Pediatric heart transplantation from donation after circulatory death using normothermic regional perfusion and cold storage from a distant donor: First US experience

From the Division of Cardiothoracic Surgery, Department of Surgery, and Division of Pediatric Cardiology, Department of Pediatrics, UCLA Health Sciences, Los Angeles, Calif; and Perfusion and ECMO Services, UCLA Cardiothoracic Surgery, Los Angeles, Calif. Supported by the Rachel Cooper Foundation. Disclosures: The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Received for publication Jan 23, 2023; revisions received April 6, 2023; accepted for publication May 1, 2023. Address for reprints: Reshma Biniwale, MD, Division of Cardiothoracic Surgery, Department of Surgery, UCLA Health Sciences, Suite 62-266 Clinical Health Sciences Building, 10833 LeConte Ave, Los Angeles, CA 90095 (E-mail: rbiniwale@mednet.ucla.edu). JTCVS Techniques 2023;-:1-4 2666-2507 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). https://doi.org/10.1016/j.xjtc.2023.05.010 Heparin 0 hours Agonal phase BP <50th centile, Saturation <70% Handsoff CTOD 28 min Skin incision ECMO start Off ECMO Back On ECMO


CENTRAL MESSAGE
DCD NRP technique is a viable method to expand the pediatric heart donor pool.
donated after determination of circulatory death (DCD) has been proposed as a novel method to increase the pool of donor allografts. In 2008, the first pediatric series of DCD implants used direct procurement and perfusion, followed by implantation in the recipient. In 2015, adult series of DCD donors with normothermic machine perfusion (NMP) from Australia as well as normothermic regional perfusion (NRP) from the United Kingdom with now 5-year follow-up 1 were published. NMP is expensive, with the heart in a box machine exceeding $50,000 per patient. 2 NMP does not allow for a functional assessment in a loaded state of the donor organ before transplantation. NMP technology is also not available for pediatric-sized donors. NRP is a thoracoabdominal in situ method of reperfusion of the transplantable organs using a modified extracorporeal membrane oxygenation (ECMO) circuit. NRP allows in situ organ assessment. The first pediatric DCD heart transplant using NRP occurred in 2019 in Belgium, 3 and we report the first US DCD NRP experience in a 17-kg pediatric recipient. IRB#21 to 001629 approval was obtained September 20, 2021. An 8-year-old 28-kg donor became available after being found unresponsive at home after a viral illness. The recipient was a 5-year-old redo heart transplant patient weighing 17 kg with left-sided pulmonary venous obstruction that had previously been stented. The recipient had decompensated due to coronary allograft vasculopathy requiring ECMO and Centrimag biventricular assist device complicated by a new stroke on computed tomography scan; however, the patient was responding to verbal stimuli VIDEO 1. Visual donor heart function at 60 minutes off normothermic regional perfusion. Video available at: https://www.jtcvs.org/article/ S2666-2507(23)00184-0/fulltext. VIDEO 2. Epicardiac donor echocardiogram at 60 minutes off normothermic regional perfusion. Video available at: https://www.jtcvs.org/ article/S2666-2507(23)00184-0/fulltext. and moving extremities. The recipient also was in renal failure on dialysis. Donor/recipient height ratio was 1.26 and weight ratio was 1.64. Informed consent for publication of data was obtained from the donor family for DCD donation as well as the recipient family. The donor was located 85 miles away from the accepting institution with a travel time of 20 minutes door to door via helicopter.
After systemic heparinization, the donor withdrawal of life support was performed by the donor hospital personnel per their hospital policy. The donor died within the acceptable time frame. After declaration of death and a 5-minute hands-off period, sternotomy was performed and the head vessels were clamped. Donor was expeditiously placed on NRP through the aorta and right atrial appendage. The NRP circuit was blood primed. A cardiac index approximately 2.0 L/min/m 2 and age normal mean arterial pressure was maintained. This was sufficient flow to correct acidosis because cerebral blood flow was eliminated. The donor heart recovered in sinus rhythm within a minute of reperfusion, and was weaned off in an hour (Video 1) after correcting electrolyte and base deficits and transfusing packed red cells (Table 1). Abdominal organ dissection was completed during this time. Epicardiac echocardiography off NRP (Video 2) showed an ejection fraction of 50% with no valvular regurgitation. After returning to NRP briefly, the donor aorta was crossclamped and standard heart procurement carried out.
Implantation of the heart required explantation of the Berlin cannulas and Centrimag biventricular assist device as well as sutureless repair of the left pulmonary veins. The aortic crossclamp was removed following the left atrial and aortic anastomoses. The heart was supported on bypass for additional time to complete the transplant, rewarm the patient, and support the right ventricle to avoid the need for postoperative ECMO. 1 The heart returned in sinus rhythm with a 50% to 55% ejection fraction on epinephrine and milrinone drips. All times are summarized in Figure 1. The total ischemic time was 2 hours 32 minutes.
The recipient had a prolonged postoperative course to allow for renal recovery as well as physical rehabilitation and was discharged to home. Ejection fraction at discharge was 59%.
An analysis of the International Society for Heart and Lung Transplantation Registry to review the worldwide DCD pediatric experience demonstrated only (0.5%) of pediatric heart transplants were from DCD. There was no significant difference in the survival at 1 year between donor after brain death and DCD infant recipients. 4 We hypothesize that DCD heart transplantation using NRP is a costeffective technique that will safely expand the donor pool of available pediatric hearts and demonstrate similar outcomes to transplantation following donor after brain death.