Heart transplantation from controlled donors: First case report in Spain
Alonso Mateos Rodriguez1, Marina Perez-Redondo2, Juanjose Rubio2, Sara Alcantara2, Juan Ignacio Torres-Gonzalez1, Esther Casado-San Juan1, Alberto Forteza2, Francisco Jose Del Rio-Gallego1.
1Oficina Regional de Coordinacion de Trasplantes, Consejeria de Sanidada, Madrid, Spain; 2Coordinacion de Trasplantes, Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain
Introduction: Heart Transplant from controlled asystolic donors have been described in medical literature in different countries like Belgium, Australia and United kingdom. Transplant procedure includes in many cases organ exvivo recuperation in Organ Care System (OCS) devices after retrieval. There are only 4 cases described in which heart is recoverd before be explanted, performing thoraco abdominal normothermic reperfusión (TANR) with ECMO. The fifth case in medical literature, and first one in Spain is described.
Materials and Methods: Potential heart donors include all patients who meet donation criteria in controlled asystole with:
a) Age between 18 and 45 years
b) Consent for donation
c) LVEF > 50% in echocardiogram prior to life support withdrawal
d) Estimation of death after withdrawal of life support of less than 30 minutes
The criteria for selecting the recipient are the following: all those patients on the waiting list for elective, non-urgent and therefore non-VAD cardiac transplants, who have signed the informed consent to receive a donor organ in controlled asystole
Whenever cardiac extraction is assessed, limitation of medical vital support (LMVS) must be performed in the operating room as follows:
1. Cannulation of both femoral vessesls of a groin prior to LMVS
2. Prepare surgical field including the cervical region, thorax, abdomen and both groins.
3. Family . accompaniment until cardiac arrest (CA)
4. LMVS including terminal extubation and, Anticoagulation according to protocol.
5. After CA, a 5 minutes “no touch period” must observed according to the law
6. Certification of exitus.
Once the death is certified, the surgical procedure and the “in situ” evaluation of the graft will begin:
1. Extended median sternotomy with left cervicotomy.
2. Opening of pericardium sack.
3. Location of intrapericardial aortic arch.
4. Dissection and clamping of supraaortic trunks and ligation of all the vessels that contribute to cerebral circulation. If necessary, the unnamed vein will be divided for better access.
5. Beggining of TANR - ECMO support.
Maximum warm ischemia time (from SBP<60 mmHg to the beginning of ECMO) will be 30 minutes. If after 30 minutes, it has not been possible to exclude the supraaortic trunks and initiate ECMO, clamp of the descending aorta (thoracic or abdominal level according to accessibility) will be performed and the evaluation / extraction of lungs and abdominal organs will be carried out according to general protocol.
6. asses the absence of cerebral perfusion by carotid doppler. , and BIS and EEG minitorization
8. Initiation of ATNR-ECMO, with coronary reperfusión and and recovery of the heartbeat
a) Decompression of cardiac cavities if necessary. b) Defibrillation with internal blades if ventricular fibrillation, if the first shock is not effective, the decompression of the cardiac cavities must be ensured and a second shock applied. If it is not possible to recover the heart rate after 2 crashes attempts, the cardiac extraction donation will be rejected. c) Stimulation with ventricular epicardical cables if asystole d) Vasoactive agents (norepinephrine, dobutamine) will be initiated at medical criteria.
9. Analytical will be extracted that includes gasometry, lactate and troponin every 15-30 min.
10. Echocardiographic (ETE) and hemodynamic assessment with Swan-Ganz catheter.
11. Progressive ECMO weaning as heart function is recovered and hemodinamic stability is reached only under heart dependence
12. hemodynamic, echocardiographic and analytical control.
13. Analytical and macroscopic validation of abdominal organs in order to validate them for transplant puurpose. Organ harvesting accordng to standard protocols
Results: A donation procedure in uncontrolled cardiac asystole was performed in January 2020 for a 45-year-old recipient who is discharged from hospital in good clinical condition three weeks after transplant. Kidneys and liver were transplanted to three different recipients. Ocular and bone tissues were obtained.
1. ATNR – ECMO is an excellent method to obtain valid haerts for transpnats from CDACD.
2. Its is crucial to asses the absence of neurological activity and/or circulation
3. Retrieval of abdominal organs is posible for Transplant purposes with excellent results.
4. Sanitary expense is clearly lower with this method because OCS it is not necessary
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