What is the potential increase in the heart graft pool by cardiac donation after circulatory death?

Abstract

Summary Heart transplantation remains the only definite treatment option for end‐stage heart diseases. The use of hearts procured after donation after circulatory death (DCD) could help decrease the heart graft shortage. The aim of this study was to evaluate the potential increase in heart graft pool by developing DCD heart transplantation. We retrospectively reviewed our local donor database from 2006 to 2011, and screened the complete controlled DCD donor population for potential heart donors, using the same criteria as for donation after brain death (DBD) heart transplantation. Acceptable donation warm ischemic time (DWIT) was limited to 30 min. During this period 177 DBD and 70 DCD were performed. From the 177 DBD, a total of 70 (39.5%) hearts were procured and transplanted. Of the 70 DCD, eight (11%) donors fulfilled the criteria for heart procurement with a DWIT of under 30 min. Within the same period, 82 patients were newly listed for heart transplantation, of which 53 were transplanted, 20 died or were unlisted, and 9 were waiting. It could be estimated that 11% of the DCD might be heart donors, representing a 15% increase in heart transplant activity, as well as potential reduction in the deaths on the waiting list by 40%.

Heart transplantation from donation after circulatory determined death

“…However, we can say with increasing confidence that the current experience with DCD hearts has thus far proven to provide heart failure patients with at least equivalent outcomes to DBD heart transplantation. Additionally, the conservative estimates for the potential for DCD heart transplantation to increase transplant activity have been exceeded (28,29). Despite it being 50 years since the first DCD heart transplant, the use of DCD hearts with distant procurement and isolated heart perfusion is in its infancy, and further research is required into defining the limits of this technique as well as mechanisms for optimising DCD hearts.…”

“…Although DCD heart transplantation has relied heavily on ex-situ organ perfusion where normothermia was the preferred strategy (27), there are a number of heart perfusion devices currently being developed which may offer an alternative strategy to preservation of the DCD heart (28).…”

High-risk donors

“…Subsequent reperfusion initiates a complex cascade of events that cause intracellular Ca 2þ overload and propagate myocyte death through the development of hypercontracture, activation of calcium-dependent proteases, generation of reactive oxygen species, activation of the mitochondrial permeability transition pore and initiation of apoptotic pathways [15][16][17]. Until now, DCD heart transplantation has not reached clinical practice because of concerns regarding the potential deleterious effects of warm ischemia and reperfusion injury occurring during DCD procurement on heart graft functionality and viability [18,19] Therefore, the establishment of evidence-based guidelines for DCD heart resuscitation is essential before clinical application can occur [20] and several concerns, especially about the functionality of such grafts, still need to be addressed [19]. Studies on animal models showed promising results after 30 min of normothermic ischemia [21][22][23][24].…”

“…Within the same period, 82 patients were newly listed for heart transplantation, of which 53 were transplanted, 20 died or were unlisted and nine were waiting. It could be estimated that 11% of the DCD might be heart donors, representing a 15% increase in heart transplant activity, as well as potential reduction in the deaths on the waiting list by 40% [19].…”

Organ Procurement and Transplantation in Belgium

“…The procurement of DCD organs originating from euthanasia patients may allow to increase the availability of kidneys, pancreata, livers, and lungs 19 with the potential of hearts once future basic and clinical research has confirmed favorable outcomes. 20 …”