Beating Heart Implant Technique in Donation After Circulatory Death Utilizing Ex Vivo Normothermic Organ Perfusion

In a standard donation after circulatory death (DCD) heart transplant, there are two cycles of ischemic reperfusion period. The first one is in the donor hospital and the second one is in the recipient hospital. In general, DCD heart transplant will show a 10-20 percent higher primary graft dysfunction rate compared to a brain death heart transplant. The novel beating heart implant technique (reported by the Stanford group) eliminates a second cardiac arrest and may have the potential to further improve the outcome of a DCD heart transplant (1, 2).

Procurement was performed on a circulatory death donor (DCD). At the donor hospital, the heart was procured via an ex vivo heart perfusion technique and placed on the TransMedics Organ Care System (OCS). 

Once the donor organ arrived at the recipient operating room, a modified setup that allows for tandem OCS and cardiopulmonary bypass (CPB) was initiated. 

It is important to understand that the posterior part of the donor heart is facing the surgeon (toward the ceiling) while the donor heart is on the OCS. 

First, a buttress stitch was placed on the ascending aorta close to the aortic root. An aortic root cannula was then inserted on the right side of the aorta (right atrium and superior vena cava side). 

A small aortic cross-clamp was placed just superior to the antegrade cannula to perfuse the donor heart from the recipient CPB circuit. OCS support was terminated, and the donor heart was separated from the OCS machine by cutting the aortic connection, pulmonary artery (PA) cannula, left ventricular vent, and pacing wires. Similarly, both superior and inferior vena cava stitches were removed. 

Next, warm recipient blood from a cardiopulmonary bypass was perfused through the aortic root cannula, which was pressurized at 200-250 mmHg for perfusion flow of 150-200 cc/min. Temporary pacing wires were not placed as the donor heart continued to beat by itself. 

After inspection of the donor heart, anastomoses were performed. Details of the transplant technique have been previously reported in CTSNet (3). The order of anastomosis was the same as the standard implant technique. 

Left atrial (LA) anastomosis using a 3-0 polypropylene suture with an MH needle then started at the level of the left upper pulmonary vein. The LV vent was advanced to the LV through the mitral valve. Care should be taken to not insert the LV vent deeply, as deep insertion can cause LV injury in the setting of the beating heart. The other side of the 3-0 suture was used to complete the anterior LA suture line, including the atrial septum of the recipient. 

Inferior vena cava (IVC) anastomosis was performed after releasing the snare of the IVC. In this case, the inclusion technique was used in the posterior wall to enhance visualization. A 4-0 polypropylene suture with an SH needle was used. Both donor and recipient PAs needed to be trimmed as short as possible to prevent kinking. A running 4-0 polypropylene suture with an RB needle was used for PA anastomosis. After completion of the bottom half of the PA anastomosis, a Swan-Ganz catheter was passed through the donor superior vena cava (SVC) to the opening of the IVC anastomosis. The Swan-Ganz catheter was guided to the right PA by using a big C-shaped clamp, which was passed through the PA anastomosis, pulmonic valve, tricuspid valve, and IVC anastomosis. The anterior wall of PA anastomosis was then completed. 

The ascending aorta was trimmed to adjust the length. Aortic anastomosis was performed using a running 4-0 RB suture while both aortic cross-clamps were placed on the donor and the recipient aortas. After completion of aortic anastomosis, deairing was performed by releasing the aortic cross-clamp on the donor aorta. 

The aortic cross-clamp on the recipient aorta was subsequently removed, which is the end of the aortic root perfusion to the donor heart. Next, the rest of the IVC anastomosis was completed, while the donor heart was being perfused. When the heart started beating, the LV vent was removed. Finally, SVC anastomosis was performed using a 4-0 RB suture. It was paramount to avoid kinking. Care was taken to prevent a purse string effect. Epicardial pacing wires were then placed. Hemostasis, separating from cardiopulmonary bypass, was performed in a routine fashion. 

This technique can also be applied to a brain death donor heart that is recovered and transported utilizing the OCS. 

References

1. Krishnan A, Ruaengsri C, Guenthart BA, Shudo Y, Wang H, Ma MR, MacArthur JW, Hiesinger W, Woo YJ. Beating Heart Transplant Procedures Using Organs From Donors With Circulatory Death. JAMA Netw Open. 2024 Mar 4;7(3):e241828.
2. Krishnan A, Kasinpila P, Wang H, et al. First-in-human beating-heart transplant. JTCVS Tech. 2023;19:80-85. doi:10.1016/j.xjtc.2023.02.015
3. Ohira S, Spielvogel D, Kai M. Orthotopic Heart Transplant Using Bicaval Technique Part 2: Implantation of Donor Heart. March 2023. doi:10.25373/ctsnet.22232908.v1

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