This video is part of the 2020 Sentara Cardiac Grand Rounds, "Heart in a Box: The Future is Now," originally broadcast September 15, 2020. David Baran, MD, FACC, FSCAI, FHFSA, reviews the history of heart transplants and the donor process.
thank you to everyone. I appreciate those who also tuned in online. I think this is extraordinarily exciting. It's been a rough few months with coronavirus, and now toe be able to come back to grand rounds with something really completely different that I think will transform in many ways the lives of patients and also our heart transplant program. Here it's in terror. In terms of disclosures, I worked with a variety of companies in the field of cardiogenic shock, not particularly relevant to what we're talking about today. So the first transplant was done now, more than 50 years ago, in December 1967 in South Africa. And unlike today, where a lot of things they're just in regular medical journals. This was really a worldwide event. This is Time magazine of that point, and Christian Bernard is the person on the cover. Uh, really, the idea that you could take patients who are dying of heart disease that point there were no meds for heart failure except for D. Jackson, and actually saved them was really incredible. It captured the imagination of people all over the world. But then, really, the question now we fast forward 51 years. And there's many hard transform programs in United States and all over the world. And some things that maybe we haven't thought about is where to donors come from. Even patients who are undergoing transplant oftentimes asked me, Is the donor here yet or, you know, when did they die? And people don't quite understand. So your understanding that taking a heart transplant requires that you have a definition of death. So how do you take a dead organ and make it live again? In fact, you have to have organs that are beating. But in a donor who's actually dead, and what we take for granted today didn't always exist. Brain death, which allows modern organ transplantation, is defined as irreversible loss of all functions of the brain, including brain stem and the three key findings or coma. Lack of reflexes and apnea on what about non brain dead donors? So they're sometimes very severely impaired donors, and there is a concept we'll talk today about donation after circulatory determination of death or DCD. So bringing it back home because we're in Virginia, you know, one of the oldest transplant programs in the United States is a few miles away in Richmond Ashley. So the first program was Stanford in United States. But Dr Richard Lower actually was over it. What was called Medical College of Virginia on at that time there first heart transplant was in May of 1968 just about a year after Christian Bernard, a few months after Christian Bernard's amazing transplant in South Africa. On there's lots of controversy that we won't go into it this moment, but realized that there was a whole controversy at that point because they took a patient where there was no concept of really consent and there was no concept of brain death. Patient appeared to be very severely impaired, but there were no laws around brain death. And in fact, eventually they took the patient of the O. R. They withdrew life support, and after he died, they took the heart, and they saved somebody else's life with it. But the family later on suit about a year later and said, You took the heart out of a patient who's already alive. You killed him. And so and this is an excerpt from the court. But when did he die? Tucker versus Lower the surgeon, all his colleagues were sued. And as a part of this, actually, the court ruled that brain death is when the patient died, and therefore it was not murdered. Um, what are the typical pathways to donor status? You know, we now have things much better worked out than we did. So this is just a particular, uh, scenario that you can imagine. And oftentimes donors are not typically older folks. The younger people, Oftentimes bad things happen in the setting of otherwise good events. So friends air out. Unfortunately, drunk driving leads to a to a terrible tragedy. This is still a fairly common between accidents and drug use. Still very common ways that young people, unfortunately to come in ways that allow them to be donors, um, but yet not alive. So imagine in this scenario, somebody severely injured after an accident is in a coma and the injuries or the easy part to address what's hard to address is the unknowable is the brain on dso. Once the things have gone poorly in, the patient has severe neurologic dysfunction. There's really only three ways that this goes. You either have what we all hope for medicine. They hope that there's a miracle in the patient recovers and make some decent recovery. You have, uh, scenario on the top right of brain death. So on the left is a normal cat scan. Profusion on on the right is unexamined. Somebody who's experienced brain death. Where there is no profusion, the brain is no longer taking up any blood. Uh, and on the bottom panel, you have the middle sort of the netherworld of of these patients, the vegetative state, the patient's clearly not dead butts, never gonna live normally. And so in these cases, on the bottom is where donation after circulatory determination, death really applies. So if if there's no chance of meaningful life, family could decide to just withdraw care, and then there'll be no donation. Sometimes patients will request to donate organs such as corneas or what not that don't involve, uh, complexity couldn't even be done after the patient is in the mortuary. But increasingly, families were choosing the option of donation after circulatory determination of death. In other words, the patient will never be able to live purposely. You can go ahead and live, withdraw life support and do whatever you could do to save others. And in those cases, life can be given
