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. Author manuscript; available in PMC: 2022 Jul 1.
Published in final edited form as: J Card Surg. 2021 Mar 30;36(7):2596–2597. doi: 10.1111/jocs.15520

Commentary: Planes, Trains, and Automobiles – Effective use of Prolonged Ex-Vivo Heart Preservation

Evan P Rotar 1, Irving L Kron 1
PMCID: PMC8187278  NIHMSID: NIHMS1685484  PMID: 33783039

Abstract

Throughout the world, a shortage of donor organs has prompted development of unique strategies to expand the donor pool. Here, we review a report by Medressova and colleagues to the Journal of Cardiac Surgery detailing the 3-year follow-up of a patient who successfully underwent a heart transplant after 17 hours of ex-vivo preservation.

Commentary:

The shortage of organs for transplantation has been well reported, and numerous efforts to expand the donor pool are underway including utilization of marginal function organs, donation after circulatory death (DCD), organs from high-risk patients, and advancement of organ preservation technology1–4. Ex-vivo organ perfusion has been an exciting development in combating some of these problems allowing for procurement teams to travel further to obtain suitable organs and allow for utilization of organs which would otherwise be high-risk with standard preservation techniques5,6. In this report by Medressova and colleagues, they detail the long-term (3-year) outcomes of a patient who underwent orthotopic heart transplantation (OHT) utilizing normothermic ex-vivo perfusion with the Organ Care System (OCS) from TransMedics Inc7.

The authors highlight the clinical course of a 48-year old male and his cardiac surgical history including reoperative aortic and mitral valve disease and left ventricular device implantation before being listed for heart transplantation. The details surrounding the transplantation efforts are heroic, with procurement efforts complicated by regional geography and weather necessitating transportation via train; hardly the most expeditious means of travel in the context of a heart transplant. The authors acknowledge the donor was marginal as evidence by the donor age (60 years), unstable hemodynamics prior to procurement requiring vasopressors complicated by periods of asystole necessitating cardiopulmonary resuscitation, evidence of high lactate levels and bradycardia requiring pacing while in the OCS. Further, the donor was not size-matched to the recipient, and data regarding the size matching would be a valuable addition to this report8. In light of challenging pre-transplant circumstances and a tenuous post-operative course requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO), multiple explorations for bleeding and numerous transfusions, the patient was successfully discharged within 2 weeks of his admission. At 3 years, the authors report the patient continues to progress and has returned to a normal life. The patient did have evidence of Grade 1R rejection, but did not require treatment outside his guideline-directed regimen.

The authors and their entire cardiac transplant team are to be commended on a terrific effort and a positive outcome. Transplant coordination can be a herculean effort in its own right, but adding train transport in winter conditions with an OCS is testament to how important effective communication and teamwork is. Timing amongst the procurement and recipient teams is critical for making adequate preparations and minimizing ischemic time9. It is wise not to take irreversible action before arrival of donor organ, however it would be beneficial for the authors to give clarity to the 3.5 hours of time the organ was in the OCS upon arrival to the recipient hospital. Additionally, it is worth reinforcing the importance of echocardiography in the early postoperative period, especially in cases with prolonged donor ischemic time, perturbations in the pre-preservation course of the donor organ, or in patients who exhibit early postoperative complications. Transesophageal echocardiography remains one of the most useful tools for close monitoring of transplant cardiac function, and relating to patient hemodynamics may mitigate delays in treatment10.

Ex-vivo perfusion technology will continue to help with long-distance transplant, but is still imperfect as evidence in translational models where myocardial functional deteriorates over time11. Further investigation is warranted to elucidate cellular pathways precipitating functional decline and potential impact of pharmaceuticals aimed at mitigating ischemia reperfusion injury12,13. It is reassuring to know this technology can support long-distance travel and positive outcomes can be achieved with OCS time greater than 17 hours, especially in an organ meeting extended criteria donor (ECD) status6,14. Finally, it cannot be understated how important donor selection is. While extenuating circumstances may prompt transplant teams to stretch criteria accommodate patients in dire need, priority should continue to be placed on matching the patient with the most suitable donor in effort to avoid significant post-transplant complications8,15–17.

Figure:

Figure:

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Evan P. Rotar, MD, MS (left), and Irving L. Kron, MD (right)

Acknowledgments

Funding Statement:

This work was supported by a research grant from NHLBI/NIH (T32HL007849). The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.

Footnotes

Disclosures: The authors have nothing to disclose

Data Availability Statement: This invited commentary does not include any original data.

Conflict of Interest: none

IRB approval and informed consent: N/A

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