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Purpose Primary graft dysfunction (PGD) continues to be a potentially life-threatening early complication of heart transplantation despite advances in treatment options. PGD rates in the UK are about 36% and is the leading cause of 30-day mortality. The current ISHLT definition includes a severity scale for biventricular PGD. Our aim was to ascertain if the severity of PGD influences survival post-transplantation. Methods A retrospective review all adult patients who underwent heart transplantation between 1 October 2012- 30 September 2016 in the 6 UK heart transplant centres. The cohort of patients was divided into 3 groups based on PGD severity; mild, moderate and severe PGD respectively. Time to event survival analysis was performed with all-cause mortality as the outcome measure. Multivariable Cox regression analyses were used to measure the associations between the groups and all-cause mortality after adjusting for potential confounders: recipient age, donor age, gender, warm ischaemic time, recipient diabetes mellitus, and donor-recipient gender mismatch and size mismatch. Kaplan-Meier curves were used to show survival analysis. Risk estimates were presented as hazard ratios with 95% confidence intervals. Log-rank tests were performed to compare survival curves. Results for all analyses were deemed statistically significant at p-values <0.05. Results A total of 221 patients (73% male) were included; 11(5%) in Mild PGD, 101(46%) in Moderate PGD and 109 (49%) in severe PGD. The mean age of the recipients in the study was 46.8±13.2 years. Independent predictors of 5-year survival were recipient diabetes mellitus (HR 3.0 (CI 1.8-5.1) p<0.05), Male Donor: Female recipient (HR 2.5 (CI 1.08-5.6) p<0.05), and PGD severity (HR 4.8 (CI 2.8-4.1) (p<0.05)). Conclusion Although the recovery of cardiac function post-PGD is possible using a combination of inotropes or mechanical assist devices, it still confers a poorer survival at up to 5 years. PGD severity affects outcomes post heart transplantation. [ABSTRACT FROM AUTHOR]

Purpose Around 2000 heart transplants are performed in Europe annually. Primary Graft Dysfunction(PGD) rates in Europe are among the highest in the world. The increasing use of marginal donor organs has been suggested as a potential cause. Novel techniques using ex-vivo normothermic perfusion have garnered increasing interest but incur a significant cost. We present a series of patients who underwent heart transplantation at our unit using a novel implantation technique to reduce PGD that is cost-effective and reproducible Methods The donor heart is removed from cold storage and placed in an ice slush basin on arrival to our unit. An aortic cross clamp is applied distal to the donor ascending aorta. An antegrade infusion of 600mls of cold blood cardioplegia is followed by cold oxygenated blood (4-6°C) to achieve a mean aortic root pressure of 60-70 mmHg. This continuous antegrade perfusion is maintained throughout the left atrium and aortic anastomosis with a left ventricular vent in situ. A warm cardioplegia hotshot is infused into the aortic root prior to removal of the recipient aortic cross-clamp. The remaining anastomoses are carried out in the usual fashion sequentially. We compared our experience with this method with the national UK cohort (2015-2016) of patients (Control Group). We performed multivariable logistic regression comparing the two cohorts with PGD as the primary outcome measure. Confounders adjusted for include donor age, recipient age and donor-recipient gender mismatch. Results 139 (71.6 %) patients were male. 46(18.6%) of the patients had ischemic cardiomyopathy. The odds ratio of PGD in the control group was 2.99 (95% CI 1.02- 8.75) when compared to the Extended Cooling. Conclusion This novel approach is associated with significant reductions in PGD rates post-transplantation likely due to the shorter warm ischemic time. Larger studies are needed to show differences after further adjustment for known confounders of PGD. We believe this novel technique is safe, cost-effective and reproducible. [ABSTRACT FROM AUTHOR]

The severe acute respiratory syndrome coronavirus (SARS-CoV-2) pandemic has caused widespread changes to healthcare practice. Demand on capacity, concerns for transplant recipients, including the risks of nosocomial infection, and the availability and safety of donors, lead to continuation of transplantation for only urgent and super-urgent, in-patient candidates, in the UK from March to May 2020. The aim of this study is to evaluate the impact of these practice changes on heart and lung donor utilisation during the pandemic period. Data on all adult and paediatric heart and lung donors offered, and transplants performed, between 1 March and 30 September 2019 and 1 March and 30 September 2020 were obtained from the UK Transplant Registry. The early pandemic period is defined as 1 March to 31 May 2020. Ideal lung donors are defined as age <56 years and no smoking history. Lung transplant activity during the early pandemic period fell by 77% (13 transplants compared to 56 in 2019). Heart transplant activity fell by 10% (38 compared to 42 heart transplants in 2019). The number of donors, who donated at least 1 solid organ, fell by 51%. The lung donor utilisation rate during the early pandemic period was 11%, compared to 24% for the same period of 2019. The heart donor utilisation rate during the pandemic period was 35% compared to 26% during the same period of 2019. The proportion of ideal lung donors, from donors where lung(s) were offered, was 23% in 2020 compared to 24% in 2019. Following the early pandemic period (1 June to 30 September 2020), there has been an increase in the number of lung donors, lung transplant activity and utilisation, rising from 11% in March to May to 14% in June to September. This compares with a utilisation rate of 21% for the same period of 2019. During the SARS-CoV-2 pandemic, changes to practice led to the continuation of heart transplantation, with minimal impact on activity, whilst lung transplant activity fell. The number of organ donors fell, while the 'quality' of potential lung donors remained unchanged. As the evidence base guiding clinical practice is evolving, along with improved donor testing, lung transplant activity is again increasing, however the utilisation of donors remains lower than in 2019. On-going analysis of activity is required to fully assess the impact of the SARS-CoV-2 pandemic on the UK lung transplant population. [ABSTRACT FROM AUTHOR]

The impact of donor and recipient age on outcomes following heart transplantation remains controversial. The aim of this study was to evaluate the impact of donor and recipient age on 5-year survival following heart transplantation in the UK Data were extracted from the UK Transplant Registry held by NHS Blood and Transplant on 3192 adult (≥18) DBD heart transplants in the UK between 1995 and 2018 inclusive. Donors and recipients were divided into 3 age groups (18-40, 41-50, 51+ years) for analysis. Kaplan-Meier survival curves and Cox-proportional hazards models (adjusted for donor cause of death, donor BMI, recipient BMI, creatinine, VAD status, primary disease, sex mismatch, ischemia time, and OCS use) were used to estimate the effect of recipient and donor age on 5-year patient survival and survival conditional on 90-days The overall median recipient and donor age was 50 years and 38 years, respectively, with donor age increasing over time Un-adjusted analysis showed a significant difference in 5-year survival for both donor and recipient age groups, p<0.001 and p=0.005, respectively. After excluding patients who died within 90-days of surgery there was no longer a difference in outcome (Fig 1) Donor age, but not recipient age, was a predictor of inferior 5-year survival once added to a risk-adjusted model (p=0.008). A recipient receiving a heart from a donor aged 51+ had a 1.2 times higher risk of death than a recipient receiving an organ from a donor aged <40. After removing patients that had died within 90-days of transplant from the model, there was no longer a significant difference, indicating that the effect of donor age is only important short-term We have demonstrated that donor age is a statistically significant variable in modelling post heart transplant survival at 5 years. However, once a patient has survived the first three months post-transplant, donor age no longer significantly impacts on longer-term outcomes [ABSTRACT FROM AUTHOR]

Primary Graft Dysfunction (PGD) is the leading cause of early mortality after heart transplantation. Several risk factors of PGD have been identified, including; prolonged warm ischaemic time, advanced donor age, gender mismatch and recipient diabetes mellitus. We adopted a novel method of implantation using "antegrade myocardial perfusion (AMP)" during implantation and compared this to the conventional approach. We obtained the retrospective data retrospectively from the Golden Jubilee National Hospital heart transplant database, ClinicalPortal and CIS databases from January/2012-May/2018. Missing data were obtained from the hard copy case notes. We performed AMP utilising continuous cold blood (4-6°C) antegrade cardioplegia to achieve aortic root pressures of 60-70 mmHg. Leucocyte filer was utilised. The infusion would continue with an LV vent insitu until the left atrial and aortic anastomoses were complete. "Hotshot" warm blood was then infused prior to removal of the cross clamp. Multivariable logistic regression with moderate/severe PGD as the outcome measure. Confounders were adjusted for recipient age, total ischaemic time, bypass time, predicted left ventricular (LV) mass mismatch, recipient diabetes mellitus and donor age. A total of 75 patients were included in this study. 44% (n=33) underwent AMP and 56 % (n=42) had orthotopic heart transplantation with the conventional approach. There was no statistically significant difference in age, gender, incidence of diabetes mellitus, preoperative utilisation of mechanical circulatory support between the AMP and the control group. We found that total ischaemia time was significantly shorter in the AMP cohort (154+/-50.2 vs. 181+/-47.1 min, p=0.018). The rate of postoperative VA ECMO support was significantly lower in the AMP cohort (15% vs. 54%, p<0.001). The rate of moderate-severe PGD was significantly lower in the AMP cohort (21% vs. 69%, p<0.001). The odds ratio of PGD in patients in the historical cohort vs AMP was 4.15 (1.21-14.24). Our implantation technique utilising AMP significantly lowers the rate of moderate and severe PGD when compared to the standard implantation technique employed by the historical cohort. [ABSTRACT FROM AUTHOR]

Purpose Donor right ventricular (RV) function is difficult to assess prior to organ retrieval. The RV is also subjected to a multitude of insults post brainstem death which may be exacerbated by prolonged ischaemia prior to implantation. To date, there is no consensus on a method to accurately evaluate RV function in a transplant cohort. We propose using the 'step-up'(Mean Pulmonary Arterial Pressure - Right Atrial Pressure) pressure as a tool to evaluate donor RV function. Our aim was to study this association and the incidence of Primary Graft Dysfunction Methods A retrospective review all patients who underwent heart transplantation between June 2010-October 2018 at our centre. We identified 92 donors who had invasive haemodynamic monitoring prior to retrieval at the donor hospitals. The primary endpoint for the study was ISHLT-defined PGD. We stratified the cohort into 2 categories of step-up pressure<10mmHg (reference category), Group 2: >10mmHg. Multivariable logistic regression analysis was performed to calculate the odds ratio of developing PGD in Group 2 compared to Group 1. Potential confounders adjusted for were donor age, donor inotrope score, warm ischaemic time, recipient pulmonary vascular resistance, donor-recipient gender mismatch and preoperative mechanical circulatory support in the recipient. Results The mean age of donors was 39.4±12.2years. There were 41(44.6%) female donors. The median age of recipients was 46.6±11.7 years. The incidence of PGD was 36(39%). Conclusion The step-up pressure is not a predictor of PGD in our cohort. Donor age and warm ischaemic time were both associated with PGD [ABSTRACT FROM AUTHOR]