DCD for Heart Transplantation

Abstract

The history of human organ transplantation had begun in 1954 [1], when Joseph Murray, later a Nobel Laureate, and his team carried out a human organ transplant, taking a kidney from an identical twin. In 1962, Murray performed the first successful cadaveric kidney transplant [2]. In 1963, Starzl [3] achieved the first human liver transplant and Hardy [4] performed the first lung transplant. In those days, the surgical team brought a brain-dead donor into the operating room with the recipient for the removal; the respirator was then stopped, and everyone waited for the donor’s heart to cease to beat. Technically, therefore, these donors were donation after cardiac death (DCD) donors.

Although this has not been well known by the general public as well as many physicians, the first heart transplantation (HTx) by Barnard [5] on 3 December 1967 was also performed from a DCD donor. A 54-year-old man dying of end-stage ischemic heart disease received the heart from a motor vehicle accident victim who had suffered severe brain injury. The donor’s ventilator was switched off. Her heart would stop beating naturally from hypoxia within 10–12 min. She was certified dead 5 min upon absence of ECG activity, spontaneous respirations, and reflexes and placed on cardiopulmonary bypass, and the heart was resuscitated. The graft was perfused with the cardiopulmonary bypass machine in a fashion of Marcus’ “interim parabiotic perfusion” technique and transplanted using a Lower–Shumway technique. The recipient, diabetic and undergoing treatment for Pseudomonas cellulitis of the legs, recovered, but died of Pseudomonas pneumonia after 18 days.

On 6 January 1968, Shumway and Stinson et al. did the first heart transplantation from a controlled DCD donor. After the donor was diagnosed as brain dead by neurologists and declared dead, he was extubated and the heart was procured.

Until the first set of criteria for brain death (BD) was issued by the Ad Hoc Committee of the Harvard Medical School in July 1968 [6], many HTxs were performed from DCD donors. Even after the number of HTxs from brain-dead (BD) donor increased, outcomes of HTx had not been satisfactory until cyclosporine was introduced. However, as donor shortage from BD donors had been severe at that time, many investigators had studied HTx from DCD donors, but their results were poor. Then the number of animal experiments of HTx from DCD donors was gradually declined as BD donors increased after then.

In the late 1980s, Shirakura et al. [7, 8] and Gundry et al. [9] separately reported that administration of steroid, prostaglandin, and calcium blocker arrested the heart without ventricular fibrillation after asphyxia and that function of the cardiac graft transplanted from such a DCD donor was as good as that of heart-beating donor hearts. The author of this chapter had worked with these two investigators and studied HTx from DCD and multiple organ transplantation from DCD using percutaneous cardiopulmonary bypass (PCPS) [9] as described later in basic researches.

Finally three infant HTxs from DCD donors were preformed in Denver Children’s Hospital between 2004 and 2006 [10]. This chapter would introduce the protocol of HTx from DCD donors as a representative protocol, because they were only the recent cases of HTxs from DCD donors in the world.