title: Adult heart transplantation with distant procurement and ex-vivo preservation of donor hearts after circulatory death: a case series.
abstract: BACKGROUND
  Orthotopic heart transplantation is the gold-standard long-term treatment for medically refractive end-stage heart failure. However, suitable cardiac donors are scarce. Although donation after circulatory death has been used for kidney, liver, and lung transplantation, it is not used for heart transplantation. We report a case series of heart transplantations from donors after circulatory death.
  
  
  METHODS
  The recipients were patients at St Vincent's Hospital, Sydney, Australia. They received Maastricht category III controlled hearts donated after circulatory death from people younger than 40 years and with a maximum warm ischaemic time of 30 min. We retrieved four hearts through initial myocardial protection with supplemented cardioplegia and transferred to an Organ Care System (Transmedics) for preservation, resuscitation, and transportation to the recipient hospital.
  
  
  RESULTS
  Three recipients (two men, one woman; mean age 52 years) with low transpulmonary gradients (<8 mm Hg) and without previous cardiac surgery received the transplants. Donor heart warm ischaemic times were 28 min, 25 min, and 22 min, with ex-vivo Organ Care System perfusion times of 257 min, 260 min, and 245 min. Arteriovenous lactate values at the start of perfusion were 8·3-8·1 mmol/L for patient 1, 6·79-6·48 mmol/L for patient 2, and 7·6-7·4 mmol/L for patient 3. End of perfusion lactate values were 3·6-3·6 mmol/L, 2·8-2·3 mmol/L, and 2·69-2·54 mmol/L, respectively, showing favourable lactate uptake. Two patients needed temporary mechanical support. All three recipients had normal cardiac function within a week of transplantation and are making a good recovery at 176, 91, and 77 days after transplantation.
  
  
  CONCLUSIONS
  Strict limitations on donor eligibility, optimised myocardial protection, and use of a portable ex-vivo organ perfusion platform can enable successful, distantly procured orthotopic transplantation of hearts donated after circulatory death.
  
  
  BACKGROUND
  NHMRC, John T Reid Charitable Trust, EVOS Trust Fund, Harry Windsor Trust Fund.
authors.affiliation: Heart & Lung Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia; Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, NSW, Australia; The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia. Electronic address: kumud.dhital@svha.org.au.
authors.forename: Kumud K
authors.initials: KK
authors.lastname: Dhital
authors.affiliation: Heart & Lung Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia; Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, NSW, Australia; The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia.
authors.forename: Arjun
authors.initials: A
authors.lastname: Iyer
authors.affiliation: Heart & Lung Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia; Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, NSW, Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Connellan
authors.affiliation: Heart & Lung Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia; Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, NSW, Australia; The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia.
authors.forename: Hong C
authors.initials: HC
authors.lastname: Chew
authors.affiliation: The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia.
authors.forename: Ling
authors.initials: L
authors.lastname: Gao
authors.affiliation: The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia.
authors.forename: Aoife
authors.initials: A
authors.lastname: Doyle
authors.affiliation: Department of Clinical Pharmacology, St Vincent's Hospital, Sydney, NSW, Australia; The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; Department of Physiology and Pharmacology, University of New South Wales, Randwick, NSW, Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Hicks
authors.affiliation: The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia.
authors.forename: Gayathri
authors.initials: G
authors.lastname: Kumarasinghe
authors.affiliation: Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, NSW, Australia; Department of Clinical Perfusion, St Vincent's Hospital, Sydney, NSW, Australia.
authors.forename: Claude
authors.initials: C
authors.lastname: Soto
authors.affiliation: Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, NSW, Australia; Department of Clinical Perfusion, St Vincent's Hospital, Sydney, NSW, Australia.
authors.forename: Andrew
authors.initials: A
authors.lastname: Dinale
authors.affiliation: Department of Anaesthesia, St Vincent's Hospital, Sydney, NSW, Australia.
authors.forename: Bruce
authors.initials: B
authors.lastname: Cartwright
authors.affiliation: Department of Intensive Care, St Vincent's Hospital, Sydney, NSW, Australia.
authors.forename: Priya
authors.initials: P
authors.lastname: Nair
authors.affiliation: Heart & Lung Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia; Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, NSW, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia.
authors.forename: Emily
authors.initials: E
authors.lastname: Granger
authors.affiliation: Heart & Lung Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia; Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, NSW, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia.
authors.forename: Paul
authors.initials: P
authors.lastname: Jansz
authors.affiliation: Heart & Lung Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia; Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia.
authors.forename: Andrew
authors.initials: A
authors.lastname: Jabbour
authors.affiliation: Heart & Lung Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia; Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia.
authors.forename: Eugene
authors.initials: E
authors.lastname: Kotlyar
authors.affiliation: Heart & Lung Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia; Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia.
authors.forename: Anne
authors.initials: A
authors.lastname: Keogh
authors.affiliation: Heart & Lung Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia; Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia.
authors.forename: Christopher
authors.initials: C
authors.lastname: Hayward
authors.affiliation: Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia.
authors.forename: Robert
authors.initials: R
authors.lastname: Graham
authors.affiliation: Heart & Lung Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia; Department of Cardiothoracic Surgery, St Vincent's Hospital, Sydney, NSW, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia.
authors.forename: Phillip
authors.initials: P
authors.lastname: Spratt
authors.affiliation: Heart & Lung Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia; Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Macdonald
mesh_terms: D000328:Adult; D019571:Arrhythmogenic Right Ventricular Dysplasia / Q000503:physiopathology / Q000628:therapy*; D001706:Biopsy; D002311:Cardiomyopathy, Dilated / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D006324:Heart Arrest, Induced; D016027:Heart Transplantation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009205:Myocarditis / Q000628:therapy*; D009206:Myocardium / Q000473:pathology; D009926:Organ Preservation / Q000379:methods*; D012769:Shock / Q000473:pathology; D014019:Tissue Donors / Q000145:classification*; D009927:Tissue and Organ Procurement / Q000379:methods*; D016896:Treatment Outcome; D014777:Virus Diseases / Q000628:therapy; D052096:Warm Ischemia