ArticlesAdult heart transplantation with distant procurement and ex-vivo preservation of donor hearts after circulatory death: a case series
Introduction
The first successful clinical heart transplantation was done with a heart donated after circulatory death in 1967 by Christiaan Barnard and the South African Groote Schuur Hospital team.1 In that era, before the establishment of brain-stem death criteria, numerous heart transplantations were carried out around the world with the donor and recipient located in adjacent operating rooms.2 The introduction of brain-death legislation and the adoption of cardioplegic arrest and static cold preservation, enabled distant procurement and avoided the necessity of transferring donors to the recipient hospital.
Unlike hearts from brain-dead donors who still have a beating heart, for which cardiac structure and function can be assessed after death, hearts donated after circulatory death have unknown functional status, risk of occult pathology, and substantial warm ischaemic insult. The difficulties of assessing the suitability of hearts donated after circulatory death and of co-locating multiorgan donors and recipients has meant that heart transplantation has had to rely solely on donation after brain death.
New policies related to donation after circulatory death have aimed to narrow the gap between the number of patients awaiting a new heart and the number of suitable organs available.3 Use of organs donated after circulatory death has improved the number and outcomes of kidney and lung transplantation,4, 5 and to a lesser extent, liver transplantation.6
A series of three successful paediatric heart transplantations from colocated neonatal donors after circulatory death was described in 2008,7 in whom in-situ cooling following pre-withdrawal heparinisation and insertion of femoral cannulae were done. In 2009, in-situ resuscitation of an adult human heart donated after circulatory death with subsequent weaning from cardiopulmonary support was reported.8 The major hurdles to the transplantation of hearts from human donors after circulatory death are the ability to mitigate warm ischaemia during withdrawal of life-support, the need to preserve the heart during transportation from the donor to the recipient hospital, and the need to assess the viability of the heart before transplantation. In preclinical studies, we have shown that the tolerance of a heart donated after circulatory death to warm ischaemia can be enhanced by modification of the initial flush solution9 and that normothermic ex-vivo perfusion preserves the heart better than hypothermic storage and enables the heart's viability to be assessed.10 These findings, combined with those of other investigators,9, 10, 11, 12, 13, 14, 15 have led to a renewed effort to explore the potential for clinical heart transplantation from donors after circulatory death.16
The transportable Organ Care System (TransMedics; Andover, MA, USA) enables both standard and marginal-criteria ex-vivo donor hearts to be preserved,17 and enables detection of occult pathology during normothermic ex-vivo perfusion. The heart Organ Care System has been used for 246 orthotopic heart transplantations worldwide. We report the first three successful human heart transplants after distant procurement of orthotopic hearts donated after circulatory death.
Section snippets
Recipients
The patients were included in the Marginal Heart Study at St Vincent's Hospital (Sydney, Australia), which involves a protocol for the use of extended-criteria donor hearts including those donated after circulatory death. This single-centre study defined extended-criteria for both hearts donated after brain death and hearts donated after circulatory death. We considered all Maastricht category III controlled hearts from donors after circulatory death aged younger than 40 years with less than 30
Results
Cessation of circulation occurred in less than 20 min in all three patients and the start of cardioplegia delivery took another 3–6 minutes (table 2). Attachment of the heart to the Organ Care System took an additional 23–28 min, as a result of the additional time needed to deliver pneumoplegia for procurement of lungs.
For patient 1, closure of both the inferior vena cava and the superior vena cava led to an immediate distension of the heart, particularly the right side. The superior vena cava
Discussion
To our knowledge, this report describes the first successful clinical heart transplantations after circulatory death with donor organs procured at a distance necessitating reanimation, resuscitation, and transportation with use of an ex-vivo cardiac perfusion device (panel). Of the strategies to slow the growing discrepancy between the number of patients awaiting transplantation and the scarcity of suitable donors, the use of organs donated after circulatory death has been successful for lung
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