Ann Thorac Surg 2010;90:1337-1338. doi:10.1016/j.athoracsur.2010.03.025
© 2010 The Society of Thoracic Surgeons
Case Reports
Successful Re-Use of the Transplanted Heart
Petr Nemec, MD, PhD*,
Helena Bedanova, MD, PhD,
Tomas Ostrizek, MD
Centre of Cardiovascular Surgery and Transplantations, Brno, Czech Republic
Accepted for publication March 16, 2010.
* Address correspondence to Dr Nemec, Centre of Cardiovascular Surgery and Transplantations, Pekarska 53, Brno, 65691 Czech Republic (Email: petr.nemec{at}cktch.cz).
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Abstract
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The case of re-use of a previously transplanted heart after brain death of the first recipient is reported. The second recipient was a 60-year-old man who suffered end-stage ischemic heart disease. The operative and postoperative course was uneventful, with the exception of secondary diabetes. The patient is post-transplantation by more than 10 months and is now in New York Heart Association functional class I. This case confirms the possibility of using this procedure, particularly in the situation when there is a shortage of organ donors.
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Introduction
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The permanent profound shortage of organ donors has led to the liberalization of criteria for organ donation and use of organs from marginal donors. The exact criteria for marginal donors are not generally defined. They depend on the practise and experience of a particular transplant society or even an individual institution. One of the rare sources of marginal donors can be organ recipients who suffered irreversible brain damage resulting in brain death. We present a successful case of heart transplantation in which the heart graft was procured after brain death from a previous recipient.
The first heart transplantation was performed in a 52-year-old man with end-stage ischemic heart disease. The donor was a 38-year-old man who suffered from cerebral trauma and his heart had normal function. The transplantation and early postoperative course were uneventful; his blood pressure was within normal range. The immunosuppressive regimen included tacrolimus, mycofenolic acid, and steroids. On post-transplantation day 15 he first had a headache develop and then suddenly became unconscious. Massive intracerebral hemorrhage was found on computed tomography. In spite of aggressive treatment, the neurologic examination showed no brain-stem reflexes, and the diagnosis of brain death was made. Echocardiography showed excellent function of the heart and the decision was made to re-use the heart in another recipient. After thorough evaluation of the other organs, the multiorgan procurement (ie, heart, pancreas, and kidneys) was planned and performed.
The recipient for the heart was a 60-year-old man with end-stage ischemic cardiomyopathy in New York Heart Association functional class III-IV. At the time of the graft offer, he had been on our elective waiting list for 23 days. During donor surgery there were some mild adhesions in the pericardial cavity, but the procurement passed smoothly. The cold ischemia time was 193 minutes. The transplantation in both cases was performed by the bi-caval technique, and the second recipient received only the original heart without any tissue from the first recipient. The surgical procedure was uneventful and the patient was weaned from a cardiopulmonary bypass on low-dose inotropic support. Immunosupression was induced with anti-CD25 antibodies and was maintained with the same regimen as it was in the donor (ie, tacrolimus, mycofenolic acid, and steroids). In the early postoperative period, an acute renal failure with the necessity of dialysis occurred. The high level of tacrolimus may have contributed to this complication. Extubation had to be postponed to postoperative day 8 due to ventilation problems. The second biopsy (on postoperative day 14) showed grade 1B rejection, and this was treated with an increased dose of steroids. All other biopsies were grade 0, according to the Banf classification. The patient is more than 10 months post-transplantation, in an excellent condition, and with normal heart function. The only postoperative complication is secondary diabetes. Insulin therapy, which was necessary, was recently decreased in connection with reduction of the steroid dose.
In terms of immunology, the original donor had blood group O Rh-, and both recipients had O Rh+. There was no human lymphocyte antigen match between the original donor and the first recipient, and there was one match on locus A between the original donor and the second recipient. Panel reactive antibodies were not assessed, but the lymphocytotoxic test was negative in both transplantations.
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Comment
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The re-use of transplanted organs can raise discussion on several issues. The first is an ethical issue. The relatives of such a patient may find it difficult to face this unforeseen situation, especially early after a long-term expectation and successful transplantation. On the other hand they have already been familiar with the concept of organ donation and may be able to understand the benefit that can serve another human being. Also, this very rare and unusual situation may be an ethical challenge for the recipient who becomes a "second-hand owner"of the heart, and therefore a thorough discussion with the recipient is obviously necessary.
The second issue involves the risk of additional trauma because the necessity of a second preservation period and ischemia reperfusion injury. However, it was reported in the literature that the clinical significance of organ injury is not so great. In our case there were some doubts concerning the anticipated longer cold ischemia time due to the procurement at a distance, requiring transport. By strict adherence to all the rules of organ preservation we achieved a successful result, even with the cold ischemia time of greater than 3 hours.
The chronic toxicity of immunosuppressive drugs can be of some concern in the organs, such as the liver or kidneys, but probably not in the heart. Moreover, it becomes important after a longer period of time. On the other hand, the exposure of an organ to immunosuppressive drugs before transplantation can modify the immunogenicity of the graft [1], and therefore the risk of rejection can be reduced, which can cause a prolonged graft survival. We suggest that a continuing administration of the primary immunosuppression may have a positive impact.
In this era of increasing organ shortage, any additional donor that can be identified represents an interesting contribution. There are anecdotal reports on vitally important organ allografts being re-transplanted to a second recipient [2–6]. Only two studies with a greater number of patients come from the United Network for Organ Sharing registry [7, 8]. The Lowell study comprises 95 patients receiving cadaveric organs from 52 donors who had previously received any prior organ transplant between 1987 and 1996 [7]. However, in this cohort no patient received the heart from a donor who was primarily a heart transplant recipient. All heart recipients received their grafts from the recipients of other organs. Graft survival in the kidney and liver recipients was comparable with that in the group of patients whose donors had not been previously transplanted. Survival of the heart recipients is difficult to evaluate due to the small numbers. The first case of a re-used heart allograft was reported in 1993 by Pasic and colleagues [2]. Since then, two other cases have been reported in detail by groups in Munich [9] and Los Angeles [10]. The time interval from original implant to donation was 42 hours, 5 days, and 13 days, respectively, in the aforementioned cases [2, 9, 10]. It is noteworthy to report that the functional outcome in all of these patients (including our own case) was excellent, and that the re-use of the heart graft is a valuable possibility.
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Acknowledgments
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The authors thank Mrs Zdena Dolezalova for valuable help during manuscript preparation for this article.
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References
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- Arvieux C, Cornforth B, Gunson B, et al. Use of grafts procured from organ transplant recipients Transplantation 1999;67:1074-1077.[Medline]
- Pasic M, Gallino A, Carrel T, et al. Brief report: reuse of a transplanted heart N Engl J Med 1993;328:319-320.[Medline]
- Moreno Gonzales E, Gomez R, Gonzales Pinto I, et al. Reuse of liver grafts after early death of the first recipient World J Surg 1996;20:309-312.[Medline]
- Nafidi O, Letourneau R, Willems BE, Lapointe RW. Reuse of liver graft from a brain dead recipient Clin Transplant 2007;21:773-776.[Medline]
- Rubay R, Wittebolle X, Ciccarelli O, et al. Re-use of liver allograft; an exceptional opportunity to enlarge the organ pool Transpl Int 2003;16:595-597.
- Tayar C, Karoui M, Laurent A, et al. Successful reuse of liver graft 13 years after initial transplantation Transplantation 2006;82:1547-1548.[Medline]
- Lowell JA, Smith CR, Brennan DC, et al. The domino transplant: Transplant recipients as organ donors Transplantation 2000;69:372-376.[Medline]
- Ortiz J, Reich DJ, Manzarbeitia C, Humar A. Successful re-use of liver allografts: three case reports and a review of the UNOS database Am J Transplant 2005;5:189-192.[Medline]
- Meiser BM, Uberfuhr P, Reichespurner H, Stang A, Kreuzer E, Reichart B. One heart transplanted successfully twice J Heart Lung Transplant 1994;13339–4.
- Simsir SA, Fontana GP, Czer LS, Schwarz ER. Heart allograft transplanted twice Eur J Cardiothorac Surg 2008;34:918-991.[Abstract/Free Full Text]
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Abstract
Introduction
