Transplantation of donor hearts after circulatory death using normothermic regional perfusion and cold storage preservation

Abstract

OBJECTIVES Hearts donated after circulatory determination of death are usually preserved with normothermic machine perfusion prior to transplantation. This type of preservation is costly, requires bench time adding to warm ischaemia, and does not provide a reliable evaluation of the unloaded donor heart. We report on 4 successful donation after circulatory death (category III) hearts transplanted after thoraco-abdominal normothermic regional perfusion (NRP) and static cold storage. METHODS After life sustaining therapy was withdrawn and death was declared, perfusion to thoraco-abdominal organs was restored using extracorporeal circulation via cannulas in the femoral artery and vein and clamping of supra-aortic vessels. After weaning from extracorporeal circulation, cardiac function was assessed. Once approved, the heart was retrieved and stored using classic static cold storage. Data are expressed as median [min–max]. RESULTS Donor and recipient ages were 44 years [12–60] (n = 4) and 53 years [14–64] (n = 4), respectively. Time from the withdrawal of life sustaining therapy to start of NRP was 22 min [18–31]. Cold storage time was 72 min [35–129]. Thirty-day survival was 100% with a left ventricle ejection fraction of 60% [50–60]. CONCLUSIONS Donation after circulatory death heart transplantation using thoraco-abdominal NRP and subsequent cold storage preservation for up to 129 min was safe for 4 procedures and could be a way to expand the donor heart pool while avoiding costs of machine preservation.

Critical warm ischemia time point for cardiac donation after circulatory death

“…Indeed, several retrospective series have showed excellent results for cardiac transplantation following a period of cardiac arrest in the organ donor (mean: 15 min) 20,21 . In our population, the median time from WLST to CA was 9 min (range: 4–19 min); this aligns with previous reports by Chew et al 22 (10 ± 4 min) and Messer et al 23 (median: 7 min) and is shorter than other small series (range: 8–22 min) 10,12,24 . However, we recognize that times in our cohort were remarkably uniform and shorter than those reported in unselected DCD populations.…”

Consensus statement on normothermic regional perfusion in donation after circulatory death: Report from the European Society for Organ Transplantation’s Transplant Learning Journey

“…Experience with heart transplantation after TA‐NRP is limited to small case series in cDCD, with outcomes comparable to those after ISP (Table S2) [2]. Successful heart transplantation after TA‐NRP with short cold ischaemic times and without ex situ normothermic perfusion has been described [2, 10]. There is one published report mentioning transplantation of lungs after TA‐NRP (Table S2) [2, 10].…”

“…Successful heart transplantation after TA‐NRP with short cold ischaemic times and without ex situ normothermic perfusion has been described [2, 10]. There is one published report mentioning transplantation of lungs after TA‐NRP (Table S2) [2, 10]. Reporting of outcomes of these cases and careful comparison with ISP DCD lungs is important.…”

“…Ex situ perfusion might allow better uDCD liver selection, given high PNF rates after NRP with static cold storage. For the heart, static cold storage has been reported when the cardiac cold ischaemia time was short, with the donor at or very close to the recipient centre, and only after assessment during TA‐NRP [2, 10]. If cold storage was safe, it would avoid considerable cost and complexity of ex situ heart perfusion after TA‐NRP.

We recommend comparison of donor conversion rates and organ utilization rates after NRP with those of ISP in DCD and DBD, in well‐designed studies (not graded).

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Successful lung transplantation with graft recovered after thoracoabdominal normothermic perfusion from donor after circulatory death

“…3,4 Vandendriessche et al have mentioned a case of lung transplant among four successful DCD TA-NRP heart transplants but did not describe details of the technique or transplant 5. …”