Rohan M. Goswami, M.D., heart transplant physician at Mayo Clinic, presents on donor selection strategy at Mayo Clinic as it relates to heart transplantation. He discusses the importance of understanding donor and recipient qualities that portend a positive outcome and prolonged graft survival, what to look for in an "ideal donor," optimally using donors, donor and recipient matching, and more.
and there that, um, will be, um, doing our 18th North Florida car developer Symposium conference this year, of course, will be very 12 due to the pandemic. Um, it will be a half a day of virtual conference. Um, you might have received already an email or a brochure out. This conference will be done on Saturday, April 17th, 2021. It's a virtual modality. Will be, uh, providing CMI and CEO credits. The speakers are phenomenal, and the registration for physicians is $100 for, Ah, nurses texts. Um, it will be $50 but if you get a physician to register you, you can register for free. So any of the mid levels that might be on the call you can get registered for free for this virtual conference if you get your physician to register for free. So, um, get them involved and we're hoping to have I got 250 participants, which is what we have had in the live conference as well perform, um at U N F. In the past, we used to have them in Pontevedra used to be called the Pontevedra Card, the wild card symposium for 17 years. And then, uh, we transitioned to u N f a couple of years ago. University of North Florida. So, um, again, due to the pandemic we canceled last year. But this year we will be virtual. It's just half a day or a Saturday, and again, you can register at any time. You should have received a brochure, um, or the email with the link. And hopefully we'll get to see you guys there. Also, our electrical series goes from the it follows the academic year for the social programs. So it will end in June. Uh, will restart again. I believe in, um, August. Um, but if you have any particular topics that you would like to discuss in the future, please let us know. Uh, we'll try to arrange some of the lectures for next year. Well, some of them will be repeated. I definitely would like to have your input and see if there's any lectures that we might be able to cover as well as, um, your own clubs. Um different, um, articles that you guys might want to discuss during or monthly your own club. And finally we would like to have your input in terms of case, the cases that we can discuss, we'll try to do those, um, at least every trimester where we can discuss real cases that many of you have referred here to me, you or that we have, uh, co manage. And definitely those are always interesting cases to kind of look at real world practice. So we know further delays. We have Dr Goswami onboard, and, uh, he'll be talking about, um, donor selection strategies. So we no further delays? Uh, romantic over. All right, everybody thinks for the patients. My computer has given me some technical difficulty sharing my screen, so hopefully everybody should be able to see it now. Morning, everyone. So happy march. Hopefully spring will bring some better weather. We're going to talk a little bit about donor and recipient matching in heart transplantation today in the goal is to kind of understand what the role of the donor and the recipient qualities are that pretend a positive outcome with, ah, with heart transplantation. And so just an interesting fact of the day. Wilt Chamberlain set the record for scoring 100 points today in 1962. Sadly, it wasn't televised. There's no video of it, but they 169 246. All right, so what makes up an ideal donor? So when we think about an ideal donor, there's multiple qualities that we need to look for. These are kind of the the standard qualities that I s h l t you nose and heart failure societies and transplant societies across the world. Look for obviously looking for the age of the Joan er gender to see if there is a mismatch. Height and weight and BMI have been kind of the ideal targets for matching patients in the past. And then we're looking at their ratios of that What the left ventricle looks like, what the right ventricle looks like, um, and then the grams of the heart to see if it'll fit within the donor cavity. Arabic roots size caused the death for the donor. And then any prior medical history, that may be significant for us to look at. And so one thing that we definitely do no is that donor risk factors have been shown to really affect recipient outcomes, which is kind of an interesting, uh, way to think about things because now you're managing a new organ and new patient and also dealing with that patients prior histories and so traditionally what we'll look at our height and weight and gender. Um, And then there's new criteria that have come about in the last 5 to 10 years, uh, regarding extended criteria, donors, new organ allocation policies and how we can optimally utilize donors. And then now, in the 21st ah, century, we're looking at D. C D vs DVD donors, meaning donation after circulatory, death or donation after brain death and last week's talk for the journal club focused on D. C. D. And we'll touch a little bit on that today as well. So if anybody ask questions during the talk about things that were discussing, please feel free to chime in. So when we look at S. H L T. The International Society for Heart and Lung Transplantation, we look at their approach to donors starting number of years ago and looking when the first guidelines were generated, there was an official donor assessment and selection statement created in 2000 and six, and then they updated in 2017, and there's an increased scrutiny on the quality and health care with particular emphasis in heart transplant survival outcomes and an important aspect of successful transplant is appropriate donor selection. And that comes directly from S H L T. And I think that really hones in on the point of the impact that a donor heart or a donor's history really makes on the recipient survival. And so the two central concepts that I like to think about before we go into the nitty gritty of the data behind donors is it is divided this way and the quality of the donor. So thinking about the age of the donor, the function of the donor and how that function has changed since they've been listed as an organ donor. And how far that organiz and then also are we meeting the needs of the recipient. So is it a size match? Are their antibody incompatibilities that we need to worry about and the ischemic time for the donor, and then also that includes the ischemic time or the bypass time for the recipient? And so these are slides taken from the S H L T 2020 update, which was published in October, and so when we look at adult heart transplants in the United States or in Northern America specifically, Um, we have, um, donors that have a history of smoking, and we can see that the amount of the percentage of donors with smoking history has declined, Um, right between 10 to 15%. And so I think what that tells us is one we're doing a better job of not smoking, but to, um the the quality of donors has improved. And then the donors history of alcohol kind of staying stagnant over time. And so when we look at two other complicating factors whenever we see patients currently, especially with the increase in other non um you know, um, illicit drug use cocaine has still only seen a rise in the number of transplant donors and, not surprisingly, donors that are using opiates such as, um, you know, narcotics and sedatives and hypnotics and then also marijuana is now included in this other drug. History has climbed significantly, so more than half. And I think if you look at the 2020 2019 preliminary data, it's almost two thirds of our patients, about 65% that actually have marijuana, narcotics sedatives or hypnotics in their blood when they're they're evaluated to be a donor. And so we have to kind of think about the short and long term effects that those drugs have on the heart. Um, and also on the ability for donors to stay stable, optimized and travel Well, um, and so one of the things that we don't know, especially with cocaine and now with some of these stimulants in marijuana, is how that affects the micro vascular structure of the donor. And so when we're assessing donors, we have echoes. We have Catholics, we have CT scans, et cetera. And the question is, how does this affect structures that we can't look at? And so the microvascular bed is something that we're really concerned about, especially in patients that have renal failure or platelet dysfunction, or in D i C. Because those organs, if they're put on traditional um transport processes and are put under ice and kept cool, sometimes can have microvascular dysfunction. Or, um, you have Stasis of blood flow and then re perfusion injury that can cause a lot of dysfunction in the in the in the recipient later on. And so, if we look at the survival in patients based off of their age. You know, one of the things we would say is, Okay, you shouldn't take an older donor because the heart is going to be really old and you're going to put it in somebody that's young. And if you look at it, the one year survival, Um, for older donors above age 50 ah is actually around 75% 77%. Uh, if you look at donors that are kind of middle aged, the survivals around 85%. And if you look at the one year survival in donors that are even less than 35 years old, their survival is below 90%. And so obviously there's a big difference there. It's definitely significant from a statistical standpoint, but one thing that we have to think about that's not elicited in this side is what are the qualities of these donors that were taken or a lot of them high risk or a lot of them far away. Um, and where is there a complication because of the recipient that may have led to this mortality? Um, And so then we look at the donor cause of death and the donor left ventricular ejection fraction. And so this is looking at five year outcomes now. So this is this slide. So all the patients that made it one year Now we look at those patients that are making it five years, and so both the left side is significant. The right side is significant, but not, um uh, not as strong. And so when we look at the cause of death in the donor, we look at anoxia, CVR, stroke and then head trauma. And some of these may overlap. Um and so it's not a perfect picture, but you do see that the survival hovers around 85%. And I think that that's something important to think about from a cardiologist standpoint, is when we do cardiopulmonary exercise, stress testing, and we do evaluations for heart transplantation. One of the things we look at is what is the one year what is the three year what is a five year benefit of considering heart transplantation in a patient who may be a candidate and so if they're five year survival is less than 80% then I think that it's something to consider, um, reasonable that they may have a better five year survival if they are able to undergo transplant and survived the first year. And we know that if they survived the first year, most likely the long term survival is is better. Um, and then the other thing we can look at is donor ejection fraction. And so there's quite a few institutions. If you look at the national data that's available, it will take a donor ejection fraction that's hovering between 45 50% reported in our data that we get is ejection fraction less than 60%. And so there are quite a number of centers that will take ejection fraction of less than 60%. Uh, and a lot of times have stable outcomes in patients who may not receive an organ that has a normal ejection fraction but is likely to be better than their severely reduced or less than 10% or somebody on ECMO to survive kind of situation. Um, and so if you look at this, the survival for ejection fraction greater than 50% mimics that of the donor cause of deaths right around 85 88% ejection fraction less than 50%. Although you can see it's much smaller number, Um, the survival is closer to 80%. And so I think when we're selecting donors, one of things you have to think about is what's the likelihood that this Oregon is gonna give a five year survival? Uh, and what's the likelihood that there's going to be, uh, a significant issue as far as, uh, in hospital stay icy length of stay and and multiple complications within the first month? And so just a few factors among many for donors that are important that we need to think about, too, is, um, you know, donor age has been proven as an independent predictor of mortality, and we kind of showed that, um, the older you are, the more likely you are to have complications within the first year or, you know, potentially 30% chance of not surviving for donors above 40 or 50 years old and the donor quality. So a lot of times, the initial echo will be due to stunning or hypertension or, you know, insufficient resuscitative measures. There may be a drop in the ejection fraction of 35% or there may be some wall motion abnormality. And so a lot of times we look at that echo versus the echo done 24 hours after they were declared brain dead. Um, And then, you know, obviously the troponin trend to see was the the accident that occurred from a cerebral vascular standpoint significant enough to spill them. A large amount of proponents. And does that indicate there may be some underlying microvascular disease or some myocardial dysfunction that may not be demonstrated on an echo? Um And then, of course, if there's trauma, we want to avoid trauma to the chest cavity that would affect the right ventricle, especially lung contusions, causing hypoxia that may affect myocardial perfusion as well. And then the stability and the support of um, the donor is important. There's a lot of times things that will happen on the donors, donors and such as, you know, patient having acute renal failure, um, and, um, allowed to be hypertensive because of the cerebral profusion that needs to be maintained. Um, volume overload and the need for initiating dialysis and all of these things we have to take into account because those costs surrogate changes within the organ that we're interested in. You know, if you have an elevated right sided filling pressure at the time of X plantation of an organ, um, the likelihood of it to survive transport over a long period of time in a cooled situation isn't as great as if somebody who had a normal filling pressure. One of the biggest things that we worry about is right ventricular function after transplantation. You know, if you think about the right ventricle, kind of like a big vein, you want to be able to support that as it gets product transfusions while they're waiting from bypass and being able to support to fill the left ventricle. So there's a lot of factors that come in from the donor standpoint that really need to We need to look at and so so far. What if we kind of we've talked about? So we've talked about donor age. We've talked about smoking status. You know how long they've been smoking? Um, we've talked about other factors and how they're impacting the one in five year outcomes and then looking at organ utilization, you know, cocaine and alcohol and donor. Cause of death may not be as impactful as we previously thought. It's possible that the effect of alcohol may have been over over analyzed in the past and a lot of patients who had high alcohol use we were concerned about potential myocardial dysfunction. But over the last decade, my alcohol use has kind of stayed the same. Um, cocaine use is on the rise, and so that's a concern as far as micro vascular disease and then same with the donors cause of death. And so what are the other things that we look for? Right? So we talked about the echocardiogram. Now it's really important to think about how much support the donors on at the time of the echocardiogram and that goes directly hand in hand with the cause of death for the donor. And so, if the donor has a significant neurological insult or spy nickel transaction or some sort of an economic issue, they may require a higher vase oppressor or in the tropics support in order to maintain normal profusion to support the other organs, because those are also potentially transplantable. And so if the if the donor is on less than 10 mics per kilogram per minute of w demean or dopamine or less than 0.5 of leave a fed or norepinephrine and I s H L T and you knows, feel that those are considered low or minimal support. And so organs can be considered usable if their ejection fraction is acceptable on that support. The other things that we know our age greater than 40. If they have a smoking history, if they have an unknown cause of death or they have significant diabetes. Um, and then now adding to that cocaine use is we're going to request a cardiac cath. And the one thing we have to think about with cardiac catheterization is, you know, quality of the study that's being done, engagement of the coronaries and then also, um, the amount of support the patients on during that catheterization because that may affect the filling pressures that may affect my cardio counter activity. And and sometimes we're actually even with those characteristics, making the patient at high risk for coronary disease, we actually may not have the ability to do a cath, and so a lot of times we have to decide if the risk of going to that donor site is it worth it. And then the other circumstantial factors that I kind of touched on a few slides ago are, you know, the need for renal replacement therapy, volume overload affecting the right and left ventricles. Pulmonary hypertension affecting the performance of the right ventricle in the acute setting, especially if there's concern for trauma and potential for undiagnosed or underwhelmed pulmonary embolism. Burden. Uh, those all may affect the quality of the right ventricle, either coming on to bypass or coming off bypass and then the transfusion requirements of the donor. You know, one thing that's important to remember is that transfusions are directly toxic to the right ventricle. A lot of the preservatives and the situate as well as the volume itself. Ah, and the calcium load really affect the right ventricles ability to tolerate longer ischemic times and higher pulmonary pressures in the recipient, and so so kind of factors to keep in mind when we're looking at donors. The other thing is, uh, you know, what's the donor location? Are they down the street or are they 2000 miles away? I need to flight. That's going to take four hours. Um, are there taller or shorter than the recipient. And, you know, it should be less no less than 30% lighter than the than the recipient. There are multiple studies that have shown that 70% is kind of the cut off for weight. Um, there was a beautiful study done about four or five years ago that looked at the 18,000 patients at the time in the U. S. Database, and they're cut off was 30% weight and no other discriminating factor. And they they found that just going beyond 30% cut off for weight had an increased one year mortality in the range of an increase of about 10 to 20%. And so, for some reason, the weight is an important factor that has been kind of looked at over time. The other thing, um, is the preoperative need for transfusion the donor, like I mentioned. And then, of course, the HL antibody compatibility and cross match. And so, you know, we have donors and recipients that are paired. They may look fantastic. The height and weight may be a great match. There's a group may be perfect fit, and then we scroll down and look at their h l a antibody profile, and they have one or two that may cross react with our recipient. And so one of the things that we can do in the current age, which is kind of nice, is, um uh, what's called a virtual cross match and we can actually just have some computer in the cloud, probably supported by Amazon. Uh, maintain and, um, assess. The antibiotic compatibility is a lower medium or high risk for, uh, immediate amnesty response. Er what's considered an acute reaction acute transplant reaction within the operating room causing primary graft failure. And so when we look at this, you know, how do we evaluate this was the data that were given, And so one of the things I think that we do and has been shown to kind of improve the outcomes is looking at the initial ph. A lot of times were reported data that may not be as, um as accurate as we would want. And so, looking at the pH may give us a better idea of the story that's being told from this donor. Looking at the down time, a lot of times CPR that's performed for more than 45 minutes really does not pretend a greater prognosis for organ recovery. And then a lot of times, let's say the downtime they report is 10 minutes, and the pH was normal when we look at other surrogate markers of RV dysfunction or and organ dysfunction. So creating, of course, is always there and then asked an adult and trending that in the donor really help us kind of assess and evaluate what's going on. So this is just a screenshot from what we look at, um, on the donor side, um, on unit. And so here you can see, you know, were reported. This was a donor from the 26 26 27 28. Just a snapshot here. What they're ventilator settings were in their A B G settings to initial pH was 73 p. A. C 02 was 50 by garbage 25 not on a ventilator and then optimizing the patient, ventilating them and kind of maintaining their pH, um, and their pho to in order to be able to truly get a assessment of what's going on from a ventilatory standpoint. So these are just a screenshot of some things that we look at. Um, lab values are reported in similar fashions as well. Um, and so one thing to think about is how do we How do we look at recipient factors and how do we How do we match donor recipient qualities together? And are there some ratios? Are there other things that we should be looking at? So traditionally, we look at height, weight and h l a compatibility. And then ratios of those and contemporary literature would tell us that recipient qualities actually have a lot to do with the success of the transplant. Obviously, the fellas, um, one of the things that we were interested in here is, you know, are there better parameters rather than just the height and weight? Because, you know, people can be fat fat, or people can be skinny fat, right? They can be thin on the inside and big on the outside. And does that really affect the donor organ? Uh, and the size of that organ, compared to people that aren't, you know, either morbidly abuse or on the other side, and and and are kind of hectic. And so we looked at the Arabic root relationship and we found that it independently predicted patient success at one year, meaning survival. Um, compared to height, weight and BMI in a Multivariate analysis and the gender mismatch, which is something that's played a lot of centers had absolutely no bearing on our one year graft and patient survival. And so just so you guys understand what we did. So we looked at all heart transplants that came in from 2014 to 2019. And over that five year period, um, we looked at all patients. Um, we looked at what records we had available, and then we looked at, um, those that had data available and those that didn't We performed our own Arabic group measurement. And so we looked at the donor and recipient Arabic root sizes. And we compared that in a Multivariate analysis to standard criteria for weight, height and body surface area. Um, and interestingly enough, the we had 100 and eight patients evaluated, and the outcomes are actually kind of intriguing. So when we looked at outcomes, so this is kind of an inverse curve, so the higher it goes up, the more they died and follow up time in five years. So from the time of initial transplantation, what we did is we decided to divide up the area, recruit into turtles of less than 27 millimeters between 27 30 and then greater than 30 millimeters. And what we found is that those patients, independently of their height and weight compatibility their predictive heart mass index, their body surface area, any other factor that's currently used to manage donor and recipient pairing This actually predicted a higher incidents of mortality that was statistically significant. And so if the donor Arabic root size is less than 27 the five year mortality ST around 10% the higher, the bigger the root size, Um, the higher the mortality client As time went on. And one of the things that we thought that may explain this is you know, one is it's surgical time, too. So, in a higher, bigger root size, is there a, um, potential that you're taking a bigger organ for somebody who is more sick? And so what we did is we actually divided up this into the listing status at the time, and we did find that patients who were status one who were the sickest on the list had a much more varied Arabic root size acceptance compared to those that were status to our status. Three. And if we divide this chart up into the status for mortality, we see that the status to patients had the highest five year. I'm sorry, the status one patients had the highest five year mortality, Um, compared to the other statuses, which which makes sense. If you think about somebody who's sick, you're going to be less discriminatory in taking an Oregon. And so maybe this is more an indicator that the patient that received the organ was sicker. Um, but, uh, even when we tried to annul that out, the mortality rate still stayed about the same. So just an interesting study that we did here locally, Um, that we've sometimes used to help us in assessing, uh, donor selection. And then next. One thing that we should talk about that's really important in the last few sides here is, uh, the extended donor criteria, and so thinking about that it's age greater than 55. Some centers use 60 echo abnormalities such as potentially localized wall motion that may be difficult to define because of the echo quality or the ability to image that patient with the T V rather than trans thoracic echo. UM, potentially increased ischemic times in D B D donors, uh, which are greater than four hours. And we've done a couple of those here, um donor recipient size mismatch of greater than 30% in any one specific index if they do have positive blood cultures that haven't cleared at the time of organ procurement, in the setting of concern for endocarditis and then looking at patients that are hepatitis B or hepatitis C positive. And one of the things that we found and we're going to be publishing data on this soon is that the hepatitis C positive donor population in our two year outcome study so far has shown that they don't have any increased incidents of rejection or immuno Um uh, immunological complications such as donor specific antibody development or, um, liver dysfunction or viral infection, and their their survival is the same as a non hep C transplanted organ. I think one of the reasons for that is, is our team here is very aggressive on starting them on hep C medical therapy to cure and eradicate eradicate the viral load within the first three months. And we've been successful in all of our patients by three months to have no hep C within the system. Hepatitis B. We transplant those patients fewer, but the treatment with the medication for one year has also shown no increased risk of issues. But we've only had about four patients this last year that had been happy. Positive? Um, so when we think about, you know, what are the things that we can do to, um, to improve donor outcomes? How can we improve donor selection? You know, one of the things we have to think about is we need more donors. So how can we get more donors? This was a paper was published, uh, in 2014. It talked about optimal donor selection and what things to do to improve the, uh, the donor pool. And so we're currently we're in this little small circle here. Um, and then everything outside of this small circle is the extended criteria donors. And so, you know, are we a little bit over over calling LV dysfunction? Are we looking at LV hypertrophy and somebody who may be under filled their ventricles. Maybe, um, contracting a little bit hyper dynamically. And so the walls look a little bit thicker, you know? Is there a biomarker that we can use? Is there a donor risk that we can assess? Currently, there's no donor risks score such as, like, meld or KDP I for kidneys. Um, that can assess donor risks. Were working on something here that may be indicative of that, but there's nothing that's panned out. Um, ex vivo profusion we'll talk about in a second has really been something that's coming to the forefront of allowing us to do donation after cardiac death and remove an Oregon Reaper, fuse it and see the quality of it prior to transplanting it. Uh, and then, of course, hepatitis C. Positive donors we've been doing now for a number of years. Um, and then this red stuff here is, you know, are there donors that are coming from outside of your region outside of your country? Are their donors coming from Zeno transplanted organs? So I think that's something that you know we'll have to see in the future. And so one of the things that we have to think about with all of this. This is in the prior era of, uh, data that was done prior to the U. S. Change in 2018 is when we think about assessing donor and recipient matching and risk reduction when we look at assessing donor risk. So low risk medium or medium, high or high. So medium low is somebody who is low risk but has one or two factors that would make them a moderate risk. Medium high risk. Somebody has three or four factors, and then high risk is somebody has more than five factors. So including, um, the ones that we mentioned. So downtime distance initial pH uh, need for renal replacement therapy, height and weight mismatch or potential increase in donor incompatibility for HLS. And so when we look at that based off of our status, you notice the status ones. One being one to, um, the risk for recipients surviving one year of transplantation is higher in patients that are less sick. Uh, versus those that are, um, that are more sick. And I think the reason for that is because the patients that are status ones or status one a usually get a lot more focused attention within the first 3 to 6 months after transplantation because we know we may be choosing a marginal organ for them. And so we're a little bit more cautious versus those patients that may be hanging out at home or on China tropes. Arnell VOD and we feel like we pick an organ. That's that's good for them. But there may be something that we're missing. And so their risk of, um, of, of being compromised on the wait list versus being transplanted with an organ that may be higher risk is less. But then their mortality will go up. And so the ratio for do they get transplant or do they stay waiting? Increases? Um, And so if you're taking a patient that's been waiting on the list for three years, and then you transplant them with an organ that you may not consider high risk. But based off of criteria is high risk. Their mortality are there. Hazard ratio for increased mortality is higher, and so the longer you wait, Sometimes the organs you get are are Your thinking is is a good match. But there may be other factors in the recipient that we're missing. Um, and vice versa. Those patients that are much sicker, you're going to take an organ. That's maybe not as great. But you're going to really stay on top of that Oregon. It just seems to be a bias that they're showing within the department that the whole field of transplant, as in general. Um, and so last couple slides, um, to talk a little bit about the d c D donation. So donation after circulatory death? Um, we're currently doing this May of Florida. We've done two transplants here. One was just on last over the weekend. And, uh, D c d donors, um, have a very strict criteria. It's hiring under FDA review for becoming an appropriate, uh, method of transplantation or an acceptable method of transplantation nationwide. Um, and you know, most of our patients have a total ischemic time or a total cold ischemic time outside the human body that's not being perf used for about 15 minutes, and we have a 92 day in one week survival that has had not had any incident. Um, both of our transplants that were done with D. C. D were transplanted on mechanical circulatory support r 92 day patient was transplanted with bridge to, um Bridge to D. C. D with the Impeller 5.5 axillary device, which was the first that was done there. And then we did the first ECMO to D c d transplantation this week as well. Um, so trying to really move the needle forward and and and and work on that now it's interesting with donor selection on D. C. D s. Because a lot of times these patients don't get cardiac catheterizations because the patient's families trying to minimize testing prior to withdrawal of care. And sometimes you have to look at other factors that may give you surrogates for, um, for potential coronary disease based off the patient risk factor. Um and so just kind of for you guys to see this is the machine that we use that we talked about last week. Um, And so it's, um, uh, the Oregon is placed on this machine by transmit IX within this chamber that sealed, um, and, uh, the organ is beating within this chamber. So, uh, kind of a neat setup. Very cool to watch. And hopefully with this technology, the donor pool will increase and we'll be able to transplant more patients. But with that, that kind of ends my talk. I don't know if there's any questions out there that I can help answer. Thank you. And it was a very helpful talk for many of us who work in the transplant field. But also, they will be helpful for many of the people on the call. So, um, um, I'll start with one question That kind of a common thing that I see we promote organ donation, you know, with social media and ads, etcetera. And, uh, I always get feedback from, you know, from some very eagerly individuals. Uh, you know, who will say I'm also an organ daughter, but, you know, there might be, um, elderly or some of them actually post dress. But So, um, are they okay being organ donor, someone who is, you know, 70. And they say, I just want to donate my organs or someone who had a transplant that you know this If something happens to me, I'll donate my transplanted organ. Yeah, so that's a good question. Uh, and it's a very generous patient that you spoke with, but unfortunately, patients who have been transplants are not considered organ donors. Um, at this time, I think a lot of patients have had a lot of h l A issues. And the potential for one organ to go from one recipient to another isn't something that would be considered. Um, and then the donation of older age individuals is very select. A lot of times, Um, have they not been a transplant candidate? They may be a candidate to donate kidneys or or skin or eyes, but, um, from a hard heart transplant standpoint, I think the ideal donor would be less than age of 60. Um, you know, usually 55 is our cut off. But that being said, there have been institutions that have taken older age donors up to 65. Okay, One thing I think that's interesting and and good for the general providers who are listening is when you think about organ transplantation as a whole, uh, you know, one of the things that we struggle with a lot is receiving patients that have, um, that have qualities as a recipient. They may make them an increased risk, mainly in those patients who have ischemic heart disease. That have full metal jackets that were trying to help preserve function. Um, and their ejection fraction is 60% but they have a lot of angina, and a lot of times those patients have a very pro viso dilatory milieu. And there's some information that's been published recently that talks about patients with ischemic heart disease and more than five stents with significant angina having a lot of as a pledge, a after heart transplantation. And so one of the things that we also take into account is how much support the patient's going to need after transplant to preserve renal function in order to not allow that new graft to have RV dysfunction or require a lot of product transfusions. And so sometimes in the ischemic patients that we see in referral once they're starting to get into the 5 to 10 stent zone, even if they have preserved ejection fraction, you know it may be beneficial in the longer, and if they need transplant just to send them earlier just because the potential for them to have complications after transplant because of their kind of, you know, increased nitric oxide production, increase the dentist in response, maybe something that could compromise them after transplant. So interesting data is coming out. I s h l t is coming up in April, I saw about two or three talks about about this specific subject. So just something to think about keeping the back of your mind that, you know, more interventions can give them, you know, maybe some time. But in the long run, if they need transplant because of progressive ischemic heart disease, they may not do well in the immediate post transplant period. Thanks. And that's a very valid point. We had a couple of patients with normal ejection fraction and in stage ischemic cardiomyopathy. And I recall even one of our physiology is asking me Why are we transplanting this patient? His election pressure is normal, but again, this was someone on a balloon pump with maximum anti annual regiment. So just because the EF is normal doesn't mean that they are not candidate for trust, especially if they have a new tractable and Gina unlimited quality of life. Alright, let's open for other questions from the audience. Mueller. Well, I actually I have another question, and this is actually for people on the call many times um, you know, we feel that the daughters in the daughter hospitals are not well managed or they're not match adequately to preserve preserved, you know, their vital functions in their organs. You know, it's always, uh, sad when someone has been declared brain dead, and then pretty much they they go into the other care becomes goes onto the side because, you know, there are more important patients to take care of. But actually, those donors are very important because they are actually saving many lives, you know, to kidney. Still long, so hard, etcetera. So many times the management is kind of poor, and then they become hyper natural MC or they are hypertensive and their kidney function goes back, and then we can't use those orients. So, um, any words of wisdom for the participants on the call and might help with preserving these donors and making sure they fulfill their wish of being good donors by by helping their management when, while they're waiting for, um, for the organs to be harvest? Yeah, I think that's a great question. So, um, you know one of the things and, um, in the in the slides that I can send the patient to people who want their some exercise at the end that talk about, um, numbers and goals that we want. So usually for patients that are donation after brain death, we want human government above eight. Obviously, increased transfusion means potential complications. And so that's something to consider. Um, for D c D donors, we want him adequate of 25 that allows them to have appropriate viscosity on the machine. The other thing is, you know, a decent P 02 lung recruitment maneuvers. So increasing the people talking with your colleagues in the ICU about managing lung recruitment and then hyper Nutri mia is something that can be concerning as well because you get cells swelling my cardio oedema and dysfunction. Um, and so kind of keeping the sodium around 100 and 50 in patients that have have passed from a cerebral vascular issue. Uh, and then I think the other. The other thing that we always are are asking for I've I've seen this more recently is, uh, an echo maybe with some eco contrast. So if you're the cardiologist going to do the echo for a donor, you know, sometimes it helps if you give definately just to help, Better define the walls and somebody who's on the ventilator who who may be receiving, um, you know, positive pressure, etcetera. Um, I think the last point I would make is, um you know, one of the things that we do from A from a donor evaluation standpoint that I touched on a little bit, uh, what was looking at their risk factors. And so really getting a good history and kind of understanding What, uh, what their risk factors from, uh, you know, substance abuse standpoint or a a donor risk factor standpoint would be really helps. Great. Thanks very much for that. And and same with the coronary angiography. Sometimes we see that they are called non obstructive disease for normal. But when we look at them, I used to see so sometimes we cannot use those. Those are, you know, those hearts that they actually have some non obstructive, even if it's not obstructed. Yeah. Yeah. So yeah, calling normal coronaries is sometimes not helpful. But, um, the other thing that I've noticed is that there, Kath, and they're bridging vessels sometimes, you know, they will read. That s stenosis so kind of helping us differentiate. That is also helpful. And the main reason is again re profusion injury in patients who are put on ice. Um, that that that make even a 10% lesion may cause a long term issue. All right, all right. We have a few minutes. Um, any questions? Concerns comments about donor selection strategies, donor and recipient. Good morning. Near panted from Tallahassee. Quick, quick comment in regards to awareness. You know, I moved here from to Tallahassee from Reading Pennsylvania outside of Philadelphia. Practice there for 18 years, and there was a lot of awareness regarding donation over their organ donor. And here it appears to be lacking in Tallahassee, at least in this area. And I know that people are a different culture and what have you in this area, but they tend to keep their loved ones alive, are on support for much longer time before withdrawing or considering, or didn't even withdraw support at all, despite the fact that there may be no hope. And I think the culture here is so different. I don't know how, and I don't see any advertisement or any sort of, uh, information out there in this area that would help these people. I understand what you guys are doing, what we're doing when we're trying to get you guys to help our patients. Um, I don't know if there's anything out there in your area. Jacksonville certainly is much more progressive as this Gainesville. But I can tell you that Tallahassee and the Panhandle it's It's very, very backwards. It's it's Assad and unfortunate. Thank you. Yes. Um, yeah. So, yeah, definitely. Um, you know, we we do a lot of activities, and I had asked I have actually patients and family members asked me that I like, how come my family member has been waiting for a month and no organ donors, and, you know, it starts with the patient groups to promote. And I think that social media has been able to really help help that associations, you know, we do plenty of interviews about organ donations. I think that at least every three months will happen for segment on TV where we talk about organ donation. Um, I think from a policy perspective, unfortunately here in the U. S. Like in many countries, the policy is really to opt in for being an organ donor where you have to check the box when you take. Take your get your driver's license. Other countries like, for example, Spain. They have a different policy where there's actually opt out. You have to opt out to not the organizer's everybody by default. It's an organ donors, so there's some policies that we have tried to push. Some of them are again at the federal level, but where, Um, I'm not sure about within the state of Florida if there are pockets of um, are is that really don't get the right message or they don't have diffusion of of this kind of message. But, you know, I think that we need to promote it as much as we can be a social media and then to Patients Group. And if Rohan or anyone from the group as other comments about it, you know, I think now would you bring up a very good can. You guys hear me? Yes. Sorry. You bring up a very good point. I think there's a lot of heterogeneity, um, in different areas. As to organ donation. I can tell you, before I was here, was in Dallas, and I was actually surprised at, even in Dallas, the level of organ donation and what my expectations were I thought we were subpar with regards to that in such a large city. And I don't know, again, nearly as you mentioned, there may be something cultural in the South. But one thing that we can do is again partner up with our Opio. And so an opiate is an organ procurement agency. And they're actually the entity that, um uh polls these donors and actually manages the donors until transplantation. And they're actually private entities that are like congressional lines, so their territory are are like congressional lines based on the original kidney transplant program. So if you were in a program that was in a big kidney transplant program, you typically are surrounded by a very large O. P. S. Ours is life quest, and one thing we can do is give that type of feedback that you gave us an urge to life quest and actually have them partner with us and you guys, everybody else, you know, the community to actually increase the awareness and well, we may be limited from cultural standpoint. We can actually work. On the awareness standpoint, there's actually there's actually a statute in the state that all patients who are declared brain dead, all patients who are expected to withdraw support all patients who have a certain Glasgow coma score must be reported to the oh, So that's a statue that is a, um, metric that all hospitals are judged against and is reported on a regular basis. So there's there's a difference between notifying Ethiopia We call conversion, which is actually getting can separate, right? Opio has commentator because they they do go go to all the hospitals and they can tell you exactly what their rate of how often they're calling their Opio. And and there there's a gold standard. How compared to the denominator is clearly any patient who has a certain class count? ComScore. Any patient, withdraw, support any patient. The denominator and numerator is how often the appeal calls. So that's a percentage that each hospital, uh, go through. So, you know, if you ask, can we have someone on the capital regional? They There are people there who should be able to tell you exactly what their rate of how often their colony Opio with the percentages. The conversion rate is very different. It's a different entity. Where Opio is is are the ones who are approaching daughter families. It's not the it's not the clinicians. And for reasons for a reason. Yeah, we hope that we could have more. Even celebrities kind of, uh, pushed the organ donation month and even the organ donation agenda. You know, we have, you know, people who have been transplanted, like George Lopez and Selena Gomez and many people who, you know, do their. Even yesterday, I saw an ad for Morgan the Nation from Wilmer Valderrama, which is the guy from a 70 show. So, you know, I think that that will definitely help, but they're stopped. 3500 transport hard trends in the U. S. A year. And there's 10,000 people waiting for transplants. We still have a big deficit with DCB daughters. Uh, there's an expectation that we might be able to improve or transplant numbers by 20 to 30%. The technology is helping using this. Um, um, these other criteria, like Pepsi donors, have definitely helped, but we still we still are far behind. All right, well, thanks very much. for attending our Tuesday a lecture series next to us back with more interesting topics. So have a blast Tuesday and, uh, enjoy whoever is going for spring break and your your spring break. Thank you. Thank you.