first step

Journal of Thoracic and Cardiovascular Surgery (2020)

Stephanie H. Chang Deane E. Smith

10.1016/j.jtcvs.2020.07.024

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Citations (0)