EISOR Delivery: Regional experience with sharing equipe, equipment & expertise to increase cDCD donor pool in time of pandemic

Abstract

Donation after circulatory death (DCD) programs are expanding in Europe, in the attempt to expand donors pool. Even in controlled DCD donors, however, a protracted warm ischemia time occurring in the perimortem period might damage organs, making these unsuitable for transplantation. Implementing a strategy of extracorporeal interval support for organ retrieval (EISOR), a regional reperfusion with normothermic, oxygenated blood provides a physiologic environment allowing extensive assessment of potential grafts, and potentially promotes recovery of native function. Here we report the results of a multi-center retrospective cohort study including 29 Maastricht Category III controlled DCD donors undergoing extracorporeal support in a regional DCD/EISOR Training Center, and in the network of referring In-Training Centers, under the liaison of the regional Transplant Coordination Center during COVID-19 pandemic, between March 2020 and November 2021. The study aims to understand whether a mobile, experienced EISOR team implementing a consistent technique and sharing its equipe, expertise and equipment in a regional network of hospitals, might be effective and efficient in implementing the regional DCD program activity even in a highly stressed healthcare system.

Transesophageal Ultrasound-Guided Normothermic Regional Perfusion in Controlled Donors After Cardiocirculatory Determination of Death

“…We introduced TEU-assisted EISOR in a network of hospitals with an extensive experience in cDCD organ donation 9,15 in April 2022 to decrease the requirement for radiography/fluoroscopy and to enhance the ability to properly position EBOA and monitor the effectiveness of aortic occlusion. As the expertise of intensivists increased, the technique was adapted to A-NRP specificity.…”

“…To avoid any potential conflict of interest, even if the law does not require this, the EISOR team is not involved in WLST, in charge of the caring intensivists and nurses, nor in organ procurement, which is in charge of a dedicated procurement team. Detailed roles and boundaries have been previously described by our group 9,15 and are summarized in Supplementary Table 2 (Supplemental Digital Content 5, http://links.lww.com/ASAIO/B83).…”

“…The drainage cannula is advanced over the guidewire until the tip reaches ICAJ (Figure 3; Supplementary Video 3); then the guidewire is removed. A pronounced SEC is to be expected; the administration of unfractioned heparin (UFH) during WLST 1,9 should prevent the development of thrombosis, which impairs the feasibility of postmortem EISOR. Detecting small clots should alert the team, as these could be suctioned into the cannula at the initiation of reperfusion, eventually inducing an acute circuit thrombosis (Supplementary Video 4).…”

“…In fact, A-NRP may decrease the duration of total warm ischemia time (tWIT) and allow for the evaluation and procurement of grafts to be performed in a near-physiological environment. [2][3][4][5][6][7] We aimed to describe our transesophageal ultrasound (TEU)-guided technique to implement A-NRP according to a peripheral femorofemoral configuration of venoarterial extracorporeal life support (ECLS), 1,8,9 preventing coronary and cerebral reperfusion through endovascular balloon occlusion of the aorta (EBOA). 1,9,10 After assisting in the anatomical and physiopathological assessment of central vascular structures, TEU guides the insertion of guidewires and EBOA in real time.…”

“…[2][3][4][5][6][7] We aimed to describe our transesophageal ultrasound (TEU)-guided technique to implement A-NRP according to a peripheral femorofemoral configuration of venoarterial extracorporeal life support (ECLS), 1,8,9 preventing coronary and cerebral reperfusion through endovascular balloon occlusion of the aorta (EBOA). 1,9,10 After assisting in the anatomical and physiopathological assessment of central vascular structures, TEU guides the insertion of guidewires and EBOA in real time. Moreover, TEU allows us to verify the proper positioning of a venous cannula and EBOA.…”