'Excellent' Transplant Outcomes With Hearts Donated After Circulatory Death

By Will Boggs MD

April 08, 2019

NEW YORK (Reuters Health) - Heart transplantation with organs donated after circulatory death (DCD) can yield "excellent" outcomes, researchers from Australia report.

"The fact that these DCD hearts, which otherwise would have been discarded, actually can be reanimated and used for successful transplants was not a surprise," said Dr. Kumud Dhital from St. Vincent's Hospital and the University of New South Wales, in Sydney.

"The surprise was that we did not need to use temporary mechanical circulatory support, in the form of ECMO, in all our recipients, as we had initially anticipated. In effect, these hearts perform way better than expected," he told Reuters Health by email.

Dr. Dhital and colleagues report their experience of 23 DCD heart transplants from 45 DCD donor referrals between 2014 and 2018. The donor hearts were distantly procured and maintained on normothermic machine perfusion (NMP) while awaiting transport and transplantation.

The researchers attended 45 DCD heart retrievals from which 33 hearts were procured following withdrawal of life support and 23 transplanted into 17 male and six female recipients.

The mean time from cardioplegia to establishment of NMP was 28 minutes, and the mean time of organ perfusion was 276 minutes, the team reports in the April 2 issue of the Journal of the American College of Cardiology.

Most patients had heart failure due to non-ischemic dilated cardiomyopathy (16/23, 61%) or ischemic heart disease (4/23, 20%), and all recipients were New York Heart Association (NYHA) functional class 3 or 4, with a mean left ventricular ejection fraction (LVEF) of 23% within six months before heart transplantation.

There has been only one early death at six days after transplant due to primary graft failure, for an overall survival of 95%, with four patients having survived beyond three years from their transplant.

With the exception of this single early death, all hearts recovered normal function within one week of transplantation. About a third (35%) of recipients required initial ECMO support to wean from cardiopulmonary bypass, mostly (7/8) because of delayed graft function.

At last follow-up, all recipients demonstrated NYHA functional class 1 with normal biventricular function on the most recent transthoracic echocardiogram.

Rejection rates in the DCD group were comparable to those in the donation-after-brain-death (DBD) transplant group in the same period.

"The main disadvantages of the current clinical protocols include the increased manpower and costs associated with the use of NMP, which also requires an experienced team in facilitating the assessment of DCD hearts during reperfusion," the researchers note.

"DCD hearts are a very valuable source of donor hearts that can be successfully transplanted with results similar to those from hearts from DBD donors," Dr. Dhital said. "This not only helps reduce the attrition rate amongst the recipients on our wait-lists, but also minimizes the need for bridging therapy with expensive ventricular assist device (VAD) implants in those who deteriorate whilst waiting and need a bridging solution before a suitable heart is found."

"We must not discard these valuable DCD hearts and must start to consider it to be negligent not to use them whenever possible," he said. "It is time the rest of the transplant centers in North America and Europe actually woke up and embraced this pathway for successful heart transplantation for the sake of their patients and their programs. However, we do need a global effort to start getting consensus on the very definition of death and the ethics surrounding antemortem interventions towards further improving the number and quality of DCD hearts."

Dr. Francis D. Pagani of the University of Michigan, in Ann Arbor, who wrote an accompanying editorial, told Reuters Health by email, "DCD donation is a viable option and important for our patients."

"The main hurdles (to starting a DCD program) revolve around the fact that governmental oversight of transplantation in the U.S. is significant and has made the process of transplantation in the U.S. risk averse to some degree," he said. "Some centers will not want to perform DCD heart transplantation if these donors have a higher risk."

"A significant ethical and clinical framework for DCD heart donation in the United States has been made by groundbreaking efforts in Australia and the United Kingdom," his editorial concludes. "Because of the dire need for donor hearts, it is clinically necessary to resolve these controversies and challenges to expand the current heart donor pool in the United States."

SOURCE: https://bit.ly/2OyA65o and https://bit.ly/2UjUFb0

J Am Coll Cardiol 2019.