MALE SPEAKER: --that we'll be doing our 18th North Florida Cardiovascular Symposium conference. This year, of course, will be virtual due to the pandemic. It will be a half a day of virtual conference. You might have received already an email or a brochure about this conference. It will be done on Saturday, April 17, 2021.

It's a virtual modality. We'll be providing CME and CEU credits. The speakers are phenomenal. And the registration for physicians is $100. For nurses, techs, 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 get them involved.

And we're hoping to have a good 250 participants, which is what we have had in the live conference as well perform at UNF. In the past, we used to have them in Ponte Vedra. It used to be called the Ponte Vedra Cardiovascular Symposium for 17 years. And then, we transitioned to UNF a couple of years ago, University of North Florida.

So again, due to the pandemic, we canceled last year. But this year will be virtual. It's just half a day on a Saturday. And again, you can register at any time. You should have received the brochure or the email with the link. And hopefully, we'll get to see you guys there.

Also, our lecture series goes from the-- it follows the academic year for the fellowship program. So it will end in June and will restart again, I believe, in August. But if you have any particular topics that you would like to discuss in the future, please let us know. We'll try to arrange some of the lectures for next year. Some of them will be repeated. But definitely, would like to have your input and see if there's any lectures that we might be able to cover, as well as your own clubs, the different articles that you guys might want to discuss during our monthly Journal Club.

And finally, we would like to have your input in terms of case-- cases that we can discuss. We'll try to do those at least every trimester, where we can discuss real cases that many of you have referred here to Mayo or that we have co-managed. And definitely, those are always interesting cases to look at real world practice. So with no further delays, we have Dr. Goswami on board, and--

ROHAN GOSWAMI: Good morning, everyone.

MALE SPEAKER: He will be talking about donor selection strategies. So with no further delays, Rohan, take over.

ROHAN GOSWAMI: All right, everybody. Thanks for the patience. My computer is giving 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 and heart transplantation today. And the goal is to understand what the role of the donor and the recipient qualities are that portend a positive outcome 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 won 169 to 146. 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 the standard qualities that ISHLT, UNOS, and heart failure societies and transplant societies across the world look for.

Obviously, you're looking for the age of the donor. Gender to see if there's a mismatch. Height, and weight, and BMI have been the ideal targets for matching patients in the past. And then, we're looking at the ratios of that, what the left ventricle looks like, what the right ventricle looks like. And then, the grams of the heart to see if it'll fit within the donor cavity. Aortic root size, cause of 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 know is that donor risk factors have been shown to really affect recipient outcomes, which is an interesting way to think about things, because now you're managing a new organ in a new patient and also dealing with that patient's prior histories. And so traditionally, what we'll look at are height, and weight, and gender. And then, there's new criteria that have come about in the last five to 10 years regarding extended criteria donors, new organ allocation policies, and how we can optimally utilize donors.

And then, now in the 21st century, we're looking at DCD versus DBD donors, meaning donation after circulatory death or donation after brain death. And last week's talk for the Journal Club focused on DCD. And we'll touch a little bit on that today as well. So if anybody has questions during the talk about things that we're discussing, please feel free to chime in.

So when we look at ISHLT, the International Society for Heart and Lung Transplantation, we look at their approach to donors starting a number of years ago and looking when the first guidelines were generated. There was an official donor assessment and selection statement created in 2006. And then, they updated in 2017.

And there's an increased scrutiny on the quality and healthcare with particular emphasis in heart transplant survival outcomes. And an important aspect of successful transplant is appropriate donor selection. And that comes directly from ISHLT. 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 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 organ is. And then also, are we meeting the needs of the recipient? So is it a size match? Are there 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 ISHLT 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, we have donors that have a history of smoking. And we can see that the amount of the percentage of donors with smoking histories has declined 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 two, the quality of donors has improved. And then, the donor's history of alcohol is 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-illicit drug use, cocaine has slowly seen a rise in the number of transplant donors. And not surprisingly, donors that are using opiates such as 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, narcotic, sedatives, or hypnotics in their blood when they're evaluated to be a donor.

And so we have to think about the short and long term effects that those drugs have on the heart and also on the ability for donors to stay stable, optimized, and travel well. And so one of the things that we don't know, especially with cocaine and now with some of these stimulants and marijuana, is how that affects the microvascular structure of the donor. And so when we're assessing donors, we have echos. We have caths. 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 NDIC, because those organs, if they're put on traditional transport processes, and are put under ice, and kept cool, sometimes can have microvascular dysfunction. Or you have stasis of blood flow and then a reperfusion injury that can cause a lot of dysfunction in the recipient later on.

And so if we look at the survival in patients based off of their age, one of the things we would say is, you shouldn't take an older donor, because the heart's 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 for older donors above age 50 is actually around 75%, 77%. If you look at donors that are middle aged, the survival is 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 listed in this slide is what are the qualities of these donors that were taken? Were a lot of them high risk? Were a lot of them far away? And was there a complication because of the recipient that may have led to this mortality?

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 as strong. And so when we look at the cause of death in the donor, we look at anoxia, CVA or stroke, and then head trauma. And some of these may overlap. 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 the five year benefit of considering heart transplantation in a patient who may be a candidate?

And so if their five year survival is less than 80%, then I think that it's something to consider reasonable that they may have a better five year survival if they're able to undergo transplant and survive the first year. And we know that if they survive the first year, most likely the long term survival is better.

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, that will take a donor ejection fraction that's hovering between 45% and 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 fractions less than 60% 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.

And so if you look at this, the survival for ejection fraction greater than 50% mimics that of the donor cause of death. It's right around 85%, 88%. Ejection fraction less than 50%, although you can see it's a much smaller number, the survival is closer to 80%. And so I think when we're selecting donors, one of the things you have to think about is what's the likelihood that this organ is going to give a five year survival? And what's the likelihood that there's going to be a significant issue as far as in hospital stay, ICU length of stay, 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 donor age has been proven as an independent predictor of mortality. And we showed that the older you are, the more likely you are to have complications within the first year or potentially a 30% chance of not surviving if your donor's above 40-- or 50 years old.

And then donor quality, so a lot of times, the initial echo will be due to stunning, or hypertension, or 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.

And then, obviously, the troponin trend to see was the accident that occurred from a cerebrovascular standpoint significant enough to spill a large amount of troponins? And does that indicate there may be some underlying microvascular disease or some myocardial dysfunction that may not be demonstrated on an echo? 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 the donor is important. There's a lot of times things that will happen on the donor's end, such as a patient having acute renal failure and allowed to be hypertensive because of the cerebral perfusion that needs to be maintained, volume overload, and the need for initiating dialysis.

And all of these things, we have to take into account, because those cause surrogate changes within the organ that we're interested in. If you have an elevated right sided filling pressure at the time of explantation of an organ, 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. If you think about the right ventricle like a big vein, you want to be able to support that as it gets product transfusions while they're weaning 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-- that we need to look at.

And so so far, what have we-- we've talked about? So we've talked about donor age. We've talked about smoking status, how long they've been smoking. We've talked about other factors and how they're impacting the one and five year outcomes. And then looking at organ utilization, 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 overanalyzed in the past in a lot of patients who had high alcohol use. We were concerned about potential myocardial dysfunction. But over the last decade, alcohol use has stayed the same. Cocaine use is on the rise. And so that's a concern as far as microvascular disease. And then, same with the donor's cause of death.

And so what are the other things that we look for? So we talked about the echocardiogram. Now, it's really important to think about how much support the donor's 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 a spinal cord transection, or some sort of autonomic issue, they may require a higher vasopressor or inotropic support in order to maintain normal perfusion to support the other organs, because those are also potentially transplantable.

And so if the donor is on less than 10 mcg per kilogram per minute of dobutamine or dopamine or less than 2.5 of Levophed or norepinephrine, ISHLT and UNOS 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 are age greater than 40, if they have a smoking history, if they have an unknown cause of death, or they have significant diabetes. And they're now adding to that cocaine use. This is where we're going to request a cardiac cath. And the one thing we have to think about with cardiac catheterization is quality of the study that's being done, engagement of the coronaries, and then also the amount of support that the patient's on during that catheterization, because that may affect the filling pressures. That may affect the myocardial contractility.

And sometimes, we're actually even with those characteristics making the patient a 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 worth it.

And then, the other circumstantial factors that I touched on a few slides ago are 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. Those only affect the quality of the right ventricle, either coming onto bypass or coming off bypass.

And then, the transfusion requirements of the donor. One thing that's important to remember is that transfusions are directly toxic to the right ventricle. A lot of the preservatives, and the citrates, as well as the volume itself, and the calcium load really affect the right ventricle's ability to tolerate longer ischemic times and higher pulmonary pressures in the recipient. And so factors to keep in mind when we're looking at donors.

The other thing is what's the donor location? Are they down the street? Or are they 2,000 miles away and need a flight that's going to take four hours? Are they taller or shorter than the recipient? They should be less-- no less than 30% lighter than the recipient.

There are multiple studies that have shown that 70% is the cutoff for weight. There was a beautiful study done about four or five years ago that looked at the 18,000 patients at the time in the UNOS database. And their cutoff was 30% weight and no other discriminating factor. And they found that just going beyond 30% cutoff for weight had an increase to 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. This has been looked at over time.

The other thing is the preoperative need for transfusion in the donor, like I mentioned, and then of course the HLA antibody compatibility and crossmatch. And so we have donors and recipients that are paired. They may look fantastic. The height and weight may be a great match. Their aortic root may be a perfect fit. And then we scroll down and look at their HLA antibody profile, and they have one or two that may cross and react with our recipient.

And so one of the things that we can do in the current age which is nice is what's called a virtual crossmatch. And we can actually just have some computer in the cloud, probably supported by Amazon, maintain and assess the antibody compatibility as a low, or medium, or a high risk for immediate amnestic response or what's considered an acute reaction, acute transplant reaction within the operating room, causing primary graft failure.

And so when we look at this, how do we evaluate this? What's the data that we're given? And so one of the things I think that we do-- and this has been shown to improve the outcomes-- is looking at the pH. A lot of times, we're reported data that may not be 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 downtime, a lot of times CPR that's performed for more than 45 minutes really does not portend 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. Then we look at other surrogate markers of RV dysfunction or end organ dysfunction. So creatinine, of course, is always there. And then AST and ALT in trending. That in the donor really help us assess and evaluate what's going on.

So this is just a screenshot from what we look at on the donor side on U-Net. And so here you can see we're reported this was a donor from the 26. And so 26, 27, 28-- just a snapshot here of what their ventilator settings were and their ABG settings. So initial pH was 7.3. PaCO2 was 50. Bicarb was 25, not on a ventilator. And then optimizing the patient, ventilating them, and maintaining their pH and their PaO2 in order to be able to truly get a assessment of what's going on from a ventilatory standpoint. So this is just a screenshot of some things that we look at. Lab values are reported in similar fashions as well.

And so one thing to think about is, how do we look at recipient factors? And how do we match donor recipient qualities together? Are there some ratios? Are there other things that we should be looking at? So traditionally, we look at height, weight, and HLA 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 HLAs.

One of the things that we were interested in here is, are there better parameters rather than just the height and weight? Because people can be fat fat or people can be skinny fat. They can be thin on the inside and big on the outside. And does that really affect the donor organ? And the size of that organ compared to people that are either morbidly obese or on the other side and are cachectic.

And so we looked at the aortic root relationship. And we found that it independently predicted patient success at one year, meaning survival, compared to height, weight, and BMI in a multivariate analysis. And the gender mismatch, which is something that's plagued a lot of centers, had absolutely no bearing on our one year graft and patient survival.

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, we looked at all patients. We looked at what records we had available. And then we looked at those that had data available. And those that didn't, we performed our own aortic root measurement. And so we looked at the donor and recipient aortic root sizes. And we compared that in a multivariate analysis to standard criteria for weight, height, and body surface area. And interestingly enough, the-- we had 108 patients evaluated. And the outcomes are actually intriguing.

So when we looked at outcomes-- so this is 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 aortic root into tertiles of less than 27 millimeters, between 27 and 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 incidence of mortality that was statistically significant.

And so if the donor aortic root size is less than 27, the five-year mortality stayed around 10%. The bigger the root size, the higher the mortality climbed as time went on. And one of the things that we thought that may explain this is one, is it surgical time to sew in a higher-- a bigger root size? Is there a 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 aortic root size acceptance compared to those that were status two or status three. And if we divide this chart up into the status for mortality, we see that the status two patients had the highest five-year-- I'm sorry-- the status one patients had the highest five-year mortality compared to the other statuses, which makes sense.

If you think about somebody who's sick, you're going to be less discriminatory in taking an organ. And so maybe this is more an indicator that the patient that received the organ was sicker. But even when we tried to null that out, the mortality rate still stayed about the same. So just an interesting study that we did here locally that we've sometimes used to help us in assessing donor selection.

And then next, one thing that we should talk about that's really important in the last few slides here is 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 a TEE rather than a transthoracic echo.

Potentially increased ischemic times in DVD donors which are greater than 4 hours-- and we've done a couple of those here. 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 outcomes study so far has shown that they don't have any increased incidence of rejection or immunologic complications such as donor specific antibody development, or liver dysfunction, or viral infection.

And their survival is the same as a non hep C transplanted organ. I think one of the reasons for that is our team here is very aggressive on starting them on hep C medical therapy to cure and 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 have been hep B positive. So when we think about what are the things that we can do to improve donor outcomes, how can we improve donor selection, 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 that was published in 2014 that talked about optimal donor selection and what things to do to improve the donor pool. And so we're currently-- we're in this little small circle here. And then everything outside of this small circle is the extended criteria donors. And so are we a little bit overcalling LV dysfunction? Are we looking at LV hypertrophy in somebody who may be underfilled? Their ventricles may be contracting a little bit hyper dynamically, and so the walls look a little bit thicker.

Is there a biomarker that we can use? Is there a donor risk that we can assess? Currently, there's no donor risk score such as like MELD or KDPI for kidneys that can assess donor risks. We're working on something here that may be indicative of that. But there's nothing that's panned out.

Ex vivo perfusion-- we'll talk about in a second-- has really been something that's come into the forefront of allowing us to do donation after cardiac death and remove an organ, reperfuse it, and see the quality of it prior to transplanting it. And then of course, hepatitis C positive donors, we've been doing now for a number of years. And then, this red stuff here is, are there donors that are coming from outside of your region, outside of your country? Are there donors coming from xenotransplanted organs? So I think that's something that 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 data that was done prior to the UNOS 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 is somebody who has three or four factors. And then high risk is somebody that has more than five factors, so including the ones that we mentioned-- so downtime, distance, initial pH, need for renal replacement therapy, height and weight mismatch, or potential increase in donor incompatibility for HLAs.

And so when we look at that, based off of our status, you notice that status ones, 1B and 1B, the risk for recipients surviving one year of transplantation is higher in patients that are less sick versus those that are more sick. And I think the reason for that is because the patients that are status ones, or status 1As, usually get a lot more focused attention within the first three to six 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 inotropes, or on LVAD, and we feel like we pick an organ that's good for them. But there may be something that we're missing. And so their risk of being compromised on the waitlist 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.

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-- or their hazard ratio for increased mortality is higher.

And so the longer you wait, sometimes the organs you get are-- you're thinking is a good match, but there may be other factors in the recipient that we're missing. 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 organ. That just seems to be a bias that they're showing within the department-- the whole field of transplant in general.

And so the last couple of slides, to talk a little bit about the DCD donations, so donation after circulatory death, we're currently doing this at Mayo Florida. We've done two transplants here. One was just done last-- over the weekend. And DCD donors have a very strict criteria. It's currently under FDA review for becoming an appropriate method of transplantation or an acceptable method of transplantation nationwide.

And most of our patients have a total ischemic time or a total cold ischemic time outside the human body that's not being perfused for about 50 minutes. And we have a 92-day and one-week survival that has had-- not had any incidents. Both of our transplants that were done with DCD were transplanted on mechanical circulatory support. Our 92-day patient was transplanted with bridge to DCD with an Impella 5.5 axillary device, which was the first that was done there. And then we did the first ECMO to DCD transplantation this week as well. So trying to really move the needle forward and work on that.

Now, it's interesting with donor selection on DCDs, because a lot of times these patients don't get cardiac catheterizations, because the patient's family is trying to minimize testing prior to withdrawal of care. And sometimes, you have to look at other factors that may give you surrogates for potential coronary disease based off the patient risk factor.

And so just for you guys to see, this is the machine that we use that we talked about last week. The organ is placed on this machine by TransMedics within this chamber that's sealed. And the organ is beating within this chamber. So 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 ends my talk. I don't know if there's any questions out there that I can help answer.

MALE SPEAKER: Thank you, Rohan. That was a very helpful talk for many of us who work in the transplant field. But also, it will be helpful for many of the people on the call. So I'll start with one question that-- a common theme that I see. We promote organ donation with social media, ads, et cetera.

And I always get feedback from some very eager individuals who will say, I'm also an organ donor. But they might be elderly. Or some of them actually are post-transplant. So are they OK being an organ donor, someone who is 70? And they say, I just want to donate my organs. Or someone who had a transplant says, if something happens to me, I'll donate my transplanted organ.

ROHAN GOSWAMI: Yeah. So that's a good question. And it's a very generous patient that you spoke with. But unfortunately, patients who have been transplanted are not considered organ donors at this time. I think a lot of patients have had a lot of HLA issues. And the potential for one organ to go from one recipient to another isn't something that would be considered.

And then, the donation of older age individuals is very select. A lot of times, have they not been a transplant candidate, they may be a candidate to donate kidneys, or skin, or eyes. But from a heart transplant standpoint, I think the ideal donor would be less than the age of 60. Usually, 55 is our cutoff. But that being said, there have been institutions that have taken older age donors up to 65.

MALE SPEAKER: OK. Great. Thanks for that.

ROHAN GOSWAMI: One thing I think that's interesting and good for the general providers who are listening is when you think about organ transplantation as a whole, one of the things that we struggle with a lot is receiving patients that have qualities as a recipient that may make them an increased risk, mainly in those patients who have ischemic heart disease that have full metal jackets that we're trying to help preserve function. And their ejection fraction is 60%, but they have a lot of angina. And a lot of times, those patients have a very provasodilatory 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 vasoplegia after heart transplantation. And so one of the things that we also take into account is how much support the patient is 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 five to 10 stent zone, even if they have preserved ejection fraction, it may be beneficial in the long run if they need a transplant just to send them earlier, just because the potential for them to have complications after transplant because of their increased nitric oxide production, increased adenosine response may be something that could compromise them after transplant.

So interesting data is coming out. ISHLT is coming up in April. I saw about two or three talks about this specific subject. So just something to think about. Keep in the back of your mind that more interventions can give them 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.

MALE SPEAKER: Thanks. And that's a very valid point. We had a couple of patients with normal ejection fraction and end stage ischemic cardiomyopathy. And I recall even one of our anesthesiologists asking me, why we transplanting this patient? He said, ejection fraction is normal. But again, this was someone on a volume pump, with maximal antianginal regimen. So just because the EF is normal doesn't mean that they are not candidate for transplant, especially if they have intractable angina, limited quality of life. All right. Let's open it for other questions from the audience.

ROHAN GOSWAMI: [INAUDIBLE]

MALE SPEAKER: Well, I have actually-- I have another question. And this is actually for people on the call. Many times, we feel like the donors in the donor hospitals are not well managed, or they're not matched adequately to preserve their vital functions in their organs. It's always sad when someone has been declared brain dead and then pretty much they go into the other care-- goes onto the side, because there are more important patients to take care of. But actually, those donors are very important, because they are actually saving many lives-- two kidneys, two lungs, the heart, et cetera.

So many times, the management is poor. And then, they become hypernatremic, or they are hypertensive. And their kidney function goes bad, and then we can't use those organs. So any words of wisdom for the participants on the call that might help with preserving these donors and making sure that they fulfill their wish of being good donors by helping the management when-- while they're waiting for the organs to be harvested?

ROHAN GOSWAMI: Yeah. I think that's a great question. So one of the things and in the slides that I can send to patient-- or to people who want, there are some extra slides at the end that talk about numbers and goals that we want. So usually, for patients that are donation after brain death, we want a hemoglobin above 8. Obviously, increased transfusion means potential complications. And so that's something to consider. For DCD donors, we want a hematocrit of 25 that allows them to have appropriate viscosity on the machine.

The other thing is a decent PO2 lung recruitment maneuver, so increasing the P, if you're talking with your colleagues in the ICU about managing lung recruitment. And then, hypernatremia is something that can be concerning as well, because you get cell swelling, myocardial edema, and dysfunction. And so keeping the sodium around 150 in patients that have passed from a cerebrovascular issue.

And then, I think the other thing that we always are asking for-- I've seen this more recently-- is an echo maybe with some echo contrast. So if you're the cardiologist going to do the echo for a donor, sometimes it helps if you give definity just to help better define the walls in somebody who's on the ventilator who may be receiving positive pressure, et cetera.

And I think the last point I would make is one of the things that we do from a donor evaluation standpoint that I touched on a little bit was looking at their risk factors. And so really getting a good history and understanding what the-- what their risk factors from a substance abuse standpoint or a donor risk factor standpoint would be-- really helps.

MALE SPEAKER: Great. Thanks very much for that. And same with the coronary angiography. Sometimes, we see that they're called non-obstructive disease or normal. But when we look at them [INAUDIBLE], sometimes we cannot use those parts, if they actually have some non-obstructive-- even if it's non-obstructive.

ROHAN GOSWAMI: Yeah. So yeah. Calling normal coronaries is sometimes not helpful. But the other thing that I've noticed is that if they're at caths and they're bridging vessels, sometimes they will read that as stenosis. So helping us differentiate that is also helpful. And the main reason is, again, reperfusion injury in patients who are put on ice that even a 10% lesion may cause a long term issue.

MALE SPEAKER: All right. All right. We have a few minutes. Any questions, concerns, comments about donor selection or strategies, donor and recipient?

MALE SPEAKER: Good morning. Niraj Pandit from Tallahassee. Quick comment in regards to awareness. I moved here to Tallahassee from Reading, Pennsylvania outside of Philadelphia, practiced there for 18 years. And there was a lot of awareness regarding donation over there, organ donor. And here, it appears to be lacking in Tallahassee, at least in this area.

And I know that people are of different culture and what have you in this area. But they tend to keep their loved ones alive on support for much longer time before withdrawing or considering. Or they don'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 information out there in this area that would help these people understand what you guys are doing, what we're doing when we are trying to get you guys to help our patients. I don't know if there's anything out there in your area. Jacksonville certainly is much more progressive, as is Gainesville. But I can tell you that Tallahassee in the panhandle, it's very, very backwards. It's sad and unfortunate. Thank you.

MALE SPEAKER: Yes. So yeah, Niraj, definitely we do a lot of activities. I have actually patients and family members asking that are like, how come my family member's been waiting for a month and no organ donors? And it starts with the patient groups to promote. And I think that social media has been able to really help that, especially as we do plenty of interviews about organ donation. I think that at least every few months, we'll have some sort of segment on TV where we talk about organ donation.

I think from a policy perspective, unfortunately, here in the US, like as 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 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 be an organ donor. So everybody, by default, is an organ donor.

So there are some policies that we have tried to push. Some of them are, again, at the federal level, but we're-- I'm not sure about within the state of Florida if there are pockets of [INAUDIBLE] that really don't get the right message or they don't have diffusion of this kind of message. But I think that we need to promote it as much as we can via social media and through patient groups. I don't know if Rohan or anyone from the group has other comments about it.

MALE SPEAKER: I think, Niraj, you bring up a very good-- can you guys hear me?

MALE SPEAKER: Yes.

MALE SPEAKER: Sorry. You bring up a very good point. I think there is a lot of heterogeneity in different areas as to organ donation. I can tell you before I was here I was in Dallas. And I was actually surprised that 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, Niraj, as you mention, there may be something cultural in the South.

But one thing that we can do is, again, partner up with our OPO. And so an OPO is an organ procurement agency. And they're actually the entity that holds these donors and actually manages the donors until transplantation. And they're actually private entities that are by congressional lines. So their territory are like congressional lines based on the original kidney transplant program.

So if you are in a program that was in a big kidney transplant program, you typically are surrounded by a very large OPO. So ours is LifeQuest. And one thing we can do is give that type of feedback that you gave us, Niraj, to LifeQuest and actually have them partner with us, and you guys, and everybody else in the community to actually increase the awareness. And while we may be limited from a cultural standpoint, we can actually work on the awareness standpoint.