SATA

Society for the Advancement of Transplant Anesthesia

Sergio

Winter 2021 Newsletter

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In the Transplant News:

Flora Simmons, MD

UNOS Updates

  • ASTS Position Statement On The Role Of COVID-19 Vaccination For Transplant Candidates And Recipients: The American Society of Transplant Surgeons continues to recommend routine vaccination for all organ recipients (along with timely boosters). It also recommends vaccines for those on the waiting list, if possible. Read more at the ASTS Position Statement. 
  • Kidney Transplants Increase Across All Populations Following Policy Changes: Changes to kidney allocation were made in March of this year with the goal of improving access to organs and equality. Recent data shows that kidney transplants for all age groups, blood types, CPRA, and diagnoses have increased following the implementation of these new policies.  Read more at the UNOS News Section. 
  • Second Phase Of National DCD Procurement Collaborative Project Ready To Launch: UNOS has launched the second phase of a national collaborative improvement project to help organ procurement organizations (OPOs) identify and share effective practices related to recovery of donation after circulatory death (DCD) organs. Read more at the UNOS News Section.

In the Spotlight: The Miami Transplant Institute (MTI)

David Rosenfeld, MD

An affiliation between Jackson Health System and UHealth-the University of Miami Health System.

In this month’s feature we learn from Drs. Ramona Nicolau-Raducu and Yehuda Raveh some of the characteristics that are unique about MTI.  

The program is housed within the massive Jackson Memorial Hospital, one of the ten largest hospitals in the world with 2000 beds.   Year in and out they are amongst the busiest abdominal programs with a US leading 472 kidneys transplanted in 2020, including a paired exchange program.  MTI is also a front-runner in liver for the last 50 years, with over 4500 cases performed and 131 adult and 22 pediatric in 2020.  Pancreas transplant is equally robust.  For more than 20 years, and greater than 500 cases, a multidisciplinary team of experts at MTI has been treating thousands of children and adults with intestinal failure via Intestinal Rehabilitation or the Intestinal/Multivisceral Transplant Program, with outcomes well above national averages.  Along with deceased donor intestinal (~5 cases/year) and multivisceral transplants (~10-15 cases/year), autologous transplant procedures are offered.  

MTI became in recent years a bloodless center for Jehovah Witness transplants with a meticulous selection process for Jehovah’s Witness liver candidates.  A bloodless protocol has been established of using factor concentrates, hemopure (bovine hemoglobin-based oxygen carrying solution) autotransfusion and cell saver.

In February 2020 the national organ allocation system transformed from donor service area-based to an acuity circles-based model. Due to its unique geography near the tip of the Florida peninsula, the new system limits organ allocation.  As a result, use of DCD and other extended criteria grafts for liver or liver-kidney have increased, currently approximately 25% of liver grafts. In addition, patients listed for multivisceral transplantation are especially impacted by this change.  Due to specific quality requirements for suitable donors, which are typically younger and non-obese, the available donor pool is considerably smaller. Previously these patients were assigned amongst the highest status levels on the liver match run, but the current allocation model routinely prioritizes a suitable donor to a liver alone candidate that does not have the same size and quality limitations but has a high “competitive” MELD score.

The Abdominal Transplant Anesthesia Fellowship at Jackson Memorial Hospital was created in 2006 by Dr. Ernesto Pretto, Chief, Division of Transplant Anesthesia and is one of the largest in the nation with 4 fellows/year.  Transplant anesthesiology fellowships are non-ACGME accredited and are generally less popular for board eligible/certified US anesthesiology graduates, however this program has thrived through selecting highly qualified foreign graduates to consistently fill its positions.   They have graduated a remarkable 50 transplant fellows in the last 15 years (10% US graduates and 90% International).

Many thanks to Drs. Nicolau-Raducu and Yahuda for sharing details of their program. 

If interested in having your program highlighted, please contact David Rosenfeld, Mayo Clinic Arizona at Rosenfeld.david@mayo.edu

 Featured Publications in the Transplant Literature: 

Michael Trostler, MD

Living donor liver transplantation for hepatocellular carcinoma beyond the Milan criteria: outcome of expanded criteria in tumor size (Liang et al. BMC Surg. 2021) 

Since 1996 Milan criteria for hepatocellular carcinoma has been used to guide liver transplantation to those who would benefit most and restrict deceased donor organs to those with the highest likelihood of survival. Living donor transplants tend to be directed to individuals who do not meet this criteria if the donor and recipient understand the potential risk. Liang et al. out of Taiwan report on 155 patients, 78 of which were beyond Milan criteria for tumor size or number found similar outcomes and recurrence rates. They propose a new criteria: maximum tumor size <= 6cm and total tumor size < 10cm.

Challenges and opportunities for treating intrahepatic cholangiocarcinoma (Serifis et al. Hepat Med. 2021)

There is potential to expand transplant criteria for living donor liver transplantation with less stringent criteria for directed donors. In addition to the potential for an expanded hepatocellular carcinoma guideline, cholangiocarcinoma is another disease process with historically poor outcomes which may be treated by transplantation with strict selection criteria, operative staging, and neoadjuvant therapy. 

Liver transplant outcomes after ex vivo machine perfusion: A meta-analysis (Liew et al. Br J Surg. 2021)

Ex-vivo machine perfusion – Meta-analysis included 34 articles with odds ratios favoring hypothermic machine perfusion over static cold storage. Findings include: decreased early graft dysfunction, ischemic cholangiopathy, non-anastamotic strictures and graft loss. Machine perfusion was associated with shorter length of stay. Normothermic perfusion is associated with reduced graft injury. 

Machine perfusion organ preservation: Highlights from the American Transplant Congress 2021 (Pavan-Guimaraes et al. Artif Organs. 2021)

At the American Transplant Congress (June 2021) 33 abstracts on machine perfusion were presented including heart, lung, liver and kidney. Machine perfusion may become gold standard in the future as innovation and advancement bring down costs and improve outcomes. 

SATA Committee’s Update

Yong G Peng, MD, PhD

We caught up with the Quality and Standards Committee Chair, Dr. Adrian Hendrickse (Associate Professor, University of Colorado). The members of the committee have been working hard on several surveys. The first survey, led by Dr. Cara Crouch (Assistant Professor, University of Colorado), looked at Adult Liver Transplant Anesthesiology practice patterns across the US. Their research was published in the Journal of Clinical Transplantation. (Crouch et al. Clin Transplant. 2021)

Additionally, a smaller sub-committee of members are interested in living donor liver transplantation (LDLT) status. The group, headed by Dr. Tetsuro Sakai (SATA president), has investigated LDLT programs across the US. They have submitted their findings in an abstract to the 2022 IARS/AUA and ILTS meetings. They plan to prepare a manuscript of their findings. The committee has worked closely with the Korean Society of Anesthesiologists in an effort to write a collaborative review of LDLT practice, which they are planning to submit to Clinical Transplantation. 

The Q&S committee members have worked on several other research projects, including similar survey-based methods, investigating different organ transplantation services, and pursuing the development of SATA endorsed guidelines for our subspecialty.

News clips from the Executive Board of SATA

Lorenzo De Marchi, MD, Secretary, SATA

The SATA council wishes its members a happy holiday and new year.  We are always looking for ways to ensure SATA meets your needs.  Send us your suggestions.  We are listening.  Let us update you on the most recent and exciting projects in the works.  

Membership renewal:  We look forward to working with you in the upcoming year so don’t forget to renew for 2022.  There is easy access on the website. New members will receive six months free SATA membership.  Let your colleagues know. 

The SATA-Data Collection Project; a collaborative data collection project that extends the American College of Surgeons NSQIP to  anesthesia outcome measures of abdominal transplantation.  Headed by Dieter Adelman an anesthesiologist from UCSF and Stuart Greenstein, a surgeon from Montefiore.  If your center wants to participate, please reach out to Dr. Dieter Adelman (dieter.adelmann@ucsf.edu) and Dr. Sher-Lu Pai (pai.sherlu@mayo.edu) for information.

New Professional Associations: SATA and the Society for Cardiovascular Anesthesia have agreed to work together on shared interests in both heart and lung transplantation.  We thank SATA President Dr. Ted Sakai and SATA Treasurer Dr. Jiapeng Huang, in addition to  Dr. Archer Martin from SCA for their hard work on this project.

New Committee:  SATA approves new Critical Care Medicine Committee.  Please contact Dr. Ranjiit Deshpande through the SATA home link to apply and find out more.

Expanding SATA research:  Go to the web to apply for the Society’s endorsement for your research project. Submit your application to the SATA Secretary (demarchilorenzo@yahoo.com) for Council review and feedback.

Mark the calendar and pack your flipflop and sunscreen!!

The SATA annual meeting at the IARS is in Hawaii on Monday, March 21th, 2022 as an in-person meeting.  If you can’t be there don’t forget about upcoming SATA regional meetings with CME credits.  Check on the Society’s website for a complete list and dates.

Explore Educational Content

Webinars

August 2021: Rise of the Machines in Solid Organ Transplant

February 2021: Pro/Con Debate: Routine Anticoagulation in Liver Transplantation 

October 2020: Pro/Con Debate: ECMO vs Cardiopulmonary Bypass in Lung Transplantation 

June 2020: Transplant Anesthesiology during the COVID-19 Pandemic 

Vanguard Expert Lecture Series

June 2021: Evaluation for Lung Transplantation: Pulmonologist Perspective 

March 2021: Living Donor Liver Transplantation: Donor Management 

 

Fellowship Lecture Series

August 2021: Cardiovascular Assessment of Liver Transplantation Candidates 

June 2021: Multivisceral Transplantation 

May 2021: Acute Liver Failure 

 

Transplant Anesthesia Upcoming Meetings

SATA Meetings 

SATA West Coast Liver Transplant Anesthesia Meeting, December 11, 2021 9am – 12:30pm PST – Register for the Virtual Meeting

SATA Midwest Meeting, January 22nd, 2022; 8:55 am – 12:30 PM CST – Register for the Virtual Meeting

SATA National Meeting at IARS, March 21, 2022, Honolulu, HI

SATA Tristate Meeting, April 9th, 2022

Other Transplant Anesthesia Meetings

ILTS Virtual Consensus Conference January 28-29, 2022

IARS Annual Meeting March 18 – 21, 2022, Honolulu, HI

ILTS Annual Meeting May 4 – 7, 2022, Istanbul, Turkey
 
Are you enjoying the SATA Newsletter? Please fill out a quick survey!

 
BOARD OF DIRECTORS: TERM  2021 – 2022

President
Tetsuro Sakai, MD, PhD, MHA, FASA

Immediate Past President
M. Susan Mandell, MD, PhD

Founding President
Ernesto A. Pretto Jr., MD, MPH 

President-elect
Gebhard Wagener, MD

Secretary
Lorenzo De Marchi, MD

Treasurer
Jiapeng Huang, MD, PhD, FASA, FASE

Executive Council
Ranjit Deshpande MBBS
Adrian Hendrickse, BM, PgDipMEd, MAcadMEd, FRCA
Christine Nguyen-Buckley, MD
Ramona Nicolau-Raducu, MD, PhD

Newsletter Editor-in-Chief

Yong G Peng MD, PhD

 

Newsletter Editorial Board

Sennaraj Balasubramanian, MD
Amit Bardia, MD
Jiapeng Huang, MD, PhD, FASA, FASE
M. Susan Mandell, MD, PhD
Sergio Navarrete, DO
David Rosenfeld, MD
Flora Simmons, MD
Natalie Smith, MD
Michael Trostler MS, MD

West SATA Conference 2021

By

SATA WEST COAST LIVER TRANSPLANT ANESTHESIA MEETING

SATURDAY, DECEMBER 11TH, 2021 09:00 AM – 13:20 PM – PST

Course Syllabus

Program overview:

This SATA regional meeting is a virtual meeting that has been designed to provide a broad spectrum of clinicians a review of the latest updates on a variety of intra-operative and critical care management topics in Liver Transplant Anesthesia.

 

Learning objectives:

1.      To understand the concept of transfusion free liver transplantation and its limitations.

2.      To understand the concept of Extended Criteria Donors (ECD) in liver transplantation, and the effect of using grafts from ECD on perioperative and postoperative outcomes. 

3.      Discuss liver transplantation in patients with COVID related acute liver failure.

4.      Review of current developments in liver transplant anesthesia fellowship training.

5.      To understand the potential for research and quality improvement using electronic medical data.

6.      To understand challenges of performing prospective clinical trials in liver transplantation.

7.      To review the perioperative management of liver transplant recipients with hyponatremia.

8.      To review the concept of simultaneous cardiac surgery (such as aortic valve replacement) and liver transplantation.

 

Target audience: 

Specialists working in organ transplantation (e.g., transplant anesthesiologists, intensivists, transplant surgeons, other transplant medicine specialists, and CRNAs) and trainees (e.g., residents, fellows; medical students, SRNAs, and nursing students).

 

Accreditation and CME credit designation: 

SATA – The Society for the Advancement of Transplant Anesthesia, University of Pittsburgh Medical Center

 

Organizing institutions and program committee members:

Kyota Fukazawa – University of Washington, Seattle, WA

Christine Nguyen-Buckley – University of California, Los Angeles, CA

Dieter Adelmann – University of California, San Francisco, CA

 

Platform:  Zoom – virtual Webinar

 

Registration:  Registration link to follow. There will be no registration fee.

             

Program:

9:00 am – 9:10 am Welcome & Introduction

Kyota Fukazawa – University of Washington

9:10 am – 10:00 am Clinical Challenges I

Moderator: Kyota Fukazawa – University of Washington
 
Transfusion Free Liver Transplant

Sherif H. Kandil – University of Southern California
 
Extended Criteria Donors in Liver Transplantation

David M. Rosenfeld – Mayo Clinic Arizona

10:00 am – 10:05 am Break

10:05 am – 11:00 am Current Concepts

Moderator: Andrea Olmos – University of California, San Francisco
 
Liver Transplantation for Acute Liver Failure in A Patient With COVID

Kristin Kidson and Jei Park – The University of British Columbia
 
Liver Transplant Anesthesia Fellowships

Christine Nguyen-Buckley – University of California, Los Angeles

11:00 am – 11:10 am Break

11:10 am – 11:15 am SATA Address

Tetsuro Sakai – President, SATA – University of Pittsburgh

11:15 am – 12:10 pm Research

Moderator: David M. Rosenfeld – Mayo Clinic Arizona
 
The Use of Electronic Medical Data for Research and Quality Improvement in Liver Transplantation.

Rishi P. Kothari – University of California, San Francisco
 
Prospective Clinical Trials in Liver Transplantation

Dieter Adelmann – University of California, San Francisco

12:10 pm – 12:15 pm Break

12:15 pm – 1:10 pm Clinical Challenges II

Moderator: Christine Nguyen-Buckley – University of California, Los Angeles
 
Management Of Hyponatremia During Liver Transplantation

Michael Lin – University of California, Los Angeles
 
Combined Cardiac Surgery & Liver Transplantation

Colby Tanner – University of California, Los Angeles

1:10 pm – 1:20 pm Closing Remarks

Kyota Fukazawa – University of Washington

 

NOTE:

In support of improving patient care, this activity has been planned and implemented by the UPMC and SATA. The University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME).  

Physician (CME)
The University of Pittsburgh Medical Center designates this live activity for a maximum of 4.5 AMA PRA Category 1 Credit ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclaimer Statement
The information presented at this CME program represents the views and opinions of the individual presenters. It does not constitute the opinion or endorsement of, or promotion by, the UPMC Center for Continuing Education in the Health Sciences, UPMC / University of Pittsburgh Medical Center or Affiliates and University of Pittsburgh School of Medicine.  Reasonable efforts have been taken intending for the educational subject matter to be presented in a balanced, unbiased fashion and compliance with regulatory requirements. However, each program attendee must always use his/her own personal and professional judgment when considering further application of this information, particularly as it may relate to patient diagnostic or treatment decisions, including, without limitation, FDA-approved uses and any off-label uses.

 

Coagulation Current Understanding and Management: The Role of Point of Care TEG/ROTEM

By

SATA Fellow Lectures 2021-2022

Coagulation Current Understanding and Management: The Role of Point of Care TEG/ROTEM 

Aliaksei Pustavoitau, MD, MHS
Transplant Anesthesia Fellowship Program Director

Presenter: Aliaksei Pustavoitau, M.D.

Title: Associate Professor of Anesthesiology and Critical Care Medicine

Affiliation: Johns Hopkins School of Medicine

Date: 11/24/2021

Time: 05:00pm – 6:00am ET

Link:

https://miami.zoom.us/j/92597529210?pwd=MklCcWVXVHFSU0picDE0bnp3b2dDdz09

 

SATA South Regional Conference 2021

By

SATA SOUTH REGIONAL CONFERENCE

Members can watch the recorded South SATA Regional Meeting

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Course Syllabus

Program overview:

The SATA South Regional Conference is a virtual meeting designed to provide a focused review of the latest updates on perioperative and critical care management for heart, lung, and liver transplantations. 

 

Learning objectives:

Upon completion of the CME activity, participants should be able to:

  1. Identify current practice on transfusion and circulatory support management during lung transplant surgery. Apply patient care strategies for patients with specific conditions, such as lung diseases caused by COVID-19 or systemic sclerosis.
  2. Review the most recent updates on heart transplant immunology and primary graft dysfunction. Debate the appropriateness of donor after cardiac death for heart transplantation.
  3. Implement patient care process for preoperative optimization, perioperative thrombosis management, intraoperative extracorporeal membrane oxygenation, and postoperative fast-track in liver transplantation. 

 

Target audience: 

Anesthesiologists, intensivists, surgeons, fellows, residents, medical students, nurse anesthetists, advanced practice nurses, anesthesiologist assistants, physician assistants, and nursing staff who are involved in the perioperative care of transplant patients. 

Accreditation and CME credit designation: 

SATA (The Society for the Advancement of Transplant Anesthesia), University of Pittsburgh Medical Center

 

Program committee: 

  • Chair: Sher-Lu Pai, MD (Mayo Clinic in Florida) 
  • Michael Little, MD (University of Texas Health Science Center at San Antonio)
  • Scott Lindberg, MD (Houston Methodist Hospital)
  • Marina Moguilevitch, MD (Montefiore Medical Center, Albert Einstein College of Medicine)

 

Program:

7:55 am – 8:00 am  Welcome 

Sher-Lu Pai, MD 

Education Coordinator, Transplant Anesthesia

Assistant Professor of Anesthesiology

Mayo Clinic in Florida

 

8:00 am – 9:40 am  Adult Lung Transplantation Session

Moderator: Christopher Y. Tanaka, MD, FASE

Program Director, Adult Cardiothoracic Anesthesiology Fellowship Assistant Professor of Anesthesiology 

Montefiore Medical Center

Albert Einstein College of Medicine

 

8:00 am – 8:20 am Updates in Lung Transplantation and Blood Transfusion

Brandi A. Bottiger, MD

Director, Adult Cardiothoracic Anesthesiology Fellowship

Associate Professor of Anesthesiology

Duke University 

 

8:20 am – 8:50 am  Pro/Con in the World of Lung Transplant:  Circulatory Support During Lung Transplant Surgery

Pro: David Langdon MD

Assistant Professor of Anesthesiology

UT Health San Antonio

Con: Major Matthew D. Read, MD, USAF

Assistant Professor 

Brooke Army Medical Center

 

8:50 am – 9:10 am Case from the Real World:  Lung Transplant for Respiratory Failure Secondary to COVID-19

Jacek Jablonski, MD

Assistant Professor

UT Health San Antonio

David Langdon, MD  

Assistant Professor

UT Health San Antonio

 

9:10 am – 9:30 am Case from the Real World: Lung Transplantation Anesthetic Considerations in Systemic Sclerosis

Ashley Fritz, DO

Assistant Professor

Mayo Clinic in Florida 

Archer Martin, MD

Chair, Division of Cardiovascular & Thoracic Anesthesia

Associate Professor

Mayo Clinic in Florida

 

9:30 am – 9:40 am Q & A

 

9:40 am – 9:50 am Break 

 

9:50 am – 10:10 am SATA Presidential Address 

Tetsuro Sakai, MD, PhD, MHA, FASA 

President, SATA

 

10:10 am – 11:20 am Adult Heart Transplantation Session 

Moderator: Ryan Craner, MD

Assistant Professor of Anesthesiology

Mayo Clinic in Arizona

 

10:10 am – 10:30 am Primary Graft Dysfunction After Orthotopic Heart Transplantation

Alina Nicoara, MD 

Associate Professor of Anesthesiology

Director, Perioperative TEE Services 

Duke University

 

10:30 am – 10:50 am Transplant Immunology for Anesthesiologists

Kumar Vivek, MD

Montefiore Medical Center

Assistant Professor of Anesthesiology

Albert Einstein College of Medicine

 

10:50 am – 11:10 am Case from the Real World: 

DCD Heart Transplant

Jason Adkins, MD

Assistant Professor of Anesthesiology 

Montefiore Medical Center

Albert Einstein College of Medicine

Lauren Lisann-Goldman, MD

Fellow, Adult Cardiothoracic Anesthesiology 

Montefiore Medical Center

Albert Einstein College of Medicine

 

11:10 am – 11:20 am Q & A

 

11:20 am – 11:30 am Break

 

11:30 am – 1:10 pm  Adult Liver Transplantation Session 

Moderator: Marina Gitman, MD

Cleveland Clinic

 

11:30 am – 11:50 am ECMO and Liver Transplantation

Ryan Chadha, MD

Division Chair, Multispecialty Anesthesia

Mayo Clinic in Florida

 

11:50 am – 12:20 pm Pro/Con Debates: Coagulation vs. Thrombosis Management in Liver Transplantation

Pro: Scott Lindberg, MD 

Director, Liver Transplant Anesthesia 

Houston Methodist Hospital

Con: Julius Balogh, MD

Medical Director, Cardiovascular Intensive Care Unit

Interim Division Chief, Anesthesia Critical Care 

University of Arkansas for Medical Sciences

 

12:20 pm – 12:40 pm Fast-Track in Liver Transplantation: It is more than Early Extubation

Stephen Aniskevich, MD

Chair, Division of Hepatobiliary and Abdominal Transplant Anesthesia

Mayo Clinic in Florida

 

12:40 pm – 1:00 pm Case from the Real World: Pre-Liver Transplant Management of Coronary Artery Disease

Jawad Rashid, MD

Transplant Anesthesia 

Houston Methodist Hospital

 

1:00 pm – 1:10 pm Q & A

 

1:10 pm – 1:15 pm Closing Remarks

Sher-Lu Pai, MD 

Education Coordinator, Transplant Anesthesia

Assistant Professor of Anesthesiology

Mayo Clinic in Florida

 

In support of improving patient care, this activity has been planned and implemented by the UPMC and SATA. The University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME). 

 

Physician (CME)

The University of Pittsburgh Medical Center designates this live activity for a maximum of 5.0 AMA PRA Category 1 Credit ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

Faculty Disclosure

  • Tetsuro Sakai, MD, PhD, MHA: Springer Inc. (Book royalty)

 

No other members of the planning committee, speakers, presenters, authors, content reviewers or anyone else in a position to control the content of this education activity have relevant financial relationships with any entity producing, marketing, re-selling, or distributing health care goods or services, used on, or consumed by, patients to disclose.

 

Disclaimer Statement

The information presented at this CME program represents the views and opinions of the individual presenters. It does not constitute the opinion or endorsement of, or promotion by, the UPMC Center for Continuing Education in the Health Sciences, UPMC / University of Pittsburgh Medical Center or Affiliates and University of Pittsburgh School of Medicine.  Reasonable efforts have been taken intending for the educational subject matter to be presented in a balanced, unbiased fashion and compliance with regulatory requirements. However, each program attendee must always use his/her own personal and professional judgment when considering further application of this information, particularly as it may relate to patient diagnostic or treatment decisions, including, without limitation, FDA-approved uses and any off-label uses.

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Rise of the Machines in Solid Organ Transplantation

By

PROGRAM

“Liver Machine Perfusion: A Primer for Anesthesiologists”

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Diethard Monbaliu, Associate Professor, University Hospital Leuven Belgium

Diethard MONBALIU (°Oostende, Belgium in 1971), MD, PhD currently works as an abdominal transplant surgeon at the University Hospitals Leuven, and is associate professor at the Catholic University Leuven, Leuven, Belgium (anatomy and clinical bioethics). His current research and scientific interest focuses on liver transplantation from donation after circulatory death donors, machine perfusion preservation, modulation of ischemia/reperfusion injury, peritoneal dialysis access and physical exercise after transplantation. He is a Senior Clinical researcher granted by the Research foundation Flanders (FWO) since 2015. He is the founder and chair of Transplantoux which raises awareness regarding organ donation, motivates transplant
recipients to exercise and live a healthy life. He is the founder and chair of the international Transplantoux symposium Time to move.

“DCD Heart Transplantation: Where Do We Stand?”
Peter Neuberger, Associate Professor, NYU

Peter Neuburger is an Associate Professor in the Department of Anesthesiology, Perioperative Care & Pain Medicine at the NYU Grossman School of Medicine, where he also serves as Director of Anesthesia for the Heart Valve Center. He is active in the ASA where he lectures on transplant anesthesiology, regional anesthesia and structural heart disease. He is Chair of the Bylaws Committee for the Society of Cardiovascular Anesthesiologists and a Fellow of the American Society of Echocardiography. Dr. Neuburger serves on the Editorial Board for the Journal of Cardiothoracic and Vascular Anesthesia and the Journal of Cardiac Surgery.

“ECMO in Liver Transplantation: Does It Work?”
Greg Serrao, Assistant Professor, Director of Mechanical Circulatory Support, Mount Sinai Medical Center

Dr. Gregory Serrao joined Mount Sinai Heart and the Zena and Michael A. Wiener Cardiovascular Institute full-time faculty on July 15th, 2019 in the role of Assistant Professor of Medicine and Director of Mechanical Circulatory Support for the Cardiac Cath Lab. He earned a Bachelor’s of Science in Engineering at The Cooper Union for Advancement in Science and Art and a Master’s of Science in Biomedical Engineering at Columbia University FU School of Engineering. He then completed medical school at Mount Sinai School of Medicine where he graduated with Distinction in Research for his work in cardiac tissue engineering. Dr. Serrao completed his internal medicine residency at Columbia University’s NY Presbyterian Hospital. He then completed general cardiology fellowship at Mount Sinai, where he served as chief fellow in his final year, and continued on to an interventional cardiology fellowship at Mount Sinai, where he also served as chief fellow.

 

“Lung Transplantation on ECMO”
Barbara Wilkey, Associate Professor, University of Colorado

Dr. Wilkey earned her Bachelor of Science in Nursing in 1995. She then went on to earn her Master of Science in Physician Assistant Studies in 1999 and then her Medical degree in 2008. All three degrees from her beloved Alma Mater, the University of Florida. Dr. Wilkey came to Colorado in 2008, first to Presbyterian St. Luke’s Hospital for a Transitional Internship and then to the University of Colorado for Anesthesiology Residency and Cardiothoracic Anesthesiology Fellowship. Dr. Wilkey is currently working he University of Colorado as an Attending Anesthesiologist specializing in lung, heart and liver transplantation.

 

 

 

 

“Intraoperative CRRT for Transplant in 2021”
Michael Lin, Assistant Professor, UCLA

Dr. Michael Lin completed a combined residency in Internal Medicine and Anesthesiology and a fellowship in Critical Care Medicine at Stanford Hospital. He joined the faculty at the University of California, Los Angeles, in 2018, where he works in both the surgical and cardiothoracic ICUs, as well as on the liver transplant anesthesiology teams. He serves as the Medical Co-Director for the Emergency Response Team at Ronald Reagan UCLA Hospital. His research interests include angiotensin II use in cirrhotic patients and long-term outcomes of intraoperative anesthesia practices during liver transplantation.

Fall 2021 Newsletter

By

New SATA Leadership Announced on August 1, 2021

Tetsuro Sakai, MD, PhD, MHA is the new President. The new SATA leaderships include Gebhard Wagener, MD (President-Elect: Columbia University), Lorenzo De Marchi, MD (Secretary: Georgetown University), and Jiapeng Huang, MD, PhD (Treasurer: University of Louisville), as well as Executive Councilors Ranjit Deshpande, MD (Yale University), Adrian Hendrickse, BM, FRCA (University of Colorado), Christine Nguyen-Buckley, MD (UCLA), and Ramona Nicolau-Raducu, MD, PhD (University of Miami). Dr. M. Susan Mandell serves as the Immediate Past President. Dr. Ernest Pretto, Jr. is the Founding President. 

 To see more join SATA.

Table of Contents

  1. New SATA Leadership Announced on August 1, 2021
  2. President’s Message: SATA – Ever Innovative, Inclusive, and Fiercely Active!
  3. Webinar: Rise of the Machines in Solid Organ Transplantation
  4. In the Transplant News:
  5. In the Spotlight: University of Virginia Medical Center
  6. Featured Publications in the Transplant Literature:
  7. SATA Committee’s Update
  8. Council Meeting Update
  9. Transplant Anesthesia Upcoming Meetings

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Extracorporeal membrane oxygenation (ECMO) and peripartum emergency

By

Everett Jones, MD, and Yong G. Peng, MD, PhD, FASE, FASA

Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL

Case Description

This case describes a 20-year-old woman with a history of asthma (controlled with an inhaler) and illicit drug use who had COVID-19 infection about 1 month before her presentation. She also had a cesarean delivery due to breech position with premature rupture of membranes (at 38 weeks’ gestation) 1 month before presentation. The patient had recently begun to develop shortness of breath over time, which was not responding well to her inhaler. Her family member noted during this time that she was experiencing severe dyspnea, orthopnea, and lower extremity edema. Emergency medical services (EMS) were called after the patient became dyspneic and developed chest pain. While en route to the hospital, she became encephalopathic and her airway was deteriorating. EMS placed a laryngeal mask airway (LMA) after two failed intubation attempts. On arrival to the emergency department, she was pulseless and her rhythm appeared to be pulseless electrical activity (PEA). She had return of spontaneous circulation (ROSC) after successful CPR and intubation. Her urine drug screen was positive for amphetamines, cannabinoids, and opiates. Her troponin levels continued to increase throughout the first 2 days of her admission from 3873 pg/mL to 8303 pg/ml. She received broad spectrum antibiotics for persistent leukocytosis secondary to possible pneumonia. A transthoracic echocardiogram (TTE) revealed new biventricular dysfunction with a left ventricular ejection fraction (LVEF) of 15% to 20%. She was taken to the catheterization laboratory, where she underwent left heart catheterization that did not show coronary artery disease. An intra-aortic balloon pump was placed for circulatory support. She was diagnosed with postpartum/COVID-induced cardiomyopathy and taken directly from the catheterization laboratory to the operating room for central veno-arterial extracorporeal membrane oxygenation (VA ECMO) cannulation. 

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Evaluation with Transesophageal Echocardiography of Pulmonary Artery Anastomoses during Orthotopic Lung Transplantation

By

Michael Curtis, MD

University of California, San Francisco

Introduction

Lung transplantation remains only a class IIb indication for intraoperative monitoring via transesophageal echocardiography (TEE) in existing guidelines.1 However, some have suggested that TEE should become routine during these procedures2, given the multiple and varied impacts to the cardiovascular system throughout such a case (e.g., pulmonary artery clamping, reperfusion injury, air embolization, etc.) TEE may also be able to quickly detect obstruction at the pulmonary artery (PA) anastomosis at the pulmonary arteries and making immediate intraoperative revision possible if needed. While no society guidelines exist for diagnosing such a life-threatening complication on intraoperative TEE, there are many recommendations one may use to guide their evaluation.

Incidence and Related Complications

Obstruction of a pulmonary artery anastomosis is rare – it was reported in approximately 3% of lung transplantations reviewed in a recent meta-analysis by Kumar et al.3 A multitude of etiologies have been implicated, including donor-recipient size mismatch, external compression from surrounding tissue, twisting and/or kinking, thrombosis, and suture obstruction.3,4 Those with restrictive lung disease and females also appear to be at higher risk of PA obstruction. Finally, obstruction at the pulmonary arterial sites is generally accepted to be more common than at their venous counterparts, which is thought to result from differences in the surgical technique required at the different anastomotic sites.4,5

            Although relatively rare, such obstruction at a pulmonary artery anastomosis cannot be taken lightly: once diagnosed, the rate of mortality approaches nearly 25%.3 There are also associated complications that may result, such as graft failure, persistent hypoxemia, prolonged need for mechanical ventilation, and right-heart failure.3,5 These potentially devastating consequences highlight the importance of having high index of suspicion for such a lesion. For example, early clinical signs may be hemodynamic instability, pulmonary hypertension, a diminished capnography tracing, or unexplained hypoxemia or acidosis should all be concerning to providers.6,7

Role of Transesophageal Echocardiography

            With regards to objective testing, pulmonary angiography is regarded as being the gold standard for diagnosis of stenosis at the pulmonary artery anastomosis, given its imaging quality and ability to immediately intervene on the findings with catheter-based techniques.4 However, intraoperative TEE is able to provide much earlier insight into possible complications with an anastomotic site, allowing for immediate surgical revision and avoidance of any related post-operative complications.

            Unfortunately, consensus guidelines on the diagnosis of obstruction at a PA anastomosis by echocardiography do not exist. However, multiple measures have been proposed (Table 1), including the intraluminal narrowing of the pulmonary artery graft to 75% or less of the diameter of the native, ipsilateral PA, as put forth by Hausmann et al. in their 1992 publication.8 Other suggested measures that should be concerning are a mean velocity through the pulmonary artery of 2.6 m/s or greater, a gross PA diameter of less than  0.8 cm, the presence of turbulent flow on color doppler, and elevated pressure gradients across the anastomosis.3 What precisely constitutes an elevated gradient at the PA anastomosis itself lacks wide-agreement, though some having put forth using the American Society of Echocardiography (ASE) guidelines for pulmonary valve stenosis as a guide7, while others recommend that gradients should be of concern once 57 mm Hg or higher.3

            Interrogation of related structures by echo, such as the pulmonary veins, may also provide hints as to the functioning of the pulmonary arteries. For example, impaired flow as demonstrated by doppler (e.g., blunted S or D waves) or thrombosis due to stasis in the ipsilateral pulmonary veins may also be concerning for PA anastomotic obstruction.7 Similarly, evidence of increased perfusion through the contralateral pulmonary veins (e.g., increased velocities) may be a sign that a significantly greater proportion of right-heart output is going through one pulmonary artery due to the other being obstructed.

            Unfortunately, evaluation by the pulmonary arteries with TEE is inherently limited by anatomy. For example, the relative inability to evaluate the left pulmonary artery due to interference from the adjacent left mainstem bronchus. The relative orientation of the pulmonary arteries to the echo probe may also make it challenging to line up a doppler beam and obtain accurate velocities or pressure gradients. If concerned, other options that may be used intraoperatively include epipulmonary artery ultrasonography (i.e., direct, external contact with an ultrasound probe manipulated by surgical team), which one study has shown to be superior for imaging the left pulmonary artery than TEE itself.9 The surgeon may also directly cannulate the pulmonary artery of concern and measure a true pressure gradient by pullback technique.

Post-Operative Endovascular Interventions

Given that intraoperative diagnosis by TEE can be challenging, and that nearly 75% of patients diagnosed with PA obstruction post-operatively require some sort of procedural intervention3, it is fortunate that options exist now outside of open surgical techniques. For example, multiple reports of successful endovascular stenting have been published.10-12 Although balloon angioplasty alone is regarded as less useful in high-grade stenosis due to arterial elastic recoil10, it has still been shown to be successful in some cases.13

Conclusion

Although use of intraoperative TEE is not yet the standard of care during lung transplantation, it may provide information both critical to the hemodynamic management of the patient, as well as possible complications in the surgical procedure. Specifically, obstruction at a pulmonary artery anastomosis – a rare complication with high morbidity and mortality – may be caught early enough with thorough echocardiographic investigation to revise intraoperatively. However, it is important to remember inherent limitations of TEE prevent it from being a panacea for lesions at this location, and that sometimes it must be supplemented with alternative intraoperative or post-operative techniques when there is sufficient concern.

 

Table 1 – Signs Suggestive of Pulmonary Artery Anastomosis Obstruction on Transesophageal Echocardiography (TEE)
Gross Inspection of the Pulmonary Artery ·      Presence of an obstructive mass (e.g., thrombus)
Intraluminal Diameter ·      ≤ 75% of the native, ipsilateral pulmonary artery

·      < 0.8 cm intraluminal diameter
Pulmonary Artery Mean Velocity ·      ≥ 2.6 m/s
Color Doppler ·      Evidence of turbulent flow
Peak Pressure Gradient ·      No widespread agreement – however, suggestions to use gradients ≥ 57 mm Hg or ASE guidelines for grading pulmonary valve stenosis (i.e., mild < 36 mm Hg, moderate 36-64 mm Hg, and severe > 64 mm Hg)14 as a framework

 
Ipsilateral Pulmonary Veins ·      Evidence of diminished flows (e.g., blunted S or D waves) or stasis (e.g., presence of thrombus)

 
Contralateral Pulmonary Veins ·      Evidence of significantly increased flows (e.g., elevated velocities)

 

* American Society of Echocardiography (ASE)

 

 

 

 

References

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  2. Iyer MH, Bhatt A, Kumar N, Hussain N, Essandoh MK. Transesophageal Echocardiography for Lung Transplantation: A New Standard of Care? J Cardiothorac Vasc Anesth. 2020;34(3):741-3. Epub 2019/11/11. doi: 10.1053/j.jvca.2019.10.025. PubMed PMID: 31706852.
  3. Kumar N, Hussain N, Kumar J, Essandoh MK, Bhatt AM, Awad H, et al. Evaluating the Impact of Pulmonary Artery Obstruction After Lung Transplant Surgery: A Systematic Review and Meta-analysis. Transplantation. 2021;105(4):711-22. Epub 2021/03/25. doi: 10.1097/TP.0000000000003407. PubMed PMID: 33760790.
  4. Siddique A, Bose AK, Ozalp F, Butt TA, Muse H, Morley KE, et al. Vascular anastomotic complications in lung transplantation: a single institution’s experience. Interact Cardiovasc Thorac Surg. 2013;17(4):625-31. Epub 2013/06/22. doi: 10.1093/icvts/ivt266. PubMed PMID: 23788195; PubMed Central PMCID: PMCPMC3781793.
  5. Clark SC, Levine AJ, Hasan A, Hilton CJ, Forty J, Dark JH. Vascular complications of lung transplantation. Ann Thorac Surg. 1996;61(4):1079-82. Epub 1996/04/01. doi: 10.1016/0003-4975(96)00003-3. PubMed PMID: 8607660.
  6. Tan Z, Roscoe A, Rubino A. Transesophageal Echocardiography in Heart and Lung Transplantation. J Cardiothorac Vasc Anesth. 2019;33(6):1548-58. Epub 2019/02/03. doi: 10.1053/j.jvca.2019.01.005. PubMed PMID: 30709594.
  7. Abrams BA, Melnyk V, Allen WL, Subramaniam K, Scott CD, Mitchell JD, et al. TEE for Lung Transplantation: A Case Series and Discussion of Vascular Complications. J Cardiothorac Vasc Anesth. 2020;34(3):733-40. Epub 2019/10/02. doi: 10.1053/j.jvca.2019.09.005. PubMed PMID: 31570240.
  8. Hausmann D, Daniel WG, Mugge A, Heublein B, Hamm M, Schafers HJ, et al. Imaging of pulmonary artery and vein anastomoses by transesophageal echocardiography after lung transplantation. Circulation. 1992;86(5 Suppl):II251-8. Epub 1992/11/01. PubMed PMID: 1424008.
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  10. Waurick PE, Kleber FX, Ewert R, Pfitzmann R, Bruch L, Hummel M, et al. Pulmonary artery stenosis 5 years after single lung transplantation in primary pulmonary hypertension. J Heart Lung Transplant. 1999;18(12):1243-5. Epub 1999/12/28. doi: 10.1016/s1053-2498(99)00091-1. PubMed PMID: 10612386.
  11. Grubstein A, Atar E, Litvin S, Belenky A, Knizhnik M, Medalion B, et al. Angioplasty using covered stents in five patients with symptomatic pulmonary artery stenosis after single-lung transplantation. Cardiovasc Intervent Radiol. 2014;37(3):686-90. Epub 2014/02/11. doi: 10.1007/s00270-013-0758-0. PubMed PMID: 24510277.
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New Leadership at SATA

By

Tetsuro Sakai MD, PhD, MHA, FASA
SATA President

 

New leadership of SATA is announced on August 1, 2021. Tetsuro Sakai, MD, PhD, MHA is the new President.

The new SATA leaderships include Gebhard Wagener, MD (President-Elect: Columbia University), Lorenzo De Marchi, MD (Secretary: Georgetown University), and Jiapeng Huang, MD, PhD (Treasurer: University of Louisville), as well as Executive Councilors Ranjit Deshpande, MD (Yale University), Adrian Hendrickse, BM, FRCA (University of Colorado), Christine Nguyen-Buckley, MD (UCLA), and Ramona Nicolau-Raducu, MD, PhD (University of Miami). 

Dr. M. Susan Mandell serves as the Immediate Past President. Dr. Ernest Pretto, Jr. is the Founding President.