BACKGROUND:Abdominal Normothermic Regional Perfusion (A-NRP) improves outcomes for transplanted abdominal organs from Donation after Circulatory Death (DCD) donors. Concerns have been raised about the effect of A-NRP on lungs procured during multi-organ donation. We present the UK experience of performing direct procurement (DRP) of lungs from DCD donors with A-NRP. METHODS:Retrospective analysis of all 487 UK DCD lung donors between April 1, 2011 and December 31, 2023. Organ transplantation rate and 30-day, 90-day and 1-year survival rates were compared between DRP of DCD lungs, DRP of DCD lungs with A-NRP and donation after brainstem death (DBD) lungs. Primary graft dysfunction (PGD) rates were compared between DCD lungs with and without A-NRP. RESULTS:Three hundred ninety-seven DCD donors resulted in a lung transplant (22 retrieved by DRP with A-NRP). There was no difference in lung transplantation rates between DRP and DRP with A-NRP. Of the 390 first adult-only lung transplants performed from DCD donors, there was no significant difference in 30-day, 90-day and 1-year survival between DRP of DCD lungs and DRP with A-NRP. There was a significant difference in survival between standard DCD donors and DBD donors at 30-days and 90-days, but not 1 year. There was no significant difference in grade 3 PGD rates at 72 hours post-implantation for DCD lungs with or without A-NRP. CONCLUSION:In the UK experience, use of A-NRP is not detrimental to procurement of DCD lungs. We advocate the use of this technique until further studies can explore the safety and efficacy of thoraco-abdominal NRP for lungs in multi-organ retrieval.

Purpose: Describe the UK experience of direct retrieval and preservation (DRP) of lungs for transplantation alongside abdominal normothermic regional perfusion (A-NRP), with an analysis of early outcomes for lungs transplanted with this method compared to standard retrieval after circulatory death (DCD).

A priority-based stepwise approach helps conserve the blood and avoid blood loss in a procurement of donor heart and lungs in a donation after circulatory death in combination with abdominal NRP.

Utilization of abdominal normothermic regional perfusion (A-NRP) for organ procurement in donation after circulatory death (DCD) is becoming a commonplace. Simultaneous procurement of the donor lungs is technically challenging due to blood loss in the chest leading to inadequate circulatory support to the abdominal organs. We describe a priority-based stepwise approach to minimise blood loss in the chest and conserve blood that can be utilized for the A-NRP.

BACKGROUND: The United Kingdom (UK) was one of the first countries to pioneer heart transplanta-tion from donation after circulatory death (DCD) donors. To facilitate equity of access to DCD hearts by all UK heart transplant centers and expand the retrieval zone nationwide, a Joint Innovation Fund (JIF) pilot was provided by NHS Blood and Transplant (NHSBT) and NHS England (NHSE). The activity and outcomes of this national DCD heart pilot program are reported. METHODS: This is a national multi-center, retrospective cohort study examining early outcomes of DCD heart transplants performed across 7 heart transplant centers, adult and pediatric, throughout the UK. Hearts were retrieved using the direct procurement and perfusion (DPP) technique by 3 specialist retrieval teams trained in ex-situ normothermic machine perfusion. Outcomes were compared against DCD heart transplants before the national pilot era and against contemporaneous donation after brain death (DBD) heart transplants, and analyzed using Kaplan-Meier analysis, chi-square test, and Wilcoxon's rank-sum. RESULTS: From September 7, 2020 to February 28, 2022, 215 potential DCD hearts were offered of which 98 (46%) were accepted and attended. There were 77 potential donors (36%) which proceeded to death within 2 hours, with 57 (27%) donor hearts successfully retrieved and perfused ex situ and 50 (23%) DCD hearts going on to be transplanted. During this same period, 179 DBD hearts were trans-planted. Overall, there was no difference in the 30-day survival rate between DCD and DBD (94% vs 93%) or 90 day survival (90% vs 90%) respectively. There was a higher rate of ECMO use post-DCD heart transplants compared to DBD (40% vs 16%, p = 0.0006), and DCD hearts in the pre pilot era, (17%, p = 0.002). There was no difference in length of ICU stay (9 DCD vs 8 days DBD, p = 0.13) nor hospital stay (28 DCD vs 27 DBD days, p = 0.46). CONCLUSION: During this pilot study, 3 specialist retrieval teams were able to retrieve DCD hearts nationally for all 7 UK heart transplant centers. DCD donors increased overall heart transplantation in the UK by 28% with equivalent early posttransplant survival compared with DBD donors.Crown Copyright (c) 2023. Published by Elsevier Inc. on behalf of International Society for Heart and Lung Transplantation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

OBJECTIVES:Around 2000 heart transplants are performed in Europe annually. The rates of primary graft dysfunction in Europe are among the highest in the world. With increasing demand for organs and the limited supply of donors, novel techniques such as ex vivo normothermic perfusion have garnered incre-asing interest. We present a series of patients who underwent heart transplant at our unit in which we used a novel implantation technique to reduce primary graft dysfunction.MATERIALS AND METHODS:We compared our experience with the novel method detailed in our article (Glasgow experience group) with a contemporary UK cohort (2015-2016) of patients (control group). We performed multivariable logistic regression to compare the Glasgow experience with the control group with primary graft dysfunction as the outcome measure. We adjusted for donor age, recipient diabetes mellitus, urgent listing status, bypass time, and total ischemic time.RESULTS:Among 194 patients in both cohorts, 140 patients (72.1%) were men and 36 (18.6%) had ischemic cardiomyopathy. The odds ratio of primary graft dysfunction in the control group was 2.99 (95% CI, 1.02- 8.75) compared with the Glasgow experience group.CONCLUSIONS:Our novel approach was associated with significant reductions in primary graft dysfunction, with a trend toward improved 1-year survival. Larger studies are needed to show differences after further adjustment for known confounders of primary graft dysfunction. We believe this novel technique is safe, cost-effective, and reproducible.

Lung transplantation is the treatment of choice for patients with end-stage lung disease. Currently, just under 5000 lung transplants are performed worldwide annually. However, a major scourge leading to 90-d and 1-year mortality remains primary graft dysfunction. It is a spectrum of lung injury ranging from mild to severe depending on the level of hypoxaemia and lung injury post-transplant.This review aims to provide an in-depth analysis of the epidemiology, pathophysiology, risk factors, outcomes, and future frontiers involved in mitigating primary graft dysfunction. The current diagnostic criteria are examined alongside changes from the previous definition. We also highlight the issues surrounding chronic lung allograft dysfunction and identify the novel therapies available for ex-vivo lung perfusion. Although primary graft dysfunction remains a significant contributor to 90-d and 1-year mortality, ongoing research and development abreast with current technological advancements have shed some light on the issue in pursuit of future diagnostic and therapeutic tools.

Purpose The donation after circulatory death (DCD) pathway is an emerging contributor to heart transplantation. Selected UK centres started their adult programs in 2015, followed by a centrally funded national pilot commencing September 2020. The purpose of this study is to review the activity and outcomes of the UK National DCD heart transplant program during this pilot. Methods Data on DCD heart transplants between September 2020 to August 2021 were extracted from the UK Transplant Registry, held by National Health Service Blood and Transplant. The Registry contains data on all offered organs from potential donors, proceeding donations and organ recipients. Additional data were collected on the DCD Heart travel document. The DCD hearts were procured by 3 specialist retrieval teams, with national organ allocation to all 7 adult and paediatric heart transplant centres. Endpoints The hearts of 143 potential DCD donors were referred for offering during this 12-month period, from all areas of the UK. This resulted in 77 acceptance, 60 retrievals, 33 hearts retrieved and 30 transplants. Direct procurement and machine perfusion was the technique used for all DCD heart retrievals with 2 hearts retrieved during abdominal normothermic regional perfusion. Six procurements were performed by a hybrid team consisting of members from 2 retrieval teams, and 21 were transplanted by a different centre to that of the retrieval team. Median donor and recipient age was 33 (range: 12-50) and 46 (range: 13-62), respectively. Seven recipients were super-urgent and 13 were urgent; with a median wait time of 20 days (range: 1-320). In the same period there were 105 adult and 18 paediatric donation after brain death (DBD) heart transplants; DCDs representing 19% and 22% of the programs, respectively. Two patients died within 30 days, making the 30-day survival rate 93.3% (95% CI: 76-98), similar to the DBD cohort. Extracorporeal membrane oxygenation in the first 30 days was required for 15 out of 30 transplants. Conclusion In the 12-month pilot, DCD heart transplantation was 20% of the total heart transplant activity. This UK wide program was underpinned by unprecedented collaboration between UK cardiothoracic teams, and with abdominal teams, improving communication and shared learning. High volume, specialised procurement teams are key to a successful DCD heart sharing program to overcome challenges from the learning curve.

Abstract Prolonged post-operative hospital stay is associated with worse patient healthcare outcomes. Aim To identify parameters which correlate with longer post-operative hospital stay (POHS) following first time Coronary-Artery-Bypass-Graft (CABG) Method Data was collected retrospectively on 50 patients who underwent a first time CABG between 12/02/2020 – 21/09/2020 at the Golden Jubilee National Hospital (GJNH). Data included patient demographics, body-mass-index (BMI), presence of co-morbidities, peri-operative blood results, pre-operative renal dysfunction, left ventricular systolic dysfunction (LVSD), severity of left main stem disease, New York Heart Association (NYHA) Functional Classification score, number of grafts, cross-clamp time and bypass time. Results The mean POHS was 7.5 days. Patients with a POHS>7.5 days had a total mean POHS twice as long (12.07 vs 5.7 days, p < 0.001). They spent more time in intensive care unit (2.6 vs 0.97 days, P = 0.05), high dependency unit (2.5 vs 1.2 days, p = 0.005) and ward (7 vs 3.5 days, p = 0.001) compared to the shorter POHS group. They had a higher mean age (69 vs 65, p = 0.036), lower mean CrCl (80.32 vs 95.14, p = 0.141), higher mean renal dysfunction severity grades (0.8 vs 0.28, p = 0.014), higher mean LVSD severity grades (0.33 vs 0.17, p = 0.35) and higher mean NYHA scores (2.2 vs 1.88, p = 0.17). More of the patients had renal dysfunction (p = 0.01), were on ≥ 2 anticoagulants (p = 0.028), had sub-optimal pre-operative bloods (p = 0.075) and required blood transfusion post-operatively (p = 0.02). One patient in the longer POHS group died. Conclusions Longer POHS was associated with older age, worse renal function, presence of co-morbidities, sub-optimal peri-operative blood levels and requirement for post-operative blood transfusions.

Abstract Introduction Blood loss following cardiac surgery is a recognised complication associated with post-operative mortality and morbidity. Aim To identify parameters associated with blood loss and need for blood transfusion following first time coronary-artery-bypass-graft (CABG). Method Data was collected retrospectively on 50 patients who underwent a first time CABG between 12/02/2020 – 21/09/2020 at the Golden Jubilee National Hospital (GJNH). Parameters included pre-operative and post-operative haemoglobin, platelets, INR, calcium levels, patient age, body-mass-index (BMI), creatinine clearance (CrCl), presence of co-morbidities, anti-coagulant drug use, cross-clamp time, bypass time, re-exploration rates and number of grafts. Patients who required a blood transfusion post-operatively were compared with those who did not require transfusion. Results Seventeen of the 50 patients required a blood transfusion. This group had a lower mean post-operative haemoglobin levels (90.82 vs 107.82, p = <0.001), lower mean post-operative platelet levels (138.47 vs 187.09, p = 0.02), higher post-operative INR (1.25 vs 1.15, p = 0.15), higher mean BMI (27.93 vs 30.433, p = 0.063), higher mean renal dysfunction severity grades (0.7 vs 0.3, p = 0.044) and lower mean CrCl (78 vs 97, p = 0.025). The transfused patient group had older mean age (68.29 vs 64.84, p = 0.065) and a longer mean post-operative hospital stay (9.38 vs 6.67 days, p = 0.043). More patients had pre-operative haemoglobin <120 (p = 0.26), post-operative haemoglobin <90 (p = <0.0001) and post-operative platelets <100 (p = 0.0029). One patient in the transfused group died post-operatively. Conclusions Sub-optimal peri-operative blood levels, renal dysfunction, patient age and patient BMI can influence blood loss and requirement for transfusion following first time CABG.

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

Central MessageOur technique demonstrates the proof-of-concept for a novel minimalist transcervical approach for ascending aortic anastomosis of a left ventricular assist device outflow graft.See Commentaries on pages 195 and 197. Minimally invasive techniques to implant centrifugal left ventricular assist devices (LVADs) have been described as alternatives to the classic full sternotomy approach. Implantation of the pump is done through a left anterior thoracotomy. The outflow graft is anastomosed to the ascending aorta via upper hemisternotomy or right anterior thoracotomy.1Schmitto J.D. Krabatsch T. Damme L. Netuka I. Less-invasive HeartMate 3 left ventricular assist device implantation.J Thorac Dis. 2018; 10: S1692-S1695Crossref PubMed Scopus (28) Google Scholar,2Ayers B. Sagebin F. Wood K. Barrus B. Thomas S. Storozynsky E. et al.Complete sternal-sparing approach improves outcomes for left ventricular assist device implantation in patients with history of prior sternotomy.Innov Technol Tech Cardiothorac Vasc Surg. 2020; 15: 51-56Crossref Scopus (7) Google Scholar The goal is to decrease periprocedural bleeding, achieve early mobilization, reduce in-hospital stay, and facilitate future sternotomies in patients where assist devices are used as a bridge to transplantation. We hypothesized that the outflow graft anastomosis could be achieved through a minimalist transcervical incision avoiding a sternotomy/right thoracotomy. This report shows evidence to support this hypothesis. This was a proof-of-concept implantation performed on a cadaveric model embalmed via the Thiel technique, which optimally preserves the consistency, color, transparency, and flexibility of tissues making it a practical model for assessing vascular surgical techniques.3Healy S.E. Rai B.P. Biyani C.S. Eisma R. Soames R.W. Nabi G. Thiel embalming method for cadaver preservation: a review of new training model for urologic skills training.Urology. 2015; 85: 499-504Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar Graft anastomosis is facilitated by a novel access system (CoreVista, CardioPrecision Ltd, Glasgow, United Kingdom) specifically designed for cardiothoracic surgery via the minimalist transcervical approach. This device comprises a frame fixed to the operating table to which is attached a single-use retractor with in-built illumination used for the different steps of the procedure. A high-definition surgical monitor is attached to the lifting arm of the frame and its position adjusted for optimal viewing by the surgeon. The monitor is encased in a sterile, disposable drape with optically clear central window to allow the graft anastomosis to be performed onscreen using long-shafted minimally invasive cardiac surgery instruments (Figure 1). The insertion of the centrifugal pump and tunneling of the outflow graft are well established and were not replicated in the cadaver. The technique for outflow graft anastomosis can be broken down in a number of reproducible and easy-to-perform steps. Firstly, a simple transverse skin crease incision is done at the base of the neck and soft tissues immediately behind the sternum and under each sternoclavicular joint are mobilized with electrocautery. The sternohyoid muscles are detached from the posterior surface of the sternum. Following introduction of the retractor and elevation of the sternum, the brachiocephalic artery is identified and followed into the chest. The innominate vein is identified and the pericardium incised just caudal to this level. The ascending aorta is then exposed and the outflow graft pulled upward. After measuring, trimming, and orienting the graft, a sideclamp is used to isolate the best anastomotic site on the ascending aorta. The aorta is incised and the outflow graft sutured in a continuous fashion using 4-0 Prolene sutures starting at the heel and working toward the surgeon on each side. The anastomosis is optimally performed onscreen using minimally invasive cardiac surgery instruments and a Derra-Cooley clamp. The specially designed illumination provided by the CoreVista Retractor as well as the in-built high-definition monitor in the line of the incision greatly facilitates surgery (Video 1). Once the anastomosis is complete, de-airing is performed either through the toe of the graft or via a root vent placed into the ascending aorta beyond the graft. Sutures are hand tied and the clamp released. The orientation of the graft is inspected with the aid of the thoracoscopic camera. Hemostasis is readily achievable through this approach, as demonstrated previously in transcervical surgical aortic valve replacement (SAVR).4Dapunt O.E. Luha O. Ebner A. Sonecki P. Spadaccio C. Sutherland F.W.H. First-in-man transcervical surgical aortic valve replacement using the corevista system.Innov Technol Tech Cardiothorac Vasc Surg. 2016; 11: 84-93Crossref Google Scholar A trial investigating the lateral thoracotomy implant approach for a centrifugal-flow LVADs could decrease bleeding complications and length of stay.5McGee E. Danter M. Strueber M. Mahr C. Mokadam N.A. Wieselthaler G. et al.Evaluation of a lateral thoracotomy implant approach for a centrifugal-flow left ventricular assist device: the LATERAL clinical trial.J Heart Lung Transplant. 2019; 38: 344-351Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar The main advantage of our new transcervical approach, performed on- or off-pump, is that it completely avoids the hemisternotomy or right-sided thoracotomy.1Schmitto J.D. Krabatsch T. Damme L. Netuka I. Less-invasive HeartMate 3 left ventricular assist device implantation.J Thorac Dis. 2018; 10: S1692-S1695Crossref PubMed Scopus (28) Google Scholar,2Ayers B. Sagebin F. Wood K. Barrus B. Thomas S. Storozynsky E. et al.Complete sternal-sparing approach improves outcomes for left ventricular assist device implantation in patients with history of prior sternotomy.Innov Technol Tech Cardiothorac Vasc Surg. 2020; 15: 51-56Crossref Scopus (7) Google Scholar This not only avoids the pain and bleeding complications of full or partial sternotomy but also eliminates the impaired lung function and potentially difficult access associated with right-sided thoracotomy. The aortic arch is also accessible for cannulation with this approach. This technique should also minimize the risk for the well-described right ventricle decompensation that is precipitated by full opening of the pericardium. This minimalist transcervical approach has already proved feasible for transcervical transcatheter aortic valve replacement and SAVR in live patients, the latter with endotracheal tube, transesophageal echocardiography probe, and central lines in situ.4Dapunt O.E. Luha O. Ebner A. Sonecki P. Spadaccio C. Sutherland F.W.H. First-in-man transcervical surgical aortic valve replacement using the corevista system.Innov Technol Tech Cardiothorac Vasc Surg. 2016; 11: 84-93Crossref Google Scholar Given the much higher complexity of SAVR, we believe that, after an initial learning curve, using this approach should be easy and reproducible. The main limitation is the use of the cadaveric model. Although this aims to replicate the anatomical conditions encountered in a live patient, some differences remain in patients undergoing surgery. Our proof-of-concept implantation study illustrates a novel approach to LVAD outflow graft anastomosis that completely avoids sternotomy or thoracotomy.

This proof of concept demonstrates that a sternotomy-free implantation of a LVAD is feasible and should prove reproducible with the help of the novel transcervical access system. The approach may also be suitable for implantation of an axial flow pump without the current limitations imposed by access vessel size.

Enhanced Recovery After Surgery (ERAS) incorporates multi-modal interventions that synergistically improve patient outcome.Its goals include improving patients functionally pre-operatively, reducing the stress of surgery intra-operatively to facilitate early return to daily activities.We conducted a pilot study at our unit recruiting patients undergoing elective coronary artery bypass grafting (CABG) into the Cardiac ERAS (C-ERAS) pilot and compared them with the patients undergoing CABG meeting the ERAS criteria but who not included the C-ERAS pilot (Control).Materials and Methods: 122 C-ERAS patients were compared to 91 control patients who underwent CABG only from the period of July 2015 to September 2016.All C-ERAS patients received pre-operative counselling by a dedicated ERAS Practitioner to manage expectations of the patient journey, health promotion and pre-operative optimisation advice.Emphasis was made on educating the patient on daily goals for recovery and patients were followed up daily by the ERAS practitioner post-operatively.Results: There were 122 patients in the C-ERAS group and 91 patients in the control group.The mean age was 63.6±9.9 years.181(85%) of the patients were males.After adjusting for the abovementioned confounders, C-ERAS patients had a shorter length of stay that was statistically significant.(2.36 days shorter (95% CI; 1.01-3.7 days; p<0.01).The difference in mean bed day costs was £1153.70 (95% CI, £553.70-£1753.7;p<0.01) less in the C-ERAS cohort. Conclusion:This study highlighted that C-ERAS is a safe and feasible pathway to reduce in-hospital stay with no difference in complications and readmission rates compared to routine management of patients.There was also a significant cost saving with the C-ERAS pathway mimicking the results in enhanced recovery programmes in the other surgical specialities.

Our implantation technique utilising AMP significantly lowers the rate of moderate and severe PGD when compared to the standard implantation technique employed by the historical cohort.

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

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

The evidence on the impact of patient-prosthesis Mismatch (PPM) on survival thus far has been conflicting. The aim of this study was to 1) study the effect of PPM on survival after isolated aortic and mitral valve replacement and 2) Assess the interaction between left ventricular function and PPM on survival. The study cohort was patients who underwent isolated Aortic valve replacement (AVR) and Mitral valve replacement (MVR) over a 10-year period from 2008 to 2018. PPM was defined using the projected indexed effective orifice area (EOAi). The cohort was divided into different groups based on the degree of PPM. The severity of PPM was classified using threshold values of EOAi used in the literature. The Kaplan- Meier method was used to compare survival by degree of PPM. Multivariate Cox proportional hazards models were used to generate adjusted hazard ratios (HR) with 95% confidence intervals. An interactive term for ejection fraction (EF) was added to test whether EF modifies the effect of the PPM grade on survival. In addition, sub-group analysis based on left ventricular function was performed. In the AVR cohort, there were a total of 1953 patients. The distribution of patients in the different PPM categories was as follows: no PPM 59.7%; moderate PPM 36.8%; severe PPM 3.5%. There was no significant difference in survival between the different groups. At 10 years, the adjusted HR between patients with severe PPM versus no PPM was 1.1(CI 0.5–2.4, p >  0.05) and the HR between those with moderate PPM versus no PPM was 0.97 (CI 0.74–1.23, p >  0.05). In the MVR cohort, there were a total of 298 patients. The distribution of PPM is as follows: no PPM 59.4%; and with PPM 40.6%. Again, there was no significant difference in survival between the groups. At 5 years, the adjusted HR between patients with PPM versus no PPM was 1.45 (CI 0.67–3.14, p >  0.05). In both groups, there was no significant interaction between left ventricular function (LVF) and degree of PPM on survival. In our study cohort, the degree of PPM was not an independent predictor of survival after AVR or MVR. There was also no significant interaction between LV function and degree of PPM on survival.