Original Clinical Science
Functional assessment and transplantation of the donor heart after circulatory death

https://doi.org/10.1016/j.healun.2016.07.004Get rights and content

Background

After a severe shortage of brain-dead donors, the demand for heart transplantation has never been greater. In an attempt to increase organ supply, abdominal and lung transplant programs have turned to the donation after circulatory-determined death (DCD) donor. However, because heart function cannot be assessed after circulatory death, DCD heart transplantation was deemed high risk and never adopted routinely. We report a novel method of functional assessment of the DCD heart resulting in a successful clinical program.

Methods

Normothermic regional perfusion (NRP) was used to restore function to the arrested DCD heart within the donor after exclusion of the cerebral circulation. After weaning from support, DCD hearts underwent functional assessment with cardiac-output studies, echocardiography, and pressure-volume loops. In the feasibility phase, hearts were transported perfused before evaluation of function in modified working mode extracorporeally. After the establishment of a reliable assessment technique, hearts with demonstrable good function were then selected for clinical transplantation.

Results

NRP was instituted in 13 adult DCD donors, median age of 33 years (interquartile range [IQR], 28–38 years), after a median ischemic time from withdrawal to perfusion of 24 minutes (IQR, 21–29; range, 17–146 minutes). Two of 4 hearts in the feasibility phase were unsuitable for transplantation after functional assessment. Nine DCD hearts were transplanted in the clinical phase, with 100% survival. The median intensive care duration was 5 days (IQR, 4–5 days), with 2 patients requiring mechanical support. There were no episodes of rejection (total, 1,436 patient-days; range, 48–297). During the same period, we performed 20 standard heart transplants using brain-dead donors.

Conclusions

NRP allows rapid reperfusion and functional assessment of the DCD donor heart, ensuring only viable hearts are selected for transplantation. This technique minimizes the risk of primary graft dysfunction and maximizes confidence in DCD heart transplantation, realizing a 45% increase in our heart transplant activity.

Section snippets

Methods

The research protocol was approved by the UK Donation Ethics Committee (UKDEC), Local Regional Ethics Committee (05/Q0104/111), and National Health Service Blood and Transplant (NHSBT), the responsible body for transplantation within the UK. The protocol was confined to Maastricht 3 DCD donors in 3 hospitals within the East of England between April 2014 and July 2015.14

A specialist nurse in organ donation obtained research consent from the donor’s next of kin. The decision to withdraw

Results

Seventeen potential DCD donors were attended, 8 during the feasibility phase and 9 during the clinical program. During the feasibility phase, 3 of the potential 8 donors did not arrest within 2 hours and 1 was excluded due to incomplete documentation. Most of the donors in the feasibility (Table 1) and clinical phases (Table 2) were young adults, with a median age of 33 years (interquartile range [IQR], 28–38 years). Traumatic brain injury was the leading cause of death. Vasoconstrictor support

Discussion

Despite almost half a century passing since the world’s first successful human heart transplant, also from a DCD donor, and an overwhelming body of large-animal evidence demonstrating viability,15, 16, 17, 18, 19, 20 there still remains uncertainty surrounding the safety of DCD heart transplantation. Quantifying the injury that the heart has sustained during the agonal phase after WLST and the warm ischemic period after circulatory arrest has not been possible until now. Although other centers

Disclosure statement

None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.

This research study was funded by the European Society of Organ Transplantation, The Freemasons’ Grand Charity, The Masonic Samaritan Fund, Papworth Hospital Charity Fund, the Evelyn Trust, and the Gledhill Fellowship. The funding organizations did not have any role in the collection of data, its analysis,

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