links header
  email icon  Email     printer icon  PDF

Grassroots Movement for
Unresolved Issue after November Election:
Cardiac Management of the Organ Donor


links image

NANCY W KNUDSEN, MD
Associate Professor of Anesthesiology
Assistant Professor of Surgery
Co-Director SICU
Duke University Medical Center
Durham, North Carolina, USA

nancy.knudsen@dm.duke.edu


Regardless of what political party you support, we can all agree that too much money is spent on patients with chronic disease and at the end of life in healthcare. Greater than 51% of healthcare dollars are spent on just 5% of our population per year.1 One of the patient groups who would fit in this metric include those awaiting heart transplantation. As of 11/25/2012 at 12:16 PM there are 116,580 patients waiting for an organ transplant. 3,379 people are waiting for a heart transplant and 49 people are waiting for a heart lung transplant. National data obtained from the UNOS website demonstrate that 92% of the hearts recovered are from deceased donors less than 50 years of age.2 As our population continues to age, the donor demographic will shift as well. The proportion of population over age 65 is expected to increase from 12.4% or 35 million people in 2000 to 19.6% or 71 million people in 2030.3 These statistics show an overwhelming need to optimize donors at all ages for every possible organ and tissue donation. The involvement of intensivists in management of the organ donor through use of donor management goals (DMGs) has increased donor yield or organs transplanted per donor.4

These results are encouraging but I would propose the old adage, "if mama ain't happy, ain't nobody happy" be changed to, "if the heart ain't happy, ain't no organ happy." Intensivist management makes a difference, but unfortunately the number available to care for all sick patients is less than the number needed across the country. If anyone knows how to take care of a patient with a sick heart, it is the cardiologist! We need you to make a sea change and work toward improving the function of donor hearts to aid patients on the waiting list. Optimization will become even more crucial as our population ages, whether this is through guidelines or case by case individual management or both. Reach across the catheterization lab or clinic to work with your organ procurement organization (OPO).

Whether or not the heart is utilized for transplant, an understanding of the complex hemodynamic, inflammatory, biochemical and hormonal changes that occur with brainstem death is necessary.5 These changes to the heart are often unpredictable, usually transient and occur with incidence of 10-40% in the literature.6 It is recommended that echocardiogram be obtained once volume resuscitation has occurred and vasopressors have been titrated down for goal MAP 60-70 to ensure best possible results through aggressive donor management utilizing pulmonary artery catheter or other means of assessment such as noninvasive cardiac output to improve circulatory function. Looking at Region 11 DMGs YTD for 2012 shows higher heart utilization when mean arterial pressure 60-120, <1 pressor and low dose: Dopamine <10mcg/kg/min, Neo <60mcg/kg/min, Norepi <10mcg/kg/min, as well as urine output >0.5-7 ml/kg/hr for last 4 hours as well as pH 7.3-7.5 are met.7

Venkateswaran in 2010 utilized echocardiography on donors and found abnormal function in 29/66. When possible these exams were repeated and at end assessment 45 of 66 had achieved H-function criteria with donor management.8 LV function has been shown to improve over time and repeat echocardiogram should be considered if first evaluation was poor. One region looked at time of brain death to procurement in six-hour intervals, mean of 34.5 hours +/- 19.8 hours and found no decrease in number of organs procured with increasing time.9 The use of hormone replacement therapy (HRT) in the literature includes combinations of steroids, T3 and T4 in various protocols and demonstrates improved organ yield for brain dead donors. A study in Journal of Heart and Lung Transplantation from 2009 illustrates the above concepts in harmony. The authors utilized HRT using bolus solumedrol and levothyroxine and then levothyroxine infusion titrated to cessation of vasopressors. HRT was used in concert with standardized donor management guidelines including SBP, CVP and urine output goals. Organ donors who received HRT ≥15 hours had a statistically significant improvement in hearts recovered over those donors who received <15 hours or no T4 replacement. CVP of <10mmHg also had a significantly higher rate of hearts, lungs and kidneys transplanted. Combining HRT ≥15 hours and CVP <10 yielded more hearts than either situation alone.10

The evidence seems clear. Aggressive resuscitation over time with hemodynamic endpoints, use of HRT and appropriate use of echocardiography can increase hearts available for transplantation to end deaths on the waiting list. The physiologic changes of these donors take time, energy and intelligence to manage. Guidelines and protocols are effective, but these complex changes often require outside resources for OPOs. I challenge you to ask not what your OPO can do for you, but what you can do for your OPO!

I'm Nancy Knudsen and I approved this message.



Disclosure Statement: Dr. Knudsen reports receiving consulting fees from Carolina Donor Services as Chief Medical Director.

References:

  1. A Primer on Healthcare Costs by the Kaiser Family Foundation May 2012
  2. http://optn.transplant.hrsa.gov/latestData/rptData.asp
  3. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5206a2.htm
  4. Malinoski DJ, Patel MS, Daly MC, et al. The impact of meeting donor management goals on the number of organs transplanted per donor: Results from the United Network for Organ Sharing Region 5 prospective donor management goals study. Crit Care Med. 2012 Oct;40(10):2773-80.
  5. Dujardin KS, McCully RB, Wijdicks EFM, et al. Myocardial dysfunction associated with brain death: Clinical, echocardiographic, and pathologic features. J Heart Lung Transplant 2001;20;350.
  6. Godino M, Lander M, Cacciatore A, et al. Ventricular Dysfunction Associated with Brain Trauma is Cause for Exclusion of Young Heart Donors. Transplantation Proceedings.2010. 42,1507-1509.
  7. Personal Correspondence, Susan Galbraith 10/30/2012 Region 11, DMG 1012 YTD Summary
  8. Venkateswaran RV, Townend JN, Wilson IC, et al. Echocardiography in the Potential Heart Donor. Transplantation.2010 Apr:89(7): 894-901.
  9. Inaba K, Branco BC, Lam L, et al. Organ donation and time to procurement: late is not too late. J Trauma. 2010 Jun;68(6):1362-6.
  10. Abdelnour T, Rieke S. Relationship of Hormonal Resuscitation Therapy and Central Venous Pressure on Increasing Organs for Transplant. J Heart Lung Transplant. 2009:28:480-485.