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, explains the history of organ donor selection. Dr. Baran also describes the impact of the new organ allocation system.
It's important, then to say, Well, then how our organs allocated because we understand a little bit more about where the donors come from. But who decides? Back in 1968 there were no organ procurement organization. There were no rules. You try to do the best you could do. Sometimes we did better than others. So in the US, the allocation used to be fairly straightforward. Prior to October 18 2018 there were really three statuses you knows, which is the United Network for Organ Sharing. Also in Richmond had a status one A meaning were pretty sick. You're in the hospital or you had a heart pump with complications. You got to go first. There was status, one B. You were sick, but you're not critically ill in the hospital and status to sort of everybody else. And there was a reasonable split in our program. Here. It's in terror. About 40% 30 40% of the patients would be done from home. The majority would be done from in the hospital. But at least you had a chance either way, especially if you were doing well on a heart pumping your patient, you could wait your time. But United States change allocation in October 2018 to now six statuses because it wasn't complicated enough with three, and what they did is they also decided to make multiple changes at once. And probably the biggest lesson here is if you're gonna make a change, don't make three changes at once. But that's exactly what the United States did. Um also eliminated local preference for organ sharing and decided, well, the sickest one should just get the heart. And the unintended consequence of that has been that organs now are shared in quite a different way. If you're critically ill here, it's in terror. We could get your transplant in a week, two weeks if you're truly so, so ill, and that didn't used to exist. It used to be if you were critically ill and you needed organ right away. A lot of times, the pattern we put in the heart pump because you might need a month to two or three months even critically ill because so many patients were building up waiting. Um, and on the other hand, now, if you're in the current status and you're stable, you don't get an organ right away. Because if you're stable, bad patient, you may wait many, many months because there's always gonna be somebody sicker than you. It's like intelligence is always gonna be somebody a little bit smarter, sharper, faster. And so in the current allocation, we now said, G, if you're not really sick, I don't know if we could get your heart, and that is the reason why we're going to discuss today. Necessity is the mother of invention. This is very, very true aphorism. So donation for after circulatory determination of death has been a pathway for livers, kidneys, lungs for many years. This is not new because those organs have existing pumps. You can take a patient to the operating room, withdraw life support after they die, you can flush out of kidney fat. The kidney transplant we did yesterday came on commercial aircraft. You can put these organs on pumps, and this was not suitable in the past for the heart because we didn't have any way to keep the heart alive. Certainly not if the patient already passed away, even in operating room. And so this barrier was broken back in 2000 and eight, particularly in Children where pediatric hearts of really hard to come by. So this group actually published in 2000 and eight the first use of pediatric heart transplant after D. C. D. Accompanied by a variety of editorials and the whole question of whether, you know, where does death begin on? Can you take hearts that resuscitate them after death and then still save the patient had died since you've resuscitated the heart, uh, talking about the boundaries of organ donation after circulatory death because we finally got to used to the idea that when the brains dead, the patient's dead. But what about when the patient's dead? Five minutes? Are they dead in five minutes or three minutes or 10 minutes? And so their variety of ethical issues to consider and all of these cases now stunned with the consent of families, understanding that loved one, is going to pass away but allowing organ donation. The big Society such American Society of Transplant surgeons have practice guidelines about this, uh, and there's a variety of ways if you're going to take a heart like this, so one of the ways is that you co locate or you put the donor in an operating room next to the recipient. This is what was done in Christian Bernard's case and Medical College of Virginia case. You put the donors in two operating rooms adjacent, and then it's pretty simple. You stop away until the patient dies. Clean the heart out of it, bring it next door. That's really impractical in the United States, where organs may come from very far away. And now, with the new allocation very unlikely that any organs air coming from Virginia, we're usually flying here, there and everywhere my credit to my colleagues who do all the heavy lifting. Um, there's also a concept we'll talk about Norma thermic regional profusion and then the heart in the box. There are classifications of donors and importantly, uh, the donors well used to this trial or masters three or with role of life support. So it's a controlled circumstance, so it's not, for example, somebody passes away. You find them in their house and they're cold. Andi there have expired on that. You can use those organs for transplant. You cannot. You have to do this in a controlled circumstance. And this is from a very nice Jack paper published last year, really illustrating what are the sequence of steps patients brought to an operating room? Withdrawal of life support is conducted, and then you have the period of time. As the patient dies. The blood pressure is less than 90. Eventually, the heart stops a Sicily. Then you have standoff. Remember that the heart transplant team ethically cannot be involved in any of this were not involved in the patient's passing away. The standoff period, typically 3 to 5 minutes the patient's pronounced dead. Then the surgeons from all the various parts come into play with knife to skin collection of blood and then going ahead to proceed to the pump. Norman Thermic regional profusion is another way of doing this, same way patients brought to the operating room. And after they died, the chest is open and you put them on a heart lung machine. You want to make sure that the brain does not get profusion again. You don't want any chance that that patient may somehow come back to some consciousness. Uh, so this is done in some places, but it's a bit cumbersome because you literally have to bring your whole operating room team, often times to a small hospital. So this is the heart in the box. This is actually Ah, heart after it's been perf used. Looks like it's perfectly normal. Here's the heart actually working, not inside a patient but inside a machine. It is really one of the most revolutionary things, and recently I was fortunate to travel with Dr Philpott and his colleagues, uh, to Massachusetts to actually see this being done live. This is a slide from some years ago when I was involved in experience with this. This is actually then done in adults. The first Pediatrics report in 2008 and adults. We looked our colleagues from Australia, and in 2015 they published the first three cases, and Lance in Australia is an interesting country. It's very, very large. The distance between one out of the country and the other is about 12 hours, and they have a very advanced heart transplant program. But because of that, they have a variety of large need, and you certainly can't travel to other countries to procure organs. So they started using the heart in the box technology that a commode total and colleagues on they report the first three cases, and if you see on the right, it talks about things like the warmest scheming time, or how long it took between the patient dying and the heart being put on the pump.
