Heart transplantation with donation after circulatory determination of death

Abstract

The constant shortage of available organs is a major obstacle and limiting factor in heart transplantation; the discrepancy between the number of donors and potential recipients leads to waiting-list mortality of 10-12% per year in Europe and the USA. If adopted for heart transplantation, donation after circulatory determination of death (DCDD) would be expected to improve the availability of organs substantially for both adults and children. With DCDD, however, hearts to be transplanted undergo a period of warm ischaemia before procurement, which is of particular concern because tissue damage occurs rapidly and might be sufficient to preclude transplantation. Nonetheless, the heart is able to withstand limited periods of warm ischaemia, which could provide a window of opportunity for DCDD. Development of clinical approaches specifically for DCDD is critical for the exploitation of these organs, because current practices for donor heart procurement, evaluation, and storage have been optimized for conventional donation after brain death, without consideration of warm ischaemia before organ procurement. Establishment of clinical protocols and ethical and legal frameworks for DCDD of other organs is underway. This Review provides a timely evaluation of the potential for DCDD in heart transplantation.

Avoidance of Profound Hypothermia During Initial Reperfusion Improves the Functional Recovery of Hearts Donated After Circulatory Death

“…An extensive body of literature supports the notion that therapeutic interventions delivered at the onset of reperfusion provide a significant opportunity to resuscitate the ischemic heart; however, the therapeutic window is narrow and optimal success is realized in the first minutes after reperfusion (5,6). Therefore, in the DCD context, the pathogenesis of ischemia-reperfusion injury can be mitigated by optimizing the composition of the initial reperfusion solution that is delivered at the time of organ procurement.…”

Physiologic Changes in the Heart Following Cessation of Mechanical Ventilation in a Porcine Model of Donation After Circulatory Death: Implications for Cardiac Transplantation

“…This is exemplified by the variable definitions of donor circulatory arrest (electrical asystole, absent pulse, absent pulse pressure on an arterial pressure tracing, absence of cardiac output, etc. ), standoff period durations that must be observed before death can be declared (2-20 min), and definitions of the functional warm ischemic time that are employed in the donation community (2,(8)(9)(10)(11)). An improved understanding regarding the natural history of the dying process following donor extubation is necessary to inform the development of standardized medical practices for DCD (12).…”

Donation after circulatory death

“…Indeed, DCD has been attributed to a more than 20% increase in the deceased donor pool in some centers and has demonstrated comparable early transplant outcomes to those from DBD donors, particularly with kidney, liver, pancreas, and lung transplantation [7][8][9][10][11]. Heart transplantation from DCD patients has been limited by the susceptibility of the heart to warm ischemic injury innate to the procurement protocols of the DCD population, particularly the 'hands-off' period [12]. Indeed, many factors must be considered in order to optimize graft function post-transplant.…”