title: Functional assessment and transplantation of the donor heart after circulatory death.
abstract: After a severe shortage of brain-dead donors, the demand for heart transplantation has never been greater. In an attempt to increase organ supply, abdominal and lung transplant programs have turned to the donation after circulatory-determined death (DCD) donor. However, because heart function cannot be assessed after circulatory death, DCD heart transplantation was deemed high risk and never adopted routinely. We report a novel method of functional assessment of the DCD heart resulting in a successful clinical program.
  
  
  
  Normothermic regional perfusion (NRP) was used to restore function to the arrested DCD heart within the donor after exclusion of the cerebral circulation. After weaning from support, DCD hearts underwent functional assessment with cardiac-output studies, echocardiography, and pressure-volume loops. In the feasibility phase, hearts were transported perfused before evaluation of function in modified working mode extracorporeally. After the establishment of a reliable assessment technique, hearts with demonstrable good function were then selected for clinical transplantation.
  
  
  
  NRP was instituted in 13 adult DCD donors, median age of 33 years (interquartile range [IQR], 28-38 years), after a median ischemic time from withdrawal to perfusion of 24 minutes (IQR, 21-29; range, 17-146 minutes). Two of 4 hearts in the feasibility phase were unsuitable for transplantation after functional assessment. Nine DCD hearts were transplanted in the clinical phase, with 100% survival. The median intensive care duration was 5 days (IQR, 4-5 days), with 2 patients requiring mechanical support. There were no episodes of rejection (total, 1,436 patient-days; range, 48-297). During the same period, we performed 20 standard heart transplants using brain-dead donors.
  
  
  
  NRP allows rapid reperfusion and functional assessment of the DCD donor heart, ensuring only viable hearts are selected for transplantation. This technique minimizes the risk of primary graft dysfunction and maximizes confidence in DCD heart transplantation, realizing a 45% increase in our heart transplant activity.
authors.affiliation: Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom.
authors.forename: Simon J
authors.initials: SJ
authors.lastname: Messer
authors.affiliation: Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
authors.forename: Richard G
authors.initials: RG
authors.lastname: Axell
authors.affiliation: Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom.
authors.forename: Simon
authors.initials: S
authors.lastname: Colah
authors.affiliation: Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
authors.forename: Paul A
authors.initials: PA
authors.lastname: White
authors.affiliation: Eastern Region Specialist Nurses in Organ Donation, NHS Blood and Transplant, Cambridge, United Kingdom.
authors.forename: Marian
authors.initials: M
authors.lastname: Ryan
authors.affiliation: Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom.
authors.forename: Aravinda A
authors.initials: AA
authors.lastname: Page
authors.affiliation: Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom.
authors.forename: Barbora
authors.initials: B
authors.lastname: Parizkova
authors.affiliation: Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom.
authors.forename: Kamen
authors.initials: K
authors.lastname: Valchanov
authors.affiliation: Division of Cardiac Surgery, University of Alberta Hospital, Manankowiski Alberta Heart Institute, Edmonton, Alberta, Canada.
authors.forename: Christopher W
authors.initials: CW
authors.lastname: White
authors.affiliation: Division of Cardiac Surgery, University of Alberta Hospital, Manankowiski Alberta Heart Institute, Edmonton, Alberta, Canada.
authors.forename: Darren H
authors.initials: DH
authors.lastname: Freed
authors.affiliation: Falk Cardiovascular Research Center, Stanford University School of Medicine, Palo Alto, California.
authors.forename: Euan
authors.initials: E
authors.lastname: Ashley
authors.affiliation: Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom.
authors.forename: John
authors.initials: J
authors.lastname: Dunning
authors.affiliation: Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom.
authors.forename: Martin
authors.initials: M
authors.lastname: Goddard
authors.affiliation: Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom.
authors.forename: Jayan
authors.initials: J
authors.lastname: Parameshwar
authors.affiliation: Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Watson
authors.affiliation: Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.
authors.forename: Thomas
authors.initials: T
authors.lastname: Krieg
authors.affiliation: Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom.
authors.forename: Ayyaz
authors.initials: A
authors.lastname: Ali
authors.affiliation: Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom.
authors.forename: Steven
authors.initials: S
authors.lastname: Tsui
authors.affiliation: Department of Transplantation, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, United Kingdom. Electronic address: stephen.large@papworth.nhs.uk.
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Large
mesh_terms: D000328:Adult; D016027:Heart Transplantation; D006801:Humans; D010477:Perfusion; D014019:Tissue Donors; D009927:Tissue and Organ Procurement
keywords: circulatory determined death; functional assessment; heart; normothermic regional perfusion; transplant