Successful clinical transplantation of hearts donated after circulatory death using normothermic regional perfusion

Abstract

BACKGROUND: Heart transplantation (HT) from donation after circulatory death (DCD) has yet to achieve wide clinical application despite the encouraging resultsreported recently. In this study we describe 2 cases of successful adult DCD HT performed at our institution using an original protocol. METHODS: Our local abdominal DCD protocol was updated to allow DCD heart procurement, and was accepted by the institutional ethics committee. The main features of the protocol include: pre-mortem insertion of peripheral venoarterial extracorporeal membrane oxygenation cannulas; thoracoabdominal normothermic regional perfusion (NRP) by clamping the 3 aortic arch vessels to exclude cerebral circulation; and in-situ heart resuscitation. The retrieved hearts were directly transplanted into recipients located in an adjoining operating room. RESULTS: The procurement warm ischemic time was 25 minutes for the first donor, and 26 minutes for the second donor. The cold ischemic time was 16 minutes for the first recipient and 17 minutes for the second recipient. The suture time was 30 minutes for the first recipient, and 53 minutes for the second recipient. Both recipients were easily weaned off cardiopulmonary bypass in sinus rhythm and inotropic support. Post-operative evaluation of cardiac function was excellent and the patients were subsequently discharged home. CONCLUSIONS: Transplantation of hearts from DCD donors is now a clinical reality.NRP is a useful tool for resuscitation, reperfusion, and preservation of transplanted hearts. It also offers the opportunity to assess the function and viability of organs before transplantation. However,due to ethical issues, some may object to ante-mortem intervention.

Potential for donation after circulatory death heart transplantation in the United States: Retrospective analysis of a limited UNOS dataset

“…[12][13][14] In Australia, the United Kingdom, and more recently in Belgium, upwards of 105 DCD heart transplantations have been performed. [16][17][18][19] The operational aspects of DCD transplantation require teams with well-developed protocols, and in some cases, experience with specialized and costly equipment. NRP, although invasive, requiring reanimation of the heart with the use of extracorporeal membrane oxygenation and cross-clamping of head and neck vessels, is a strategy that allows for reassessment of the heart after a period of warm ischemia.…”

Heart transplantation from donation after circulatory death donors: Present and future

“…In addition to the ischemic injury sustained during the DCD process, the heart also incurs reperfusion injury upon transplantation. At present, by the governing laws, no antemortem interventions are allowed in DCD donors to facilitate organ donation (except in Belgium where these interventions are allowed) 11 . Thus, intense attention was directed at defining the DCD ischemia times beyond which irreparable damage would occur to the heart from where it cannot be used for transplantation.…”

“…Placing a heart on the OCS requires some technical expertise and some potentially transplantable hearts were lost due to technical challenges 29 . More importantly, TransMedics OCS is expensive (each heart perfused costed 30 000.00 euros, excluding the supplies) and not within the reach of many transplantation centers 11 . Its large size also requires modifications during transportation.…”

“…At present, by the governing laws, no antemortem interventions are allowed in DCD donors to facilitate organ donation (except in Belgium where these interventions are allowed). 11 Thus, intense attention was directed at defining the DCD ischemia times beyond which irreparable damage would occur to the heart from where it cannot be used for transplantation. In addition, efforts were made to develop interventions to mitigate reperfusion injury with the hopes that no further damage should occur to the remaining viable myocardium to facilitate successful heart transplantation.…”

“…29 More importantly, TransMedics OCS is expensive (each heart perfused costed 30 000.00 euros, excluding the supplies) and not within the reach of many transplantation centers. 11 Its large size also requires modifications during transportation. As the heart's metabolism decreases by 5% with each°C drop in temperature (50% reduction in the metabolic rate at 27°C compared to 37°C)…”