Purpose: Pulmonary hypertension (PH), defined as a mean pulmonary artery pressure (mPAP) ≥ 25mmHg, is associated with increased mortality. The clinical correlates and prognostic significance of elevations in mPAP below the diagnostic threshold (subclinical PH) are not well described. We hypothesized that patients with subclinical PH would have increased mortality compared to those with normal mPAP. Methods: We used Vanderbilt's de-identified electronic medical record (the Synthetic Derivative) to identify patients who underwent right heart catheterization (RHC) between 1998-2014. Clinical, hemodynamic, and vital status data were extracted. Subclinical PH was defined based on cutoffs derived from the Veteran's Affairs Clinical Assessment Reporting and Tracking Program cohort. Results: In total, 4635 patients were analyzed: 960 (21%) with mPAP ≤ 18mmHg (NoPH), 938 (20%) with mPAP 19-24mmHg (subclinical PH), and 2737 (59%) with mPAP ≥ 25mmHg (PH). Compared with the NoPH group, patients with subclinical PH were older (61±14 vs. 59±15; p< 0.001) and more likely to have systemic hypertension (73% vs. 65%; p< 0.001), heart failure (37% vs. 26%; p < 0.001), diabetes mellitus (14% vs. 8%; p< 0.001), and chronic obstructive pulmonary disease (13% vs. 6%, p< 0.001). All-cause mortality in the subclinical PH group was intermediate between the NoPH and PH groups (Figure; p< 0.001). After adjusting for age, gender, race, and six known risk factors for PH, the hazard for mortality remained elevated compared with NoPH (HR 1.49, 95% CI 1.18-1.89, p< 0.001). Conclusion: Subclinical PH was found in 20% of patients referred for RHC and, compared to NoPH patients, was associated with increased mortality after adjustment for relevant covariates. Subclinical PH is associated with an increased prevalence of risk factors for Groups II and III PH. The etiology of subclinical PH and the optimal threshold for defining clinically significant PH warrant further study.
Background. Organ donation after euthanasia is performed in an increasing number of countries. In this donation after circulatory death procedure, it has not been possible to donate the heart. Recent literature, however, reports positive results of heart donation after circulatory death. Therefore, patients who donate organs following euthanasia might be suitable candidates for heart donation. We want to confirm this assumption by sharing the results of 2 cases of heart donation following euthanasia with ex situ subnormothermic heart preservation. Our aim is to raise awareness of the potential of heart donation following euthanasia for both clinical transplantation and research. Methods. The data of 2 consecutive heart donations following euthanasia were collected prospectively. Informed consent was obtained from the patients themselves for heart donation for research purposes. An acellular oxygenated subnormothermic machine perfusion strategy was used to preserve both donor hearts. Subsequently, the hearts were evaluated on a normothermic perfusion machine using a balloon in the left ventricle. Results. Heart donation following euthanasia was feasible without significant changes in existing retrieval protocols. Duration of machine perfusion preservation was 408 and 432 minutes, for heart 1 and 2, respectively. For heart 1, developed pressure (P dev ) was 119 mm Hg, maximal rate of pressure rise (dP/dt max ), and fall (dP/dt min ) were 1524 mm Hg/s and −1057 mm Hg/s, respectively. For heart 2, P dev was 142 mm Hg, dP/dt max was 1098 mm Hg/s, and dP/dt min was −802 mm Hg/s. Conclusions. Hearts donated following euthanasia are highly valuable for research purposes and can have sufficient quality to be transplanted. With the implementation of ex situ heart perfusion, patients who are to donate their organs following euthanasia should also be able to donate their hearts. The complex combination of euthanasia and heart donation is ethically sound and surgically feasible and can contribute to shortening the heart transplant waiting list.
The implementation of donation after circulatory death category 3 (DCD3) was one of the attempts to reduce the gap between supply and demand of donor lungs. In the Netherlands, the total number of potential lung donors was greatly increased by the availability of DCD3 lungs in addition to the initial standard use of donation after brain death (DBD) lungs. From the three lung transplant centers in the Netherlands, 130 DCD3 recipients were one-to-one nearest neighbor propensity score matched with 130 DBD recipients. The primary end points were primary graft dysfunction (PGD), posttransplant lung function, freedom from chronic lung allograft dysfunction (CLAD), and overall survival. PGD did not differ between the groups. Posttransplant lung function was comparable after bilateral lung transplantation, but seemed worse after DCD3 single lung transplantation. The incidence of CLAD (p = 0.17) nor the freedom from CLAD (p = 0.36) nor the overall survival (p = 0.40) were significantly different between both groups. The presented multicenter results are derived from a national context where one third of the lung transplantations are performed with DCD3 lungs. We conclude that the long-term outcome after lung transplantation with DCD3 donors is similar to that of DBD donors and that DCD3 donation can substantially enlarge the donor pool.Abbreviations: BLTx, bilateral lung transplantation(s); BOS, bronchiolitis obliterans syndrome; CIT, cold ischemic time; CLAD, chronic lung allograft dysfunction; CMV, cytomegalovirus; DBD, donation after brain death; DCD3, donation after circulatory death category 3; EVLP, ex-vivo lung perfusion; FEV 1 %, forced expiratory volume in 1 s as a percentage of predicted; FEV 1 , forced expiratory volume in 1 s; FiO 2 , fraction of inspired oxygen; FVC%, forced vital capacity as a percentage of predicted; FVC, forced vital capacity; ICU, intensive care unit; PaO 2 , arterial oxygen pressure; PEEP, positive end expiratory pressure;
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