Understanding the Potential Value of Cardiovascular Brain Death Donors
to Increase the Heart Donor Pool
Nicolas A. Brozzi, MD, FACC 1
David A. Baran, FACC, FSCAI, FHFSA 1
Federico Napoli, MD 1
Institution 1: Heart, Vascular & Thoracic Institute at Cleveland Clinic
Florida. Weston, Florida.
Correspondence
Nicolas A. Brozzi, MD, FACC
Surgical Director Mechanical Circulatory Support
Cleveland Clinic Heart, Vascular and Thoracic Institute
2950 Cleveland Clinic Blvd
Weston, FL 33331
brozzin@ccf.org
The implementation of a new heart allocation system by UNOS in October
2018 was primarily intended to increase donor access for patients with
advanced heart failure awaiting heart transplantation and reduce
mortality on the waiting list. Additional efforts in this regard include
the utilization of marginal donors on patients with extended criteria
for listing, transplanting hearts from donors with hepatitis C, and more
recently the progressive adoption of techniques to facilitate donation
after circulatory death including normothermic regional perfusion and
ex-vivo normothermic perfusion (Transmedics OCS) for further assessment
of donor allograft function. 1-4
The opioid epidemic in the United States has resulted in an exponential
increase in the number of people who die from drug overdose in the past
decade to an alarming 92,000 deaths in 2020. This cause of death affects
disproportionately younger people, most frequently otherwise healthy,
with those age 15 to 45 years of age accounting for 57% of the
cases.5 (figure 1)
The most common cause of death related to chemical overdose is
respiratory failure, eventually leading to cardiac arrest related to
profound hypoxemia, in patients with normal cardiac anatomy and
function, which could potentially recover normal function and be
suitable for cardiac donation. While the reality of the opioid epidemic
is a public health problem of utmost importance further exceeding the
scope of this manuscript, we can speculate that further management and
assessment of cardiac donors with cardiovascular mechanism of death,
particularly related to drug overdose, could potentially provide
suitable organs for transplantation in a number that would further
surpass all other alternative strategies combined.
Jensen et al present an extensive analysis of the UNOS database
including nearly 36,000 adult heart transplant recipients between 2005
and 2021, reporting that only 7.5% of patients received cardiac
allografts from donors with cardiovascular mechanism of donor brain
death (CV-DBD). While the unadjusted survival analysis revealed a
discrete lower long-term survival for CV-DBD recipients (12.0 vs 13.1
years, p =0.04), this difference did not persist after adjusting
the analysis for donor / recipient age, recipient comorbidities,
annualized center volume, and transplantation era. This report
highlights the importance to further evaluate CV-DBD as we strive to
provide advanced heart failure patients access to heart
transplantation.6
Recent work has examined the impact of donor toxicology and showed that
even donors with multiple positive findings on drug screen have
equivalent survival to those without such drug use.7 A
follow-up analysis further showed that the utilization of donors is
associated with most drug use in a negative fashion (more drugs are
associated with less utilization).8 This even held
true with younger donors.
In the end, each program needs to balance the needs and acuity of
individual patients when making specific decisions on a particular donor
offered. The temptation to wait for “a better donor” is significant,
but waitlist mortality is an ever-present hazard, and the patient may
not survive until the next donor offer is available. We can and must
strive to do our best to maximize the donors we are offered even when we
are sometimes out of our comfort zone.
References:
- Patel JN, Chung JS, Seliem A, Sakr A, Stoletniy L, Rabkin DG, Abramov
D. Impact of heart transplant allocation change on competing waitlist
outcomes among listing strategies. Clin Transplant. 2021
Jul;35(7):e14345. doi: 10.1111/ctr.14345. Epub 2021 Jun
6.PMID: 33977552
- Samsky MD, Patel CB, Owen A, Schulte PJ, Jentzer J, Rosenberg PB,
Felker GM, Milano CA, Hernandez AF, Rogers JG.
Ten-year experience
with extended criteria cardiac transplantation. Circ Heart Fail. 2013
Nov;6(6):1230-8. doi: 10.1161/CIRCHEARTFAILURE.113.000296. Epub 2013
Oct 2. PMID: 24088293
- Center-level
Utilization of Hepatitis C Virus-positive Donors
forOrthotopic Heart Transplantation. Transplantation. 2021 Huckaby
LV, Seese LM, Handzel R, Wang Y, Hickey G, Kilic A.
Dec.1;105(12):2639-2645. doi:
10.1097/TP.0000000000003674.PMID: 33988340
- Truby LK, Casalinova S, Patel CB, Agarwal R, Holley CL, Mentz RJ,
Milano C, Bryner B, Schroder JN, Devore AD.
Donation After
Circulatory Death in Heart Transplantation: History, Outcomes,
Clinical Challenges, and Opportunities to Expand the Donor Pool. J
Card Fail. 2022 Sep;28(9):1456-1463. doi:
10.1016/j.cardfail.2022.03.353. Epub 2022 Apr 18.PMID: 35447338
- Centers for Disease Control and Prevention, National Center for Health
Statistics.
https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates
Accessed on October 30th, 2022.
- Jensen C, Jawtiz O, Benkert A, Spencer PJ, Bryner B, Schroder J,
Milano C. Cardiovascular Mechanism of Donor Brain Death and Heart
Recipient Survival. Journal of Cardiac Surgery, 2022.
- Baran DA, Lansinger J, Long A, Herre JM, Yehya A, Sawey EJ, Badiye AP,
Old W, Copeland J, Stelling K, Copeland H. Intoxicated Donors and
Heart Transplant Outcomes: Long-Term Safety. Circ Heart Fail. 2021
Aug;14(8):e007433. doi: 10.1161/CIRCHEARTFAILURE.120.007433. Epub 2021
Jul 28. PMID: 34315226; PMCID: PMC8366767.
- Baran DA, Long A, Lansinger J, Copeland JG, Copeland H. Donor
Utilization in the Recent Era: Effect of Sex, Drugs, and Increased
Risk. Circ Heart Fail. 2022 Jul;15(7):e009547. Doi:
10.1161/CIRCHEARTFAILURE.122.009547. Epub 2022 Jun 21. PMID: 35726629;
PMCID: PMC9287105.
Disclosures:
NB has spoken for Fresenius, and Abiomed.
DB has consulted for Abiomed, Abbott, Getinge and Livanova. He serves on
the Steering Committees for Natera, CareDx and Procyrion. He has spoken
for Pfizer
Figure 1: Drug overdose related deaths in the United States.