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A persistent challenge that has limited access and delivery of digit replantation surgery is timing, as ischemia time has traditionally been considered an important determinant of success. However, reports that the viability of amputated digits decreases after 6 hours of warm ischemia and 12 hours of cold ischemia are largely anecdotal. This review evaluates the quality and generalizability of available evidence regarding ischemia times after digit amputation and reported outcomes of “delayed” replantation. We identify substantial limitations in the literature supporting ischemia time cutoffs and recent evidence supporting the feasibility of delayed digit replantation. The current treatment approach for amputation injuries often necessitates transfers or overnight emergency procedures that increase costs and limit availability of digit replantation nationwide. Evidence-based changes to digit replantation protocols could lead to broader availability of this service, as well as improved care quality.

International audience; Many variables impact islet isolation, including pancreas ischemia time. The ischemia time upper limit that should be respected to avoid a negative impact on the isolation outcome is not well defined. We have performed a retrospective analysis of all islet isolations in our center between 2008 and 2018. Total ischemia time, cold ischemia time, and organ removal time were analyzed. Isolation success was defined as an islet yield ≥200 000 IEQ. Of the 452 pancreases included, 288 (64%) were successfully isolated. Probability of isolation success showed a significant decrease after 8 hours of total ischemia time, 7 hours of cold ischemia time, and 80 minutes of organ removal time. Although we observed an impact of ischemia time on islet yield, a probability of isolation success of 50% was still present even when total ischemia time exceeds 12 hours. Posttransplantation clinical outcomes were assessed in 32 recipients and no significant difference was found regardless of ischemia time. These data indicate that although shorter ischemia times are associated with better islet isolation outcomes, total ischemia time >12 hours can provide excellent results in appropriately selected donors.

Many patients die while waiting for a heart transplant. Therefore, it is vital that all suitable organs are used for transplantation. We present a case of an allograft that was transplanted twice and outline considerations regarding tissue typing, the impact of repeated ischemic time, and ethical considerations with allograft retransplantation. (Level of Difficulty: Intermediate.), Central Illustration

In 2018, the Organ Procurement and Transplantation Network (OPTN) modified adult heart allocation to better stratify candidates and provide broader access to the most medically urgent candidates. We analyzed OPTN data that included waiting list and transplant characteristics, geographical distribution, and early outcomes 1 year before (pre: October 18, 2017-October 17, 2018) and following (post: October 18, 2018-October 17, 2019) implementation. The number of adult heart transplants increased from 2954 pre- to 3032 postimplementation. Seventy-eight percent of transplants in the post era were for the most medically urgent (statuses 1-3) compared to 68% for status 1A in the pre era. The median distance between the donor hospital and transplant center increased from 83 to 216 nautical miles, with an increase in total ischemic time from 3 to 3.4 hours (all P < .001). Waiting list mortality was not different across eras (14.8 vs 14.9 deaths per 100 patient-years pre vs post respectively). Posttransplant patient survival was not different, 93.6% pre and 92.8% post. There is early evidence that the heart allocation policy has enhanced stratification of candidates by their medical urgency and broader distribution for the most medically urgent candidates with minimal impact on overall waiting list mortality and posttransplant outcomes.

Virtual surgical planning (VSP) promises higher accuracy, efficiency, and superior patient outcomes, helping normalize outcomes from surgeons of different experience levels. A systematic review was conducted in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The objective was to evaluate the accuracy and secondarily efficiency of VSP compared with free-hand surgery, for mandibular reconstruction with free flaps. Six studies met inclusion criteria and had quantitative data suitable for meta-analysis. Intercondylar distance and gonion angle were used to assess accuracy, evaluated by mean change from preoperative VSP and postoperative imaging. The mean weighted difference in VSP intercondylar distance was 2.0 mm, compared with 3.9 mm for free hand (P=0.101) and mean change in gonion angle for VSP was 3.6°, compared with 7.7° for free hand (P

End-of-life vital organ transplantation involves singular ethical issues, because survival of the donor is impossible, and organ retrieval is ideally as close to the death of the donor as possible to minimize organ ischemic time. Historical efforts to define death have been met with confusion and discord. Fifty years on, the Harvard criteria for brain death continue to be problematic and now face significant legislative efforts to limit their authority.

The aim of the study was to assess if there is a time difference (operative time, ischemia time, planning time and hospitalization) between computer-assisted surgery (CAS) and conventional planning in cranio-maxillofacial surgery. An electronic search was performed in June 2018. Studies comparing time difference between CAS and traditional planning were included. 28 publications were included, with 536 patients in the CAS group and 784 in the control group. 18 studies reported on mandibular/maxillary reconstruction and a meta-analysis was conducted on 15 of these studies. This meta-analysis was undertaken to demonstrate the difference between the groups regarding operative time, ischemia time and hospitalization for mandibular/maxillary reconstruction and showed a decreased operative time for the CAS group with a mean difference of -84.61 min, 95% confidence interval [-106.77, -62,45], p 0.001. Ischemia time was also decreased, with a mean difference of -36.14 min, 95% confidence interval [-50.57, -21.71], p 0.001. This systematic review and meta-analysis suggests that CAS is shortening the operative time and ischemia time for mandibular/maxillary reconstruction. It also leads to a reduction in hospitalization. Additionally, CAS seems to shorten the preoperative planning time for orthognathic surgery.

Background Pre-hospital triage with ECG-transmission may reduce time to reperfusion in patients with ST-elevation acute myocardial infarction (STEMI). Less, however, is known on potential benefit of ECG-transmission triage in mountain areas, with complex orography. Methods Patients admitted for STEMI and primary coronary angioplasty (pPCI) in a mountain area served by a single cathlab and triaged with ECG-transmission were enrolled in the study and compared with controls: patients' demographics and time to coronary wire were recorded. Results Forty-seven consecutive patients were enrolled in the study: 23 patients following ECG transmission and 24 STEMI patients who presented directly to the Emergency Department. At multivariable regression analysis, pre-hospital ECG-transmission electrocardiogram was an independent predictor of shorter time-to-wire (beta −0.34, p 30 min, ECG-transmission triage achieved time-to-wire times 20% shorter. Excluding unreducible transport time, avoidable delay was reduced by 38% in the whole population, by 48% in case of peripheral areas (transport time > 30 min from cathlab) and elderly (>80 years) patients (p Conclusions Pre-hospital triage with ECG-transmission is associated with shorter ischemic time even in mountain areas with a complex orography profile. The benefit is greater in elderly patients and remote areas.

Surgical management of thoracoabdominal aortic aneurysms is complex. In particular, maintaining adequate spinal cord and reno-visceral protection during the operation can be challenging. We describe here a branch-first technique developed at our institution, endeavoring to minimized renal and visceral organ ischemic time, decrease risk of spinal cord injury, and provide a controlled and uncluttered field in which the surgeon can operate.

The safe ischemic time after a single-dose del Nido cardioplegia (DNC) infusion has not yet been established. This study evaluated the progression of myocardial ischemic injury to establish the safe ischemic time after a single-dose DNC infusion in the human heart using a transmission electron microscope.Seven hearts extracted from heart transplant recipients after infusion of 1000 mL single-dose DNC were evaluated. Serial left ventricular myocardial tissue samples were collected every 30 minutes for 180 minutes. Ischemic injuries in the mitochondria and nuclei were scored from 0 to 3 (0 = normal, 0.5 = slight, 1 = moderate, 2 = severe, and 3 = irreversible).At the time of extraction, 83.5% of the mitochondria were normal. The proportion of mitochondria with moderate ischemic injury increased gradually from 1.4% at extraction to 52.5% at 180 minutes. From 90 minutes to 180 minutes, the proportion of mitochondria with severe and irreversible injury increased from 0.8% to 4.4% and 0.3% to 1.3%, respectively. A significant linear correlation was identified between the average ischemic injury score of mitochondria and ischemic time (P .001). Most nuclei showed moderate to severe ischemic injury at every time point (61.0%-85.2%). A significant linear correlation was also found between the average ischemic injury score of nuclei and ischemic time (P .001).Myocardial ischemic injury progresses gradually, and irreversible ischemic injury begins to occur 90 minutes after initial DNC infusion in the adult human heart. Therefore, redosing of DNC may be required after 90 minutes of aortic crossclamp time during adult cardiac surgery.

The COVID-19 pandemic had an unexpected impact on cardiovascular emergencies, particularly STEMI. The France PCI registry and other studies around the world have highlighted a significant decrease in myocardial infarctions arriving at hospital. This decrease is mainly related to patients' fear of coming to the hospital and being contaminated. Although the STEMI revascularisation time targets (

Nephron mass preservation is a key determinant of functional outcomes after partial nephrectomy (PN), while ischemia plays a secondary role. Analyses focused specifically on recovery of the operated kidney appear to be most informative, yet have only included limited numbers of patients.To evaluate the relative impact of parenchymal preservation and ischemia on functional recovery after PN using a more robust cohort allowing for more refined perspectives about ischemia.A total of 401 patients managed with PN with necessary studies were analyzed for function and nephron mass preserved specifically within the kidney exposed to ischemia.PN.The nephron mass preserved was measured from computed tomography scans2 mo before and 3-12 mo after PN. Patients with two kidneys were required to have nuclear renal scans within the same timeframes. Recovery from ischemia was defined as the percent function preserved normalized by the percent nephron mass preserved. Pearson correlation was used to evaluate relationships between functional recovery and nephron mass preservation or ischemia time. Multivariable linear regression assessed predictors for recovery from ischemia.The median tumor size was 3.5cm and the median RENAL score was 8. Cold and warm ischemia were utilized in 151 and 250 patients, and the median ischemia time was 27 and 21min, respectively. The function preserved was strongly correlated with nephron mass preserved(r=0.63; p0.001). Median recovery from ischemia was significantly higher for hypothermia (99% vs 92%; p0.001) and remained consistently strong even with longer duration. Multivariable analysis demonstrated that recovery from ischemia, which normalizes for nephron mass preservation, was significantly associated with ischemia type and duration (both p0.05). However, each additional 10min of warm ischemia was associated with only a 2.5% decline in recovery from ischemia. Limitations include the retrospective design.Our data suggest that functional recovery from clamped PN is most reliable with hypothermia. Longer intervals of warm ischemia are associates with reduced recovery; however, incremental changes are modest and may not be clinically significant in patients with a normal contralateral kidney.Functional recovery after clamped partial nephrectomy is primarily dependent on preservation of nephron mass. Recovery is most reliable when hypothermia is applied. Longer intervals of warm ischemia are associated with reduced recovery; however, the incremental changes are modest.

We evaluated the effects of three-dimensional virtual planning and the use of a plate-embedded surgical guide in mandibular reconstruction with microvascular fibula flaps.We retrospectively reviewed 35 patients who underwent primary mandibular reconstruction with a free fibula flap. They were divided into three groups according to the therapy they received. In group A, 12 patients underwent reconstruction using the modified surgical guide system, including virtual surgeries, pre-bent titanium plates, screw-predesignated cutting guides for mandibular and fibular osteotomies, and plate-embedded shaping guides. In group B, 14 patients underwent reconstruction using the common surgical guide system, including virtual surgeries, cutting guides and pre-bent plates. In group C, 9 patients underwent reconstruction based on the surgeon's experience. All cases were reviewed for the total operative time, ischemia time of the fibula flaps, accuracy of surgery, and postoperative complications.All of the fibula flaps survived. In group A, the ischemia time was shorter than that of groups B and C (P .05). The average gonion and condyle shift was lower in group A than in groups B and C (P .01).Application of the screw-predesignated and plate-embedded surgical guide system can reduce the ischemia time and operation time in mandibular reconstruction with a fibula flap, and can increase reconstruction accuracy. This method is a precise and highly reliable technique for improving the clinical outcome of mandibular reconstruction.

Purpose Wider regional sharing of donor hearts under the new allocation system has led to significantly longer ischemic times (IT). Prior reports suggest longer IT increase the risk of post-heart transplantation (HTx) mortality. We sought to determine the effect of IT on HTx survival under the new allocation system. Methods The United Network for Organ Sharing (UNOS) database was queried for all candidates listed and transplanted from October 2018 to March 2020. Recipients were stratified into quartiles based on organ IT. Univariate analysis was performed using the Kaplan-Meier method. The adjusted association between IT and post-HTx survival was assessed using Cox proportional hazards models. Results A total of 2696 HTx recipients were included in this study. Median ischemic time was 3.5 hours (interquartile range 2.8-4.0). 180-day post-HTx survival was 94.4% for recipients with IT 4 hours (quartile 4) (log-rank p=0.15) (Figure 1). Compared to quartile 1, quartiles 2 and 3 achieved similar post-HTx survival (quartile 2: aHR 1.21, 95% CI 0.78-1.88, p=0.41; quartile 3: aHR 1.24, 95% CI 0.80-1.93, p=0.337), although hazard of death was significantly higher in quartile 4 (aHR 1.55, 95% CI 1.02-2.35, p=0.04). Conclusion HTx recipients with IT greater than 4 hours may be at higher risk of mortality under the new donor heart allocation system. Offers with longer IT require careful consideration for acceptance.

One of the keys to successful cardiac transplantation is preservation of the heart during explantation, transport and implantation. To date the most commonly used method has been cold static storage and this currently remains the only method available for pediatric recipients. However, there has long been interest in continuous perfusion of the donor organ during the ex vivo period to mitigate the effects of ischemia and this is now becoming a clinical reality for adult recipients with good short and early midterm results. Data to date however suggests that the greatest benefit lies in preserving marginal organs, especially those following circulatory death, or when a prolonged ischemic time can be predicted.

Since the advent of the Kidney Allocation System (KAS), matched candidates with high (>98%) panel reactive antibody (hPRA) are given priority over local candidates with lower PRA. This often leads to exporting of kidneys. Data for these kidneys are not detailed on routine reports. Twenty-two organ procurement organizations prospectively submitted data from August 2015 to July 2016, describing allocation practices of kidneys to hPRA patients and outcomes of these kidneys. Five hundred twenty out of 6924 procured kidneys were exported for hPRA recipients. Of these, 402 (77.3%) were transplanted into the intended recipient (IR); 100 (19.2%) were transplanted into unintended recipients (UR), and 18 (3.5%) were discarded. The most common reason for use in an UR was a positive crossmatch (XM) (63%). The most common reasons for discard were donor quality (44%) and ischemic time (39%). Prior to kidney export, when tissue crossmatching was done, 96.2% of the kidneys went to the IR, versus 80.7% following virtual CM, versus 56.7% when no crossmatching was performed (p < 0.0001). A significant number of kidneys exported for hPRA patients are not being used in the IR or are being discarded. The most common reason for this is positive tissue XM. We report that unintended use of the kidney was minimized when tissue was shipped and XM results were known prior to exporting the kidney.

Purpose UNOS heart allocation policy has changed with patients receiving temporary MCS being prioritized. Failure to rescue (FTR) describes a phenomenon where patients with in-hospital complications demonstrate increased 30 day mortality. We sought to identify 30 day mortality rates in BTT recipients supported with temporary MCS. Methods International Society for Heart and Lung Transplantation (ISHLT) provided de-identified patient data. Between 2005 and 2018, 63,866 heart transplant recipients ≥18 years were identified. Of these, 658 (1.0%) were bridged with VA-ECMO, 1991 (3.1%) with IABP, 11960 (18.7%) with continuous-flow LVAD. Patients who underwent re-operative heart transplantation were excluded. Results Patients who were pre-operatively supported with VA-ECMO were younger when compared to the IABP or LVAD group. Donors were more likely to be older, female, and with a slightly longer ischemic time when transplanted into VA-ECMO recipients compared to IABP or LVAD recipients (Table 1). Kaplan-Meier analysis demonstrated a post-transplant survival of 81% (124/658 VA-ECMO), 95% (104/1991 IABP), 95% (552/11960 LVAD), at 30 days (p Conclusion BTT with VA-ECMO is associated with decreased 30-day survival compared to IABP or LVADs. With the prioritization of patients transplanted from temporary MCS, multi-institutional collaborative efforts are necessary to define if FTR versus specific donor or recipient factors contribute to this survival differential.

Purpose In October 2018, a new heart allocation policy was implemented. The new system was intended to decrease time on the wait list and prioritize allocation to the sickest patients. We examined the effects of this new policy on heart transplant recipients who underwent transplant one year prior to and one year after the policy change. Methods Adult patients who underwent heart transplant at our institution from October 2017 to September 2019 were identified and divided into two cohorts based on whether the date of transplant was before or after October 2018. Patient demographics, clinical data, and bridging strategy were recorded. Early outcomes studied included ischemic time, presence of severe PGD, need for renal replacement therapy or tracheostomy, duration of ICU stay, and total hospital stay. Results In total, 66 patients were identified. 38 patients were transplanted the year prior to the allocation change and 28 patients the year after. The most common listing status prior to the change was Status 1B (74%) and after was Status 2 (54%). After the allocation change, there was a decrease in average wait-time to transplant (313 days vs. 53 days, p=.04). In addition, patients were more likely to be inpatient prior to their transplant (11% vs. 68%, p Conclusion Implementation of the new allocation system resulted in dramatic changes in the bridging strategy utilized at our institution. The number of patients supported with durable LVADs prior to transplant was substantially decreased and the use of temporary mechanical support increased following the change. Early post-transplant outcomes appear similar. Further investigation is needed to assess the long-term impact of the allocation change.

Purpose To evaluate the effect of the new donor heart allocation system on waitlist and post-transplant (HTx) mortality in candidates listed with a durable left ventricular assist device (LVAD). Methods The United Network for Organ Sharing (UNOS) database was queried for adults listed for heart transplantation with a durable LVAD between October 2015 and August 2020. Fine-Gray competing risks analysis was utilized to examine the association between implementation of the new donor heart allocation system and removal from the waitlist due to death or worsening clinical condition among candidates listed with a durable LVAD. Post-HTx survival was examined using Kaplan-Meier estimates and Cox proportional hazards analysis. Results 3399 (67.3) of the 5052 candidates included in this study were listed under the old system. Listing under the new system provided significant protection from waitlist removal due to death or clinical deterioration within 365 days (HR: 0.70, 95% CI: 0.53-0.91, p=0.01) of listing (Figure A). Of these candidates, HTx recipients under the new system were more likely to experience death or retransplant within 365 days of HTx (HR: 1.84, 95% CI 1.42-2.40, p Conclusion Candidates listed with a durable LVAD experience less waitlist morbidity and mortality under the new system compared to the old system, although post-HTx survival may suffer. This could be representative of wider regional sharing of organs and associated increases in ischemic time.

Purpose As donor criteria expand to meet increasing demand for transplantable hearts, increased focus has fallen on mitigating risk associated with extended criteria donors. It has been postulated that warm ischemic time may be as significant a factor as total ischemic time, and reduction is associated with better outcomes. This study investigates the impact of warm ischemic time on post-operative events and survival in orthotopic heart transplantation patients at a high-volume center. Methods From 2015 to 2020, patients who underwent heart transplantation were identified at a single institution in a prospectively maintained database with long-term clinical outcomes. After excluding heart-lung transplants and those with missing warm ischemic time, 388 patients were identified. Patients were classified in to three groups: Results Between warm ischemic time groups, there were significant differences in recipient sex, age, and body mass index (BMI), all p 0.05, as was 30-day freedom from PGD, 80.2% (85) vs 82.9% (141) vs 76.8% (86), 30-day survival, 98.1% (104) vs 98.2% (167) vs 97.3% (109), and one-year survival, 92.5% (98) vs 93.5% (159) vs 91.1% (102) (all p > 0.05). Warm ischemic time was not a predictor of one-year mortality, odds ratio (OR) 0.99 (95% CI, 0.97-1.02). In subgroup analysis with over 4 hours of total ischemic time, warm ischemic time was not a predictor of PGD, OR 0.94 (95% CI, 0.82-1.07), or one-year survival, OR 0.94 (95% CI, 0.82-1.07). Conclusion Although increased warm ischemic time did not predict increased adverse post-operative outcomes, continued emphasis on reducing total ischemic time is paramount.

Purpose Six hours has historically been regarded as the limit of acceptable ischemic time (IT) for lung allografts. However, smarter sharing of donor lungs often necessitates use of allografts with IT >6 hours. We characterized the association between IT ≥8 hours and outcomes after lung transplantation (LTx) using a contemporary cohort from a high-volume institution. We hypothesized that longer ITs do not predict greater mortality or graft failure. Methods Patients who underwent primary isolated bilateral orthotopic LTx between 1/2016-5/2020 were included. Patients bridged to LTx with ECMO or mechanical ventilation, and ex-vivo perfusion cases were excluded. Recipients were stratified by allograft IT Results Of 358 patients, 95 (26.5%) received IT ≥8h lungs. IT ≥8h recipients were more likely to be male (69.5% vs 54.4%, p=0.01) and have DCD donors (20.0% vs 5.3%, p Conclusion In a modern cohort, use of lung allografts with IT ≥8h was associated with similar perioperative outcomes and post-transplant survival. Further investigation is required to better understand how broader use impacts post-LTx outcomes and the implications for smarter sharing under an evolving national allocation policy.

Purpose New donor organ allocation systems can potentially result in longer ischemic times (IT). The purpose of this study was to evaluate the effects of longer donor IT on functional exercise capacity (FEC) after orthotopic heart transplantation (OHT). Methods Thirty OHT recipients (22 males; 180 min) and short IT (≤180 min). Comparisons in CPET performance were made between cohorts using Chi-Square, Fisher's Exact, and Wilcoxon-rank sum, and t-tests. Results 12 patients received a donor heart with long IT. Donor and recipient characteristics were not significantly associated with having a long IT. Recipient and donor characteristics were similar between groups with 73% male, median recipient age of 57.5 years [Q1-Q3: 54.0 - 65.0], and mean donor age of 36.0 years (standard deviation: 13.4) (Table 1). The 10-W ramped protocol was performed by 9/18 (50%) and 4/12 (33%) recipients with a short and long IT, respectively. The duration of CPET testing was significantly reduced in recipients with a long IT (p=0.04) despite similar outcomes in fall risk and FEC [peak oxygen consumption (VO2), metabolic equivalents and anaerobic threshold]. Conclusion In this cohort, there was no significant difference in FEC, however, duration of exercise was significantly reduced in patients with long IT. Additional research is warranted to investigate the impact of testing modality on FEC in OHT recipients as well as the association between increased IT and reduced CPET duration.

Background Organ transplantation, the treatment of choice in organ failure, is penalized by the lack of organs. Because the increase in the number of donors is not proportional throughout the different age groups, there is no increase in lung transplantations. The aim of this work was to analyze the use of available lungs and evaluate strategies that may help increase transplantations. Methods We analyzed the activity of lung transplantation in 2015, divided into various allocation programs. We also examined the surplus organs, in particular, their origin, their destination, their offer's outcome, the characteristics of the donor and the proposed organ, and the reasons for rejection. Results In 2015, 112 lung transplantations were performed: 66 (68.9%) with regional organs, 46 (41.1%) with extraregional organs; 21 (45.6%) of these were allocated as emergencies/return, and 25 (54.4%) as surplus (19 in the North macroarea, 6 in the South macroarea). The number of surplus lungs was 148: 67 from the North macroarea, 71 from the South macroarea, and 10 from abroad. No organ procured in the North macroarea was transplanted in the South macroarea, whereas 6 lungs coming from the South macroarea were transplanted in the North. Conclusions The acceptance criteria are not the same in different transplant centers and they include not only clinical parameters, but also ischemia time and composition of the waiting list at the time of the offer, quality and accessibility of the intensive care units where the donor is located, and organizational reasons. Offering organs which can not be transplanted within the region to other centers, without clinical foreclosures is a system that increases transplant activities by maximizing the available resources.

Purpose Ischemic time (IT) is an independent risk factor for patients’ functional exercise capacity (FEC) during the months following orthotopic heart transplantation (OHT). The OHT recipient's post-transplant FEC, measured in peak VO2, is directly associated with improved quality of life. There is debate in the literature about the deleterious impact of extended IT on FEC following OHT. Methods 15 OHT recipients (14 males; Results The minimal and maximal IT were 62 and 312 minutes, respectively. The median (IQR) recipient and donor characteristics are presented in Table 1. The Fisher's Exact Test between IT and FEC yielded a p value of 0.62. Conclusion Surprisingly, extended IT was not associated with decreased FEC (

Purpose In October of 2018, OPTN revised the heart allocation policy, allowing for offers from a wider geographic area for patients of higher acuity. This study aims to examine its effect on donor organ travel distance and ischemic time, which may adversely affect outcomes. Methods We performed a retrospective analysis of adult patients who received heart transplants in the OPTN database between May, 2018- May, 2019. Two cohorts were defined with respect to the policy's timeline: patients transplanted before (Era 1) or after 10/2018 (Era 2). Results We identified 2,434 patients 1,294 of whom were transplanted in era 1 and 1,140 in era 2. Age, gender, etiology, and comorbidities were similar. In era 2, IABP (7.7% vs. 22.5%, p 4 hours nearly doubled (15% vs 29%, p Conclusion Patients receiving heart transplants, especially those of higher acuity, experience longer ischemic windows and travel distances in Era 2. Future studies on the impact this trend on transplant outcomes is warranted.

Purpose The extreme difficulty of carrying out randomized studies in lung transplantation leads us to consider statistical methods derived from artificial intelligence. Previous studies in kidney and liver transplantations, as well as in heart surgery, showed better predictive ability than traditional statistical analysis to predict postoperative outcomes. Methods We analyzed a prospective database of all 410 double lung transplantations performed in our center, from January 2012 to June 2018. We used a Random Forest approach over 284 variables, in order to predict one-year mortality. Performance of the predictive model is evaluated at successive temporal stages of the transplantation process. Variables are incrementally acquired during the process, starting with patient-only variables at stage 1, ending with patient, donor and surgery-related measurements at stage 12. At each stage of the process, a machine-learning model has been trained based on available variables. A 80-20-cross-validation procedure has been performed at each stage, and repeated 40 times, resulting in a set of 40 area under ROC curve scores, whose distribution has been summarized using boxplots (median, 25 and 75 percentiles). Gini score allowed to each variable its weight in the model. Results The AUROC performance starts at 0.65 for step 1 and reaches 0.75 (figure) at the final step. Gini score found Lung Allocation Score as the best predictor of one-year mortality (3.17), followed by hyperlactatemia at second lung implantation (2.62), PaO2/FiO2 ratio at end-surgery (2.46) and age (2.35). Second lung ischemic time was a the 20th position in Gini Score (1.6). Conclusion Conclusion: Machine-learning approach is feasible to predict one-year mortality after lung transplantation. This study is encouraging to go further in the analysis of our database.

Purpose Data suggest that pediatric heart transplant (HT) centers can reduce waitlist time by expanding donor catchment vis expanded parameters including the maximal donor weight range. Contrary to donor weight ranges, little is known about the effect of increasing the donor distance (DD) range. We sought to determine whether increasing the DD range can reduce waitlist time and how well actual DD predicts ischemic time (IT). Methods All US children Results Among 4,240 children who met study criteria, the median age was 2 (IQR 0, 11) years, weight 12 (6, 35) kg, 53% had CHD. Centers varied considerably in their maximal DD range (1000-10,000 miles); median 1500 miles (Figure A). Overall, 86% of donors originated from ≤500 miles; 97% ≤1,000 miles (Figures A & B) with sharp drop-offs at 500 and 1000 miles (Figure B). After adjusting for patient factors, maximal DD range was associated with a shorter waitlist time. The correlation between actual DD and IT is fair (R=0.69) but explains only half (R2=0.49) of the variability in IT. Conclusion Pediatric HT centers vary considerably in their maximal donor distance ranges, though most donors still fall within 500-1000 miles of recipients. Increasing the maximal DD range appears is associated with a shorter waitlist time. Actual DD explains only half of the variability in IT. Further research is needed to understand the optimal regional sharing distance for organ allocation and whether contemporary navigational software could better predict IT than the linear distance to the donor hospital.

Symptom to door time, a constituent of total ischemic time is an important prognostic determinant. Current ECG recording involving long cables and training for their proper connection is major hindrance for home ECG recording. Torso limb electrode positions are both delto-pectoral grooves, right

We report a case of a 67-year-old woman who underwent an aortic valve replacement with a 23-mm Trifecta prosthesis (St. Jude Medical, St. Paul, MN, USA). We implanted Perceval S (LenoNova, London, UK) after resecting the degenerated leaflets three years later after the first operation. This strategy enabled us to reduce the ischemic time and hence simplify the surgical procedure in addition to providing excellent postoperative hemodynamics.

Purpose The purpose of this study is to look at impact of race on thoracic organ recipient (TOR) survival with respect to the donor, recipient, and donor/ recipient matching. Methods The United Network for Organ Sharing (UNOS) database was retrospectively reviewed from 1/2000-3/2018 for donor hearts or lungs. After exclusions for multiorgan transplant and age (donor Results Donor age ranged from 15-77 y (mean 33.2y, median 31y). 66% were male, and 4% were diabetic. The mean donor ejection fraction (EF) was 60% (median 60%) and ischemic time ranged from 0.04-15 hours (h) for both heart and lungs (mean 4.00h, median 3.72h). There were 9914 (17%) AA, 9081 (15%) H, and 40003 (68%) W thoracic organ donors. Adjusted 30-day and 1 year survival of TORs was 96.2% and 87.7% from AA donors, 96.2% and 87.6% from H donors, and 96.5% and 89% from W donors. This equates to a 13% reduction in 1-year survival among AA and H donors when compared to W donors (both OR=0.87; p 0.068). AA exhibited lower long-term survival when compared to W (HR=1.12; p Conclusion While there is evidence of racial disparity in survival outcomes after thoracic organ transplant matched race donor/ recipient may improve thoracic transplant survival.

Purpose In times of organ shortage and an increasing number of patients waiting for heart transplantation (htx), the decision for refusal of organs has to be made carefully. It is still discussed controversially to which extent one can accept hearts from older donors or with expected prolonged ischemic times. Methods Between 2010 and 07/2018, 108 patients underwent heart transplantation in our department. These recipients were retrospectively divided into 4 groups with regard to donor age and total ischemic time (TIT). Group 1 patients received hearts from donors Results Group 1 consisted of 42 patients, group 2, 3 and 4 of 26, 35 and 5 patients. Thirty-day mortality was 2.4 % in group 1, 7.7 % in group 2 and significantly higher in groups 3 and 4 with 22.9 % and 40 % (p Conclusion With our results we could show, that a longer ischemic time is acceptable in younger donors. However, in donors elder than 50 years organ acceptance should be made with great caution if the presumed ischemic time exceeds four hours. The decision mostly depends also on recipient´s status which may influence the willing to undergo an increased risk.

Orthotopic heart transplantation is the criterion standard treatment for end-stage heart failure and the number of recipient candidates has been increasing. Despite this increasing demand, there is limited donor organ supply. In order to surmount this challenge, we propose harvesting donor hearts from more distant locations and accepting longer cold ischemic times. The usual accepted total ischemic time limit for the transplanted human heart is up to 4 hours. Here, we report the successful use of a donor heart from 1268 miles away with a total allograft ischemic time greater than 6 hours.

BackgroundAlthough the intermittent Pringle maneuver is used for major transplant surgery, traumas, and hepatic protection, long ischemia time and reperfusion may limit some protection in Wistar rats. The aim of the study was to evaluate the protection effects of intermittent clamping in the total hepatic pedicle after a long period of ischemia and reperfusion in Wistar rats.MethodsForty-two male Wistar rats, weighing ±327.7 g, were anesthetized intravenously with sodium thiopental and given a U-shaped incision in the abdomen. The total hepatic pedicle was isolated and subjected to clamping with a microvascular clamp. Groups included were the continuous group (CG, n = 14, 40 minutes of ischemia/40 minutes of reperfusion); the intermittent group (IG, n = 14, 4 cycles a 10 minute ischemia/reperfusion 10 minutes); and the sham group (SG, n = 14, 80 minutes of observation time). Blood collection for transaminase dosage was carried out, and hepatic biopsy specimens were taken for mitochondrial respiration and histological evaluation.ResultsIn groups CG and IG, aspartate aminotransferase and alanine aminotransferase enzymes were elevated in comparison to group SG (P < .008); mitochondrias, when stimulated by use of adenosine diphosphate or carbonylcyanide p-trifluoromethoxyphenylhydrazone, had a significant decrease in mitochondrial respiration (P < .05), and the respiratory control ratio in the ischemic groups was lower (P < .03) when compared with the GS. On histological examination, 100% of the GC had lesions: 33% focal hemorrhagic necrosis, 17% sinuzoidal congestion and/or vacuolization, and 50% venous congestion; in the IG, 100% had lesions: 43% sinusoidal congestion and/or vacuolization and 57% venous congestion.ConclusionsThe intermittent total hepatic pedicle clamping for a long period of time in the Wistar rats had no efficacy in protection of liver injury.

SummaryThe suitable size of a graft is a key element in the success of liver transplantation. A small-for-size liver graft is very likely to sustain a significant degree of injury as a result of ischemia, preservation, reperfusion, and rejection. Usually, small-for-size grafts are a concern in living-donor liver transplantation rather than in deceased-donor liver transplantation. Here, we describe the successful transplantation of a liver from a 2-year-old deceased donor to a 61-year-old male recipient who suffered from liver failure related to hepatitis B. No report of successful deceased-donor liver transplantation with discrepancies between donor and recipient age and size to such an extent has been found in the literature. Despite unusually large discrepancies, with effort in minimizing the ischemic time, revised surgical techniques, and strong regenerative power of the “young” graft, the old patient's liver function gradually returned to normal. This again proves that the definition of a “suitable graft” evolves with time and experience.

This article describes the characteristics and outcomes of heart transplantations in patients aged 16 years or more in Spain from May 1984, when the technique was first used in the country. It contains a descriptive analysis of the characteristics of recipients, donors and surgical procedures and of the outcomes of all heart transplantations performed up to December 31, 2013. In 2013, 219 procedures were carried out in patients aged 16 years or more at the time of transplantation. These patients form part of the historical series of 6632 procedures carried out in this age group. In recent years, there has been progressive worsening of the clinical characteristics of recipients (i.e. 32% were aged over 60 years, 23% had severe renal failure, 19% were insulin- dependent diabetics, 27% had undergone cardiac surgery and 15% were on mechanical ventilation), donors (i.e. 45% were aged over 45 years and 25% had a recipient-donor weight mismatch >20%), and surgical procedures (i.e. 28% involved an ischemia time >4 hours and 37% were urgent). The survival rate at 1, 5, 10, and 15 years was 77%, 65%, 53%, and 37%, respectively. These figures have remained stable since 1995. Over the last few years there has been a slow decline in the number of heart transplantations performed in Spain. However, despite a clear deterioration in the clinical characteristics of recipients, donors and surgical procedures, mortality has remained comparable with that observed in neighboring countries.

To assess the influence of vascular clamping and ischemia time on long-term post-operative renal function following partial nephrectomy (PN) for cancer in a solitary kidney. This is a retrospective study including 259 patients managed by PN between 1979 and 2010 in 13 centers. Clamping use, technique choice (pedicular or parenchymal clamping), ischemia time, and peri-operative data were collected. Pre-operative and last follow-up glomerular filtration rates were compared. A multivariate analysis using a Cox model was performed to assess the impact of ischemia on post-operative chronic renal failure risk. Mean tumor size was 4.0±2.3cm and mean pre-operative glomerular filtration rate was 60.8±18.9mL/min. One hundred and six patients were managed with warm ischemia (40.9%) and 53 patients with cold ischemia (20.5%). Thirty patients (11.6%) have had a chronic kidney disease. In multivariate analysis, neither vascular clamping (P=0.44) nor warm ischemia time (P=0.1) were associated with a pejorative evolution of renal function. Pre-operative glomerular filtration rate (P

Primary graft failure is a rare, but often fatal complication of heart transplantation. Although exact mechanism of primary graft failure has yet to be elucidated, prolonged ischemia time is one of the risk factors of early dysfunction of the donor heart. Organ Care System is the only device available for ex vivo perfusion of human donor hearts in a warm beating state. In this article, we provide step-by-step instructions of its use.

Objective To construct high-fidelity, patient customized, physical, 3-dimensional (3D) models of renal units with enhancing renal lesions identified on cross-sectional imaging, which may aid patients, trainees, and clinicians in their comprehension, characterization, localization, and extirpation of suspicious renal masses. Methods Specialized software was used to import patient's diagnostic computerized tomography cross-sectional imaging into 3D printers and create physical 3D models of renal units with enhancing in situ lesions. Patients and trainees had the opportunity to manipulate the individualized model before surgical resection. Sterolithography additive manufacturing, a technique in which an ultraviolet laser is used to cure a photosensitive resin in sequential horizontally oriented layers, was used to build the models (Medical Modeling Inc., Golden, CO). Normal renal parenchyma was printed with a clear translucent resin, and red translucent resin delineated suspicious lesions. Renal vasculature and the proximal collecting system were printed in some models. Results We constructed 5 physical models of renal units with suspected malignancies before surgery. All patients successfully underwent partial nephrectomy (4 robotic and 1 open). Average ischemia time was 21 minutes, nephrometry score was 6.8, and all margins were negative. Anecdotally, patients, their families, and trainees consistently stated that the models enhanced their comprehension of the renal tumor in relation to surrounding normal renal parenchyma and hilar structures and improved understanding of the goals of the surgery. Conclusion Preoperative physical 3D models using available printing techniques can be constructed and may potentially influence both patients' and trainees' understanding of renal malignancies.

BackgroundTreatment of ST-elevation acute myocardial infarction has primary percutaneous coronary intervention as the preferred method of reperfusion. This study aimed to evaluate in-hospital outcomes of patients with ST-elevation acute myocardial infarction according to the total ischemic time until performing primary percutaneous coronary intervention.MethodsSingle-center registry of patients admitted with ST-elevation acute myocardial infarction undergoing primary percutaneous coronary intervention between March/2012 and February/2014, followed from admission to hospital discharge, and compared according to the total ischemic time (Group 1: symptom onset-to-balloon time6 and2 and lower primary percutaneous coronary intervention success rate. The incidences of death or non-fatal infarction (11.0% vs. 18.6%; p=0.08), death (8.5% vs. 16.8%; p=0.04) and acute renal failure (7.6% vs. 19.9%; p6hours presented higher clinical complexity and worse in-hospital outcomes when compared to patients treated earlier. Joint actions in different critical areas of patient care are essential to increase treatment efficacy and reduce adverse outcomes.RESUMOResultados da Interveção Coronária Percutânea Primária de Acordo com o Tempo Total de IsquemiaIntrodçãoO tratamento do infarto agudo do miocárdio com supradesnivelamento de ST tem a intervenção coronária percutânea primária como método preferencial de reperfusão. Este estudo teve como objetivo avaliar a evolução hospitalar de pacientes com infarto agudo do miocárdio com supradesnivelamento de ST, conforme o tempo total de isquemia, até a realização de intervenção coronária percutânea primária.MétodosRegistro unicêntrico, de pacientes admitidos com infarto agudo do miocárdio com supradesnivelamento de ST submetidos à intervenção coronária percutânea primária entre março de 2012 e fevereiro de 2014, acompanhados da admissão até a alta hospitalar e comparados conforme o tempo total de isquemia (Grupo 1: tempo dor-balão6 e2 e menor taxa de sucesso da intervenção coronária percutânea primária. As incidências de óbito ou infarto não fatal (11,0% vs. 18,6%; p=0,08), óbito (8,5% vs. 16,8%; p=0,04) e insuficiencia renal aguda (7,6% vs. 19,9%; p6 horas apresentaram maior complexidade clínica e pior evolução hospitalar em relagao àqueles tratados mais precocemente. Ações conjuntas em diversos pontos críticos da assistência ao paciente são fundamentais para aumentar a eficácia do tratamento e reduzir os desfechos adversos.

Both authors contributed equally to this work.Primary abdominal wall closure following small boweltransplantation is frequently impossible due to con-traction of the abdominal domain. Although abdomi-nalwalltransplantationwasreported10yearsago,thistechnique has not been widely adopted, partly due toits complexity, but largely because of concerns thatstoring the abdominal allograft until the end of aprolongedintestinaltransplantprocedurewouldcausesevereischemia-reperfusioninjury.Wereportsixcasesof combined small bowel and abdominal wall trans-plantation where the ischemic time was minimized byremotely revascularizing the abdominal wall on theforearm vessels, synchronous to the intestinal proce-dure. When the visceral transplant was complete, theabdominal wall was removed from the forearm andrevascularizedontheabdomen(n¼4),orusedtoclosethe abdomen while still vascularized on the forearm(n¼2). Primary abdominal wall closure was achievedin all. Mean cold ischemia was 305min (300–330min),and revascularization on the arm was 50min (30–60min). Three patients had proven abdominal wallrejection, all treated successfully. Immediate revascu-larization of the abdominal wall allograft substantiallyreduces cold ischemia without imposing constraintson the intestinal transplant. Reducing storage timemay also have benefits with respect to ischemia-reperfusion-related graft immunogenicity.Keywords: Abdominal wall, composite vascularizedallograft, ischemiaAbbreviations: CVA, composite vascularized allograft;LAD, loss of abdominal domain; UW, University ofWisconsinReceived 18 November 2013, revised 11 February 2014and accepted for publication 23 February 2014

Purpose The OCS Heart EXPAND Trial is a prospective, multi-center trial to evaluate the effectiveness of the OCS™ to resuscitate, preserve and assess donor hearts that may not meet current standard donor heart criteria for transplantation to potentially improve donor heart utilization for transplantation. Methods Donor hearts were eligible if they met any of the following characteristics: expected total ischemic time ≥ 4 hours or expected total ischemic time ≥ 2 hours plus at least one of the following risk factors: LVH, EF 40-50%, downtime ≥ 20 minutes, and age >55 yo. Hearts were perfused and assessed on OCS Heart System from donor to recipient. Hearts were eligible for transplantation if the following criteria were met: final OCS Heart arterial lactate Results 93 eligible donor hearts with a mean UNOS match run of 66 declines were assessed on OCS Heart. Donor categories were as follows: x-clamp time ≥ 4 hours 37%, LVH 23%, EF 40-50% were 23%, downtime ≥ 20 minutes 28%, older age 13% and 33% met multiple inclusion criteria. 75 of the 93 donor hearts were successfully transplanted resulting in a utilization rate of 81%. Mean OCS perfusion time was 6.35 hours. Incidence of severe LV or RV PGD at 24 hours was 10.7%. 30-day and 6-month survival were 94.7% and 88% respectively. Conclusion The use of OCS™ Heart System resulted in high utilization of ECD hearts with excellent short-term post-transplant outcomes, most notably a low rate of PGD. These results provide clinical evidence supporting its use in ECD heart preservation and assessment, and may significantly increase donor utilization for transplantation.

Purpose Efforts to increase the number of viable donors, such as ex vivo lung perfusion and donation after circulatory death, are likely to significantly alter allograft ischemic time distributions. As such, understanding the impact allograft ischemia has on short and long-term outcomes will be key in determining best practices going forward. Methods We conducted an ISHLT database study of adult bilateral lung transplant recipients between January 1, 2006 and June 30, 2016. We evaluated for an association between first and second lung ischemic time and short- and long-term outcomes post-transplant. We also performed regression modeling to evaluate factors associated with prolonged ischemic time. Results 13,183 recipients were included in the final analysis. Prolonged first but not second lung ischemic time was associated with decreased unadjusted 30-day survival (log-rank p=0.048) and higher rates of treated acute rejection in the first post-transplant year (p Conclusion First allograft ischemic time appears more strongly associated with increased 30-day and 1-year mortality as well as prolonged index hospitalization and increased acute rejection in the first year. This suggests that, in bilateral lung recipients, first lung ischemic time is more clinically relevant to allograft and patient outcomes.