SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact. SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field. In recent years, we have been observing a decrease in the number of heart transplantations being performed in Spain, despite the annual increase in the organ donor pool. The expectations of an increase in this type of transplantation have been frustrated and, in the past 2 years, it has been impossible to overcome the barrier of interventions.
A recent report of the activities of the Spanish National Transplant Organization states that the number of patients included each year in the list is greater than the number of transplantations performed, a situation that prolongs the time spent on the waiting list and reduces the probability of a patient undergoing transplantation within the year of inclusion in the list. The theoretical stability in mortality while on the waiting list may not be real, since it does not consider the deaths of patients who are excluded due to the deterioration of their clinical condition while awaiting transplantation.
We also should take into account the fact that the acknowledgement of the scarcity of donors limits the entry into the program of patients with end-stage heart disease who could benefit from this technique.
We performed a descriptive, retrospective study that included all the organ donors in a tertiary hospital, with an active heart transplant program, over 10 consecutive years Men under 50 years of age and women under 55 were considered to be potential heart donors. Finally, to consider a heart donor suitable, we required a normal echocardiogram and a normal heart when inspected at surgery. The echocardiogram was performed by the cardiology service of our hospital.
The criteria for donor acceptance and maintenance remained unchanged throughout the entire study period.. The causes of brain death were grouped as follows: head injury HI , intracranial hemorrhage ICH secondary to ruptured aneurysm or vascular malformation, cerebral hemorrhage of some other origin or stroke, and others anoxic encephalopathy, poisoning.
The causes for initial exclusion from donation or subsequent rejection for implantation were analyzed. The reasons for exclusion were grouped according to four factors: history of heart disease, echocardiographic findings, surgical findings and logistic problems lack of a recipient due to size or blood group incompatibility.. As the study is retrospective, their smoking history could not be analyzed.. The cause of death was HI in 33 cases, ICH in 32, stroke in 58, anoxic encephalopathy in 5, and methanol poisoning in The causes of brain death in this subgroup were HI in 26 cases, ICH in 24, stroke in 14, anoxic encephalopathy in 4, and methanol poisoning in 1.
Figure consists of a flow chart illustrating the different reasons for exclusion from heart donation up until the final selection. Thirteen potential donors were excluded because of a history of heart disease or cardiac risk factors, 4 of them due to cardiac arrest secondary to heart disease, 4 because of hypertensive heart disease, 2 because of long-standing type 1 diabetes, 2 because of valve disease, and 1 because of his or her medical history. There were 3 exclusions for logistic reasons, 2 due to a considerable disproportion between the size of the donor and the possible recipients and 1 because there were no recipients with the same blood group.
Table 1 shows the percentage of selected donors according to cause of death, as well as the characteristics that differentiate these donors from those who were excluded, and Table 2 shows the causes for exclusion according to the origin of brain death.. Flow chart showing heart donor selection from detection to donation.. There were no significant differences in the incidence of ventricular dysfunction when the subgroups were compared in terms of the different causes of brain death Table Twenty-nine organ donors were between 1 and 10 years older than the established age limit.
Two of them were considered for donation without performing any additional diagnostic test, such as coronary arteriography a year-old man and a year-old woman , and another 4 presented no known cardiac risk factors, but were ruled out because of their age. The remainder had been diagnosed as having heart disease or 1 or more cardiac risk factors. Table 3 shows the causes of death and the heart disease risk factors in this group. The data of the 2 donors who were accepted are included with those of the selected donors.. The most common causes for exclusion were a history of heart disease and myocardial dysfunction, the latter probably associated with brain death..
Eighteen percent of the young donors with no history of heart disease presented severe abnormalities in myocardial contraction, probably related to the hemodynamic and neurohormonal changes that take place during brain death. Thus, the ventricular dysfunction associated with brain death appears to be one of the most common reasons for excluding donors.
If it were possible to prevent, disregard or reverse this process, the donor pool would increase considerably.. With regard to prevention, although there are experimental studies on the myocardial protection provided by sympathetic block, its clinical application is very difficult and highly debatable. Only in those cases in which the brain death of the patient is inevitable and we observe the catecholamine storm in situ could the use of drugs with a short half-life, like esmolol, theoretically reduce myocardial injury.. With respect to the possibility of disregarding this problem, the use of hearts with abnormal myocardial contraction does not appear to be a valid option at the present time.
Although there are studies that point out that the transplantation of hearts presenting ventricular dysfunction may be feasible under certain circumstances, most authors recommend that their utilization be avoided. In the largest study published to date, ventricular dysfunction was shown to be an independent factor, unrelated to age, of early recipient mortality. The most interesting aspect for study is probably the reversibility of this ventricular dysfunction.
The ventricular dysfunction associated with brain death may be included among the causes of stunned myocardium and, thus, would potentially be reversible, as has been demonstrated in other entities, such as subarachnoid hemorrhage, 21 HI, or transient apical dysfunction. In their work, 13 of the 16 heart donors initially excluded due to ventricular dysfunction recovered ventricular function within a variable period of time and, subsequently, their hearts were successfully transplanted.
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For this reason, it would be useful to have tests that could be performed in every potential donor to discriminate between irreversible injury and stunned myocardium. The presence of electrocardiographic changes does not appear to be sensitive or specific enough. For example, an enhancement of contraction after stimulation with dobutamine may identify contractile reserve in dysfunctioning zones and, thus, distinguish stunned myocardium from necrotic myocardium, as is suggested by Kono et al 25 in a series of 7 brain-dead individuals.
The determination of enzyme markers of myocardial injury may also help in decision making. Riou et al 26 demonstrated the validity of troponin T and the lack of reliability of creatine kinase and its MB isoenzyme. Elevated troponin T or troponin I, in association with changes in myocardial contraction, may indicate irreversible injury or, at least, injury that is not reversible within a reasonable period of time.
Given these findings, and until new data is provided, we recommend the following management strategy:. Prolong the interval between the performance of the echocardiogram and brain death to the greatest possible extent.
With the coming into effect of the new legislation on transplantation, which will make it possible to shorten the time required for the diagnosis of brain death, a doubt has arisen in our minds: is this faster pace in the donation procedure leading to an increase in the detection of ventricular function?
In our series, 8 of the 11 cases of exclusion due to ventricular dysfunction data not shown were detected from the year on. Moreover, we recently had a case in which heart donation was ruled out because of severe systolic dysfunction, detected after performing an echocardiogram 30 minutes after brain death; 4 hours later, during lung harvest, completely normal contraction was observed visually..
Perform the echocardiogram when the hemodynamic condition of the donor is stable, with a mean arterial pressure of at least 70 mm Hg. Szabo et al 23 demonstrated that maintenance of the coronary perfusion pressure is the most important factor in reversing ventricular dysfunction. To achieve this objective, it is sometimes necessary to administer dopamine or, preferably, noradrenaline.
We have shown that the use of high doses of catecholamines plays no role in early graft failure. Determine troponin T or I systematically to assess the myocardial injury produced during brain death. Dujardin et al 11 demonstrated that the majority of the hearts presenting ventricular dysfunction showed no microscopic changes in the pathological examination. The finding of normal or nearly normal troponin levels, in the presence of echocardiographic changes, may be indicative of minimal structural damage and justify delaying the decision as to whether to proceed with the harvest for a few hours and repeating the assessment..
A second strategy that could increase the donor pool would be to widen the age range. There are published studies that demonstrate the utility of older donors. The heart of the older donor presents morphological changes hypertrophy, valve sclerosis, increased collagen and lipid contents, mitochondrial calcifications , functional changes decreases in the number and response of beta-adrenergic receptors and an increase in the incidence of coronary artery disease.
Thus, the acceptance of donors of this type would almost inevitably involve the performance of coronary arteriography to rule out the presence of coronary artery disease. The potential increment in the donor pool that widening the age range would produce is not known, but we should remember that this diagnostic test is not available in every center or on a hour basis. Thus, we consider that donors of this type could only be accepted by centers with heart transplant programs in which the recipients have a long wait.
Causes and forms of social exclusion
It has been demonstrated that the risk of death associated with the transplantation of an organ from an older donor is lower than that associated with a prolonged wait. The progressive increase in the number of requests for primary angioplasty received in the catheterization laboratories represents an opportunity t o study the possible increase in the heart donor pool through this channel..
One of the most attractive fields of study involved in the attempt to increase the heart donor pool is that focusing on individuals with ventricular dysfunction secondary to brain death or to previous severe brain injury. It is difficult to calculate the probable increment in the number of transplantations that would result from their utilization. We need a nationwide registry that reflects the incidence of this problem, as well as studies that clarify the aspects that play a role in their detection and their potential reversibility. See editorial on pages Correspondence: Dr.
Servicio Medicina Intensiva. Hospital Puerta de Hierro. E-mail: cchamorro. Accepted for publication November 17, Home Articles in press Current Issue Archive. ISSN: Previous article Next article.
Issue 3. Pages March Download PDF. This item has received. Article information. TABLE 1. TABLE 2. TABLE 3. Show more Show less. Introduction and objectives. A shortage of heart donors is limiting the expansion of transplant programs. Our aims were to investigate the impact of different heart donation exclusion factors and to examine ways of increasing the donor pool.
Patients and method. We carried out a retrospective descriptive study of individuals donating organs at a university hospital over a ten-year period. Males under 50 years of age and females under 55 years were regarded as potential heart donors.
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We recorded the etiology of brain death, initial heart donation exclusion factors, and later reasons for rejection. The site is secure. Mandatory exclusions: OIG is required by law to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, SCHIP, or other State health care programs; patient abuse or neglect; felony convictions for other health care-related fraud, theft, or other financial misconduct; and felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances.
Permissive exclusions: OIG has discretion to exclude individuals and entities on a number of grounds, including but not limited to misdemeanor convictions related to health care fraud other than Medicare or a State health program, fraud in a program other than a health care program funded by any Federal, State or local government agency; misdemeanor convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances; suspension, revocation, or surrender of a license to provide health care for reasons bearing on professional competence, professional performance, or financial integrity; provision of unnecessary or substandard services; submission of false or fraudulent claims to a Federal health care program; engaging in unlawful kickback arrangements; defaulting on health education loan or scholarship obligations; and controlling a sanctioned entity as an owner, officer, or managing employee.
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To avoid CMP liability, health care entities need to routinely check the LEIE to ensure that new hires and current employees are not on the excluded list. The effects of an exclusion are outlined in the Updated Special Advisory Bulletin on the Effect of Exclusion From Participation in Federal Health Programs , but the primary effect is that no payment will be made for any items or services furnished, ordered, or prescribed by an excluded individual or entity. This includes Medicare, Medicaid, and all other Federal plans and programs that provide health benefits funded directly or indirectly by the United States other than the Federal Employees Health Benefits Plan.