The utility of serial echocardiograms for organ procurement in brain death

Abstract

Heart transplantation rates are limited by a shortage of donor hearts, and left ventricular dysfunction is an important cause. We hypothesized that an early echocardiographic evaluation in severe brain injury (performed within 12 hours from ICU admission) could allow the detection of potentially reversible left ventricular (LV) abnormalities and thus the initiation of tailored treatment whose effects could be assessed at a second echocardiogram performed when brain death develops. We assessed this hypothesis in 49 patients with severe brain injury who were potential heart donors. A reduction in LV ejection fraction (LVEF) (<55%) was present in five patients (10.2%): diffuse hypokinesia in three patients (6.1%), segmental wall motion abnormalities in two (4.1%). Two patients showed apical ballooning (normal LVEF). The three patients with diffuse hypokinesia showed, at the echocardiogram performed 12 hours later, a complete recovery of wall motion and LVEF. Among patients with apical ballooning, a complete resolution was observed in both patients. Two patients were considered potentially eligible for heart donation, resulting in 20% increase in donor retrieval rate. In serious encephalic lesions, potentially evolving toward brain death, echocardiography performed after ICU admission allowed the identification of LV abnormalities, which could be specifically treated with complete resolution.

Management of the brain-dead donor in the ICU: general and specific therapy to improve transplantable organ quality

“…There are no major studies dictating which types of monitoring should be applied in brain-dead donors [8], but it is common sense that hemodynamic shock states should be evaluated using invasive arterial blood pressure measurements, lactate levels, (mixed) venous oxygen saturations, and echocardiography to evaluate myocardial contractility and exclude other cardiac pathology. Serial echocardiography can be used to assess potential recovery in neurogenic stunned myocardium, and guide continued support in potential donors [9], which may increase the number and quality of donor hearts. In some cases, specific invasive monitoring with pulmonary artery catheter (PAC) [8] or arterial waveform analysis-based techniques [10] can be useful to steer management.…”

Hemodynamic management in brain dead donors

“…According the results of prospective studies, a longer period of donor treatment was associated with a higher number of organs transplanted in the lack of differences in the number of DGs achieved. This phenomenon was more evident for heart and lung transplantation probably thanks to an efficacious treatment of potential reversible cardiac diseases such as stress cardiomyopathy[ 11 - 14 ]. In the United States longer periods of management are common and a “relax and repair approach” was proposed in opposition to a “rush and retrieve” one (that is, in presence of donor stability a risk of deterioration can be avoided since little can be achieved).…”

“…In 49 patients with severe brain injury (potential heart donors), our group observed that echocardiography performed after ICU admission led to the identification of LV abnormalities potentially reversible after tempestive aggressive treatment. Indeed, in our series, two patients were considered eligible for heart donation, resulting in 20% increase in donor retrieval rate[ 14 ].…”

Noteworthy Literature Published in 2017 for Thoracic Transplantation Anesthesiologists

“…Freundt et al, 80 Lazzeri et al, 81 Chen et al, 82 Madan et al 83 Donor reduced LVEF does not negatively impact recipient outcomes and mortality.…”

“…Donor hypertension 77 has been shown to affect survival, and prolonged QTc interval >500 milliseconds 78 have been shown accelerate the development of CAV. Hyperglycemia, 79 reduced LV function, 80 -83 and longer distance between donor and recipient hospital 84 have been studied recently and have not been shown to affect outcomes.…”