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Ann Thorac Surg 1996;62:1268-1275
© 1996 The Society of Thoracic Surgeons
Sections of Cardiothoracic Surgery and Cardiology, Temple University Health Sciences Center, Philadelphia, Pennsylvania
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Methods. One hundred ninety-six heart transplantations were performed on 192 patients at our institution from January 1992 to 1995 and were divided into two groups. Group A donors (n = 113) conformed to the standard criteria. Group B donors (n = 83) deviated by at least one factor and consisted of the following: 16 hearts from donors greater than 50 years of age, 33 with myocardial dysfunction (echocardiographic ejection fraction = 0.35 ± 0.10, dopamine level exceeding 20 µg•kg-1•min-1, and resuscitation with triiodothyronine), 33 undersized donors with donor to recipient weight ratios of 0.45 ± 0.04, 48 with extended ischemic times of 297.4 ± 53.6 minutes, 25 with positive blood cultures, 16 with positive hepatitis C antibody titers, and 7 with conduction abnormalities (Wolff-Parkinson-White syndrome, prolonged QT interval, bifascicular block).
Results. Thirty-day mortality was 6.2% (7/113) in group A and 6.0% (5/83) in group B. Mortality in group A was attributed to 3 patients with myocardial dysfunction, 2 with infection, 1 with acute rejection, and 1 with pancreatitis; group B had 2 with myocardial dysfunction, 1 with infection, 1 with aspiration, and 1 with bowel infarction. At 12 months, survival and hemodynamic indices were similar between the groups. Of the 16 recipients with hepatitis C–positive hearts, 5 have become hepatitis C positive with mild hepatitis (follow up, 6 to 30 months).
Conclusions. Expanding the criteria for suitability of donor hearts dramatically increases the number of transplantations without compromising recipient outcome.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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A more immediate solution is to increase the yield of hearts from currently available donors. Criteria for donor hearts have evolved over time. Originally based on the experience at Stanford, criteria have expanded, and factors that make a heart acceptable for HT are as follows [2]: age less than 50 years; echocardiogram showing no important segmental abnormalities or global hypokinesis, ejection fraction greater than 0.50, and normal valves; inotropes less than 15 µg•kg-1•min-1 dopamine; donor to recipient weight ratio 1.5 to 0.7; cold ischemic time less than 4 hours; no donor infection; negative serology for hepatitis B, hepatitis C, and human immunodeficiency virus; and normal electrocardiogram or minor ST-T wave abnormalities, with no conduction system disease. We consider these criteria restrictive and sought to find methods to expand the donor pool effectively without increasing the risk of adverse outcomes in recipients.
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Donor assessment was based on a complete clinical and laboratory evaluation and on transthoracic echocardiography. Coronary angiography was done only in cases with high risk (age, extensive smoking) or clinically suspected coronary artery disease (CAD). Angiography was not always possible; in these cases, visual palpation or benchtop explant angioscopy (Storz Inc, Germany, 1.4-mm fiber) was used. Angioscopy was done in a cold saline bath with continuous retrograde crystalloid cardioplegia to allow distention of the vessels. All transplants were procured in a normal fashion, with unmodified cold (4°C) University of Wisconsin solution (UWS) used for cardioplegia and storage.
The OHT technique described by Lower and colleagues [3] was used for the first 100 patients. The rest of the patients received bicaval OHT. During implantation, antegrade cold blood cardioplegia was given in the graft after the atrial anastomoses, followed by retrograde continuous cardioplegia until the cross clamp was removed. Baseline inotropic support in all patients consisted of dopamine 3 µg•kg-1•min-1 and epinephrine up to 2 µg/min. Use of higher doses of inotropic agents or addition of other agents was considered increased inotropic support.
Subgroups of donors were identified as follows. Group B1 (n = 16) was greater than 50 years of age. Group B2 (n = 33) had myocardial dysfunction with ejection fraction less than 0.45 on echocardiograms, left atrial pressure (measured by a catheter in the superior pulmonary vein) greater than 15 mm Hg, and more than 15 µg•kg-1 •min-1 dopamine. Donors were given triidothyronine (Triostat; Smith-Kline Beecham, Philadelphia, PA) in a 0.4-µg/kg bolus at hourly intervals for three doses, and hearts were used only if the myocardial function improved as per the discretion of the procuring surgeon. Group B3 (n = 26) was undersized for donor to recipient weight by greater than 50%; group B4 (n = 48) had a cold ischemic time of greater than 240 minutes; group B5 (n = 25) demonstrated sepsis with positive blood cultures; group B6 (n = 16) showed hepatitis C virus (HCV) antibody–positive serology; group B7 (n = 7) demonstrated substantial conduction system abnormalities on electrocardiogram.
Management after transplantation consisted of cyclosporine, azathioprine, and oral steroids. The cyclosporine dose was adjusted to maintain a whole trough blood level of 250 to 300 ng/mL, assessed by radioimmunoassay and based on the patient's renal function. The azathioprine dose was adjusted to maintain a total white blood cell count of at least 4,000 cells/µL. Patients early in the series received antithymocyte globulin or OKT3 for 2 to 5 days as early prophylaxis of rejection; routine induction therapy was eliminated over the past 2 years. As part of clinical trials for early rejection prophylaxis, 20 patients received photophoresis and 20 received mycophenolate mofetil as a substitute for azathioprine. Acute graft rejection, diagnosed by endomyocardial biopsy, was treated with pulse doses of methylprednisolone; however, resistant rejections required cytolytic therapy. Infectious episodes were defined as clinically apparent infections that necessitated hospital treatment and were documented by cultures or serologic tests.
Early posttransplantation graft performance was evaluated by echocardiography and right heart catheterization at 1 week. The tests were repeated as clinically indicated. Coronary angiograms were also performed as a baseline within 1 month after transplantation and at yearly intervals. Graft CAD was diagnosed in the presence of any focal or diffuse coronary stenosis of any degree to any vessel, based on careful review of multiple angiograms by independent observers.
The SAS program (Statistical Analysis System; SAS Institute Inc, Cary, NC) was used for statistical analysis. Continuous data were expressed as mean ± standard deviation and were evaluated for differences between groups with a two-tailed t test or analysis of variance. Discrete data were analyzed for differences between groups with the 
2 test and two-tailed Fisher's exact test when appropriate. Life-table actuarial curves were constructed for survival and freedom from CAD, and differences between groups were assessed with the generalized Wilcoxon test. Significance was assumed if the p value was less than 0.05.
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Results |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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). The causes of end-stage heart disease (group A versus B) were also similar and included ischemic (52.6% versus 44.9%), idiopathic (40.6% versus 36.8%), valvular (5.2% versus 10.2%), congenital (<1% versus 2%), and other (<1% versus 4.1%). Mortality at 30 days was 6.2% in group A (7/113), with 3 patients having donor dysfunction (inability to maintain circulation despite maximal inotropic support, intraaortic balloon pump [IABP], and mechanical devices), 2 with infection, 1 with pancreatitis, and 1 with acute rejection; and 6.1% in group B (5/83), with 1 patient having donor dysfunction, 2 with infection, 1 with aspiration with adult respiratory distress syndrome and pulmonary hypertension, and 1 with bowel infarction. Mortality at 1 year was 17.7% in group A (20/113): 7 perioperative cases plus 7 rejections, 2 pneumonia, 2 sepsis, 1 hepatitis B, and 1 pulmonary embolism. In group B, 1-year mortality was 16.9% (14/83): 5 perioperative cases plus 6 rejections, 2 sepsis, and 1 infiltrating amyloid in a patient originally thought to have amyloid isolated to the heart.
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, compared with group A, donors were significantly older in group B1, and there also was a trend toward older recipients. Intraoperative function and long-term hemodynamic indices were similar between the groups. However, even though the baseline coronary angiogram done at 1 week failed to reveal any obstructive CAD, 2 of 10 1-year survivors and 2 of 8 2-year survivors experienced marked coronary disease. All had a combination of focal and diffuse disease. One recipient died at 18 months of a large anterior-wall myocardial infarction from an occluded left anterior descending artery lesion. In addition, the 1-year survival was also decreased at 71.4%, with 2 patients dying of infection in the perioperative period and 2 dying later of rejection.
Group B2 (Myocardial Dysfunction)
One hundred ten donor offers were received, 90 of which had already been declined by at least one other transplant center. Sixty were rejected because of age (>35 years) with or without echocardiographic findings of valvular disease or substantial segmental wall abnormalities. Thirty-seven of the 50 remaining donor hearts could be used. Despite vigorous attempts at resuscitation, the other hearts were deemed unsatisfactory by the procuring surgeon. This decision was based on assessment of contraction, distention, ability to decrease inotropic agents, and improvement of left atrial pressure. Results are summarized in Tables 1 and 2. Group B2 donors were younger, had higher left atrial pressure, were receiving more inotropic support, and had lower ejection fractions on echocardiography. After triiodothyronine resuscitation, the left atrial pressure decreased. The need for inotropic support also decreased, but was still higher than in group A. There were no deaths caused by donor dysfunction in group B2. Perioperatively, more patients in group B2 than in group A required intraaortic balloon pump (IABP), inotropic support above baseline, and a longer reperfusion time (measured as the time between release of the cross clamp and completion of all anastomoses to weaning from cardiopulmonary bypass). Echocardiographic and hemodynamic indices at 1 week were similar, as were the 30-day and 1-year survival rates.
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). In group B3, the donor age was lower (range, 6 to 15 years), there were more male patients, the donor to recipient weight ratio was lower, and the ischemic times were longer. The range of the donor to recipient weight ratio in group B3 was 0.30 to 0.50. Requirement for inotropic support above baseline was higher, as was the need for external pacing and time on the ventilator. One-week hemodynamic indices reflected higher pulmonary artery and capillary wedge pressures, lower cardiac index, and higher heart rates. At 1 month, the hemodynamic variables and survival were similar. One patient in group B3 died of a superior mesenteric artery embolus from a larger recipient left atrium thrombus. One patient died of aspiration and resultant adult respiratory distress syndrome with pulmonary hypertension.
Group B4 (Extended Ischemic Time)
No heart offer was refused for the sole reason of prolonged ischemic time. Recipient characteristics were similar to those in group A (see Table 1). Ischemic times were longer in group B4 (range, 240 to 472 minutes), and there was a trend (not significant) toward requiring increased inotropic support. Hemodynamic indices at 1 week and 30-day survival were similar. Of note, the actuarial freedom from CAD was also similar in both groups. The reasons for the extended ischemia times were (1) long-distance procurement, especially with undersized hearts (n = 27), (2) complex reoperations with prolonged explant time (n = 11); and (3) hearts that could not be used by the procurement team because of recipient difficulties (n = 10). The hearts were arrested, stored in UWS, and shipped to our institution.
Group B5 (Donor Sepsis)
Forty-two offers were received, of which 17 were refused because of fungus, viral meningitis, or endocarditis. The 25 donors that were used had a history of positive blood cultures, fever, and sepsis. All were receiving antibiotics, although only 10 had specific organisms identified; 18 were septic during procurement. Heart function was normal, although 3 donors were taking norepinephrine to maintain systemic blood pressure. Ten had Staphylococcus aureus or S epidermidis. Eight had meningococcus and 7 had gram-negative organisms (4 Klebsiella, 1 Serratia, 2 Escherichia coli). All recipients were treated with vancomycin, gentamicin, and cefotaxime until final cultures in the donor allowed targeted antimicrobial therapy. The immunosuppression regimen was not altered; as is our practice, cytolytic therapy was avoided. Transient Klebsiella-positive blood cultures developed in 3 patients and resolved in 2 days. One patient had Klebsiella pneumonia, which required intubation for 1 week. In another patient, Serratia mediastinitis developed, requiring a pectoral muscle flap. No patient died because of transmitted infection; the 30-day mortality was 4.0% (1/25) caused by donor dysfunction. This was not different from the rate in group A.
Group B6 (Hepatitis C–Positive Donors)
Forty-two donor offers were received with positive serology for HCV. Donors at high risk for active viremia were eliminated, ie, active histologic or chemical hepatitis, other hepatitis-positive serologies, history of intravenous drug use, incarceration, or obvious exposure. We sought to obtain donors with low risk for viremia who might have false-positive antibody results. Of the 16 donors, polymerase chain reaction was obtained in 12. Test results in 8 of the 12 were positive for the presence of virus. Five recipients have had HCV conversion confirmed by polymerase chain reaction. One patient had three previous open heart operations, and his HCV status was not confirmed before transplantation. Three patients have received interferon, with resolution of liver chemistry abnormalities. One patient remains chronically fatigued. One patient died at 3 days of accelerated acute rejection; another died at 6 months of aggressive humoral rejection with obliteration of the coronary arteries.
Group B7 (Conduction Abnormalities)
Six donors did not have a history of conduction system abnormalities. Three had complete heart block and 2 had trifascicular block. All 5 donor hearts normalized after the second postoperative day. One donor had a prolonged QT interval (corrected QT of 47 milliseconds). The recipient had an uneventful transplantation but then had ventricular fibrillation 8 hours later. The heart could not be resuscitated; he was placed on extracorporeal membrane oxygenation and underwent retransplantation in 2 days. The other donor had a history of Wolf-Parkinson-White syndrome; the heart was transplanted and on the seventh postoperative day, the bypass tract was ablated by radiofrequency in the cardiac catheterization laboratory.
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Expansion of the heart donor pool will involve reevaluating criteria for an acceptable organ and transplanting organs that are currently being discarded. Toward this goal, we have established an aggressive program to maximally benefit our recipient population. Expanded criteria for donor organs were used for desperately ill recipients before the availability of bridge devices. We carefully considered the condition of individual recipients and weighed the chance of death on the waiting list with that of HT using expanded-criteria donors. As we gained experience with the "marginal" donor and reviewed our results, we found that the type of recipients receiving these organs had expanded as well.
This study reviewed our experience over a 3-year period with the expanded-criteria hearts. The study was retrospective and has the limitations of such a study. There was a selection bias (ie, only organs from younger donors with substantial myocardial dysfunction were resuscitated), and the study was not blinded. Nevertheless, a truly blinded and controlled study of expanding donor selection-a subjective variable-is not possible. All donors that fit the accepted donor criteria were placed in group A. Others were placed in group B. The two groups were comparable with respect to donor and recipient age and sex and 30-day and 1-year survival. Group B was further subdivided into the specific indications for considering the hearts marginal organs. Some donors were placed in multiple subgroups (eg, undersized and long ischemic time). Each subgroup in turn was compared with the accepted donor group for each particular variable with regard to the results after HT.
Group B1 consisted of donors older than 50 years of age. These hearts were preferentially placed in older recipients, as demonstrated by a trend toward older age when compared with group A. Others have reported on the use of older hearts for transplantation. There are concerns regarding the reported higher incidence of donor heart failure and CAD. There are multiinstitutional reports on the incidence of donor heart failure contributing to poor postoperative results, although these have been contradicted by other reports [5, 6]. In this series, there was no increased incidence of donor heart dysfunction. However, mortality rates at both 30 days and 1 year were higher, with the 1-year value attaining statistical significance. This was more a reflection of recipient factors, as two deaths were due to infection and two to rejection. The recipients were older than those in group A and had other comorbidities (eg, diabetes, renal dysfunction, peripheral vascular disease) before HT.
Most reports, however, do agree on the higher incidence of CAD in these organs. The freedom from substantial CAD was 80% and 75% for 1 and 2 years, respectively. This was lower than the control value, and 1 patient died at 18 months of an anterior-wall infarction. The lesions were not characterized into type 1 (focal) or type 2 (diffuse), but they did present despite angiograms with normal or minimally diseased vessels at baseline shortly after HT. Schuler and associates [7] have shown a similar incidence of diffuse transplant arteriopathy in these organs compared with younger donors, but with a higher incidence of focal CAD. A combination of the two types of CAD make it an important problem in recipients. Only 1 of the patients died of CAD, and perhaps the others will be amenable eventually to a revascularization procedure. Laks and co-workers [8] reported on donors with CAD undergoing saphenous vein coronary artery bypass before implantation. Heart function in the survivors was acceptable, but there was a high 30-day mortality rate of 30%. This might reflect a high-risk patient population, as these hearts were placed only in "marginal recipients." The present data from this study suggest that older donor hearts can be placed in older recipients or in those with a high risk for death on the waiting list, with the understanding that there will be a higher incidence of CAD in these organs, even with acceptable coronary donor angiograms.
Hearts with myocardial dysfunction comprised the next subgroup. These hearts are avoided because of reports indicating poor outcome with their use for HT. It is well documented that brain death causes a stereotypic pattern of neurohumoral derangement [9]. There is loss of catecholamine stimulation, acid-base imbalance, and deficiency in pituitary-dependent hormones such as vasopressin, cortisol, and thyroxine. Thus, hearts from young donors can present with marked myocardial dysfunction despite massive inotropic support. In addition, factors leading to brain death such as asphyxia, cardiac arrest, or prolonged hypotension can affect myocardial function. Adenosine triphosphate and other substrates are depleted, and the heart can become relatively insensitive to inotropic agents. Novitsky and colleagues [9] demonstrated that the addition of thyroid hormone in the setting of brain death–induced myocardial dysfunction can revive the heart. We have previously demonstrated successful resuscitation and use of hearts with triiodothyronine [10]. Data in this article suggest that a vast majority of these organs offered for transplantation can be revived and used without jeopardizing patient outcome. Triiodothyronine improves mitochondrial function, increases myocardial calcium, and increases sensitivity to catecholamines.
All hearts that responded to triiodothyronine with lowered ventricular filling pressures while maintaining systemic blood pressure have worked well in the recipient over the long term. Hearts were rejected if there were significant segmental abnormalities and they were from older donors, because this combination of factors could imply CAD. It should be noted that there is an increased need for IABP and inotropic support, and extended periods of decompressed reperfusion (up to 5 hours) for the hearts to separate from cardiopulmonary bypass. Within 1 week, myocardial function is normal, and it remains normal when compared at 1 year. In anticipation of poor initial hemodynamic indices, we place femoral arterial access lines (16-gauge angiocath that allows introduction of an IABP guidewire) before the initiation of cardiopulmonary bypass in these recipients. Because extended periods of cardiopulmonary bypass are often required, aprotinin is given to decrease bleeding. In addition, recipients with important vascular obstructive lesions that would not tolerate periods of hypotension are avoided. Using those indices, hearts with pronounced myocardial dysfunction can be used with excellent results, with no deaths from primary myocardial dysfunction in our series.
Undersized donor hearts can also expand the donor pool. According to the United Network for Organ Sharing statistics, patients in the 6- to 14-year range (general weight range, 20 to 40 kg) make up only 1.8% of the waiting list, whereas 10% of potential donors are available in that weight and age range. Many of these organs were not being used for heart transplantation (Delaware Valley Transplant Program statistics 1992, 1993). Because the large majority of recipients are adults, downsizing may allow transplantation of an underused resource [11]. The potential pitfalls of downsizing are: (1) pulmonary hypertension with right ventricular failure immediately after implantation, (2) inability of the graft to maintain adequate circulation because of reduced stroke volume, or (3) development of restrictive physiology [12]. Heterotopic transplantation has been used to circumvent these difficulties. By using smaller hearts, wait list times have been reduced, but other disadvantages such as the need for anticoagulation and the high incidence of pulmonary complications and infection remain [13].
Laboratory data in animal models suggest that hearts can adapt rapidly to pressure volume loads and can remodel to maintain normal circulatory demands [14]. A human model of this phenomenon is the rapid conditioning of the atrophic left ventricle in the two-stage repair for transposition of the arteries in infants and older children. Our initial experience was using pediatric undersized donor hearts in a particularly sick cohort of patients who had no other options available to them. Functional and morphologic adaptation of the hearts was demonstrated as the hearts grew by both volume and mass measurements [15]. Indications expanded with the success of the study. Data presented here demonstrate excellent survival and normalization of hemodynamic indices using undersized hearts, but with some caution. Heart transplantation with fixed pulmonary vascular resistance of more than 5 Wood units was not attempted. There are usually longer ischemic times as procurement extends longer distances. There is a significantly greater use of IABP and inotropic agents. External pacing is often required, as the only method to increase cardiac output is to increase heart rate. Stroke volume is relatively fixed and small in the initial perioperative period. Recipients often are hypotensive as a consequence of maneuvers to decrease systemic and pulmonary vascular resistance. They often need to be heavily sedated and even paralyzed, as reflected by longer periods on the ventilator. Hemodynamic indices at 1 week are usually marginal, but normalize by 1 month [15]. One patient died of an embolus to the superior mesentery artery from a large recipient left atrium. There was also a high incidence of tricuspid regurgitation. Because the bicaval technique of OHT was used, the size of the recipient left atrium has been reduced, as has the incidence of atrioventricular valve regurgitation. Recipients who we predict cannot tolerate prolonged periods of low perfusion in the immediate postoperative period are not considered for these hearts. By heeding all of these caveats, the survival from these hearts is similar to that from hearts undersized by a much lower percentage.
Improved preservation of hearts will also allow expansion of the donor pool. An ischemic time of 4 hours was considered maximal. Periods beyond that time were associated with decreased survival after HT [6]. Whenever the heart is stopped, stored without perfusion, and restarted, there will be an initial decrement in function. Better preservation will allow use of the marginal heart, as there will be less of a deterioration in function. Improved preservation will also allow an extended donor ischemic time. This increases the geographic area for possible procurement. With the proliferation of heart transplant centers, this is becoming less of an issue, but many undersized organs were retrieved from long distances. Extended preservation also allows centers to do complex reoperations that might pose difficulty in cardiac explantation. We have also been fortunate to receive hearts at times when another procurement team is ready to harvest but an unfortunate event occurs to their recipient, or the heart is considered too small. The hearts have been procured with U.W.S., transportation has been arranged, and the organs have been "drop shipped."
Throughout this study, UWS was used for cardioplegia and storage. This is an isoosmolar colloid solution containing lactobionate and hydroxyethyl starch to decrease edema, intracellular composition of electrolytes, antioxidants, and glucose. University of Wisconsin solution is used extensively in kidney, pancreas, and liver transplantation, with improvement in immediate function; UWS can extend cardiac hypothermic static ischemic periods up to 18 hours in baboons [16]. Clinically, in a blinded, randomized trial, UWS demonstrated improved preservation over crystalloid cardioplegia solution within a 4-hour period of ischemia [17]. There is also evidence for decreased myocardial edema and improved preservation of adenosine triphosphate stores. In this study, with an average ischemic time approaching 5 hours (longest, 7 hours 42 minutes), there was increased initial inotrope requirement as well as more reperfusion time, but 1-week and later hemodynamic indices were similar to those of controls. Actuarial survival was also similar to the control group. Longer preservation periods also did not increase the incidence of transplant CAD, as demonstrated by angiography at 1 and 2 years, in the group with long ischemic periods. Preservation time has been safely extended in pediatric cardiac transplantation; this study has demonstrated in a large series the safety of prolonged preservation in adult OHT.
Donor systemic infection is also considered high risk for HT. Gram-negative organisms have been shown to be transmitted from the donor and cause serious infections in the recipients [18]. In this study, all donors with suspicion of endocarditis, viral meningitis, or fungal infections were eliminated. Until final cultures were obtained, the donors were treated with broad-spectrum antibiotics. Staphylococcus species organisms and meningococcus were not transmitted. Despite antibiotics, gram-negative organisms could be transmitted from the donor, but the infections were easily treated. The only life-threatening infection was a Serratia mediastinitis, which required debridement and a myocutaneous flap. Survival data in this subgroup of donors were similar to those of controls.
Recent advances in serologic testing for HCV have made it possible to identify the serologic status of the donor before transplantation. Fifteen percent of donors in our region are HCV antibody positive (Delaware Valley Transplant Program Data, 1994). Knowledge of the transmission rate of the virus and the outcome in cardiac recipients has remained elusive [19]. In a group of desperately ill recipients, hearts from HCV-positive donors were transplanted. This was done at a time before the availability of ventricular assist devices; hence, these patients would not have survived without immediate transplantation. Patients were informed of the risk of seroconversion, but had few alternatives. Donors with a history or chemical evidence of hepatitis were excluded, as were donors with a history of blood transfusions or intravenous drug use. Low-risk donors for HCV, in whom the antibody test could have been a false positive, were selected. Of 16 recipients having transplantation, 5 have seroconverted. One recipient was not tested before transplantation; therefore, to date the seroconversion rate is 4 of 15 (27%). The 3 surviving patients have chemical hepatitis, which has resolved with interferon therapy. One is chronically fatigued. The remaining recipients are tested yearly and have not seroconverted. Blood from 12 of the 16 donors was sent for polymerase chain reaction; eight results were positive. All recipients who seroconverted received organs from polymerase chain reaction–positive donors. In this selected series, 25% of seropositive donors (RIBA) were false positives. There was an overall conversion rate approaching 30%, with an indolent course of hepatitis. Of note, longer follow-up will be required to define the clinical course of the recipients, as there is some evidence of liver failure in patients 3 to 5 years after the diagnosis of HCV [19]. Currently, we restrict the use of HCV-positive donors to recipients who face imminent death and are poor candidates for mechanical bridging.
The final subgroup identified in this study was donors with conduction system abnormalities. Brain death can cause diffuse ST-T wave abnormalities that can mimic ischemia. Some donors can exhibit artrioventricular conduction delay: complete heart block or trifascicular block. We used these donor hearts because the donors did not have a history of cardiac disease and because even if the conduction abnormalities persisted, a pacemaker could solve the problem. All abnormalities resolved after transplantation. One donor had documented Wolf-Parkinson-White syndrome. Intermittent tachycardia was present after OHT, but it was eliminated by radiofrequency ablation after the first week [20]. One donor had a prolonged QT interval (corrected QT > 47 milliseconds). The recipient had ventricular fibrillation on the first postoperative day and could only be resuscitated on extracorporeal membrane oxygenation. Since that experience, we have refrained from using any donor with a prolonged QT interval syndrome.
These data present a wide variety of methods to expand the donor pool. The shortage of donor organs influences the survival of patients on the transplant waiting list and also has serious economic implications. Bridging devices are expensive and can double the cost of an already expensive procedure. Patients waiting in the hospital as status I in intensive care units also dramatically increase the cost of OHT. Therefore, it is imperative that the limits of transplantation continue to be expanded. Ultimately, the ideal donor organ should be gauged not by its function in the donor, but by how it can adapt and safely maintain circulation in the recipient.
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Address reprint requests to Dr Jeevanandam, Section of Cardiothoracic Surgery, Temple University Hospital, Parkinson Pavilion, Suite 300, 3401 North Broad St, Philadelphia, PA 19140.
This article has been selected for the discussion forum on the STS Web site:http://www.sts.org/annals
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G. B. Luciani, G. Faggian, G. Montalbano, G. Casali, A. Forni, B. Chiominto, and A. Mazzucco BLOOD VERSUS CRYSTALLOID CARDIOPLEGIA FOR MYOCARDIAL PROTECTION OF DONOR HEARTS DURING TRANSPLANTATION: A PROSPECTIVE, RANDOMIZED CLINICAL TRIAL J. Thorac. Cardiovasc. Surg., November 1, 1999; 118(5): 787 - 795. [Abstract] [Full Text] [PDF]
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P. Vijay, V. A. Scavo, R. J. Morelock, T. G. Sharp, and J. W. Brown Donor cardiac troponin T: a marker to predict heart transplant rejection Ann. Thorac. Surg., December 1, 1998; 66(6): 1934 - 1938. [Abstract] [Full Text] [PDF]
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T. W. Prendergast, S. Furukawa, A. J. Beyer III, B. J. Browne, H. J. Eisen, and V. Jeevanandam The Role of Gender in Heart Transplantation Ann. Thorac. Surg., January 1, 1998; 65(1): 88 - 94. [Abstract] [Full Text] [PDF]
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