Monday, 14 March 2016

Transplantation of the heart after circulatory death of the donor: time for a change in law? MJA September 2015.

The author suggests that heart procurement after circulatory death does not conform to present statute law. He states that for a transplanted heart to function and sustain life in a recipient, it must mean that the circulation of the donor is never ceased irreversibly and therefore that the donor of the heart is never dead until his or her heart is removed. The author concludes that medical personnel involve in heart procurement after DCD could face criminal charges if the definition of death in the law is not changed. As anaesthetists are often present at organ harvests this article provides us with some food for thought.

Perioperative bridging anticoagulation in patients with atrial fibrillation. NEJM August 2015.
This BRIDGE trial is a randomised, double-blind, placebo-controlled trial involving 1884 patients with atrial fibrillation requiring perioperative interruption of warfarin therapy. These patients were assigned to receive bridging and no bridging anticoagulation. The primary outcome were arterial thromboembolism (stroke, systemic embolism, or TIA) and major bleeding. The incidence of arterial thromboembolism was 0.4% in the no-bridging group and 0.3% in the bridging group (significant for noninferiority). The incidence of major bleeding was 1.3% in the no-bridging group and 3.2% in the briding group (significant for superiority). The paper concludes that in patients with AF who had warfarin treatment interrupted for an elective operation, forgoing briding anticoagulation was noninferior to perioperative bridging with LMW heparin for prevention of arterial thromboembolism and decreased the risk of major bleeding. Some limitations of the study include few patients had CHADS2 score of 5 or 6 (mean score 2.3), patient undergoing major surgical procedures associated with high rates or arterial thromboembolism and bleeding were excluded, and overall rates of arterial thromboembolism was lower than expected which potentially affected the power of the trial.

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