Heart Transplantation Advances – The Use of DCD Organs Sees Renewed Focus at UPMC to Help Address Critical Shortage of Organs

Organ transplantation has extended and saved the lives of hundreds of thousands of individuals since the first successful organ transplant – a kidney – occurred in the mid-1950s, followed by countless other firsts and advances in transplantation science in the decades since, including the first heart transplant in 1968, and in 1984, in Pittsburgh, the world’s first heart-liver transplant.

And while there are many challenges still to be overcome, and many advances in the future waiting to be discovered by new generations of researchers, surgeons, and physicians, one problem has existed from the very early beginnings of organ transplantation. It persists to the present – insufficient quantities of organs are available for those in need.

“It’s not a simple problem to solve,” says David J. Kaczorowski, MD, surgical director of the Advanced Heart Failure Center at the UPMC Heart and Vascular Institute. “If it were simple, I’m confident the field would have already figured out a way to get organs to everyone that needs them. But as our experience, technology, and scientific advances have accelerated, we have been able to measurably increase the number of organs available for transplantation – hearts, kidneys, livers – the full gamut – through a number of approaches. The impact on people’s lives has been immeasurable.”

Organ preservation techniques and screening for compatible donors have led to more availability. Advances in anti-rejection therapies have steadily helped more people live longer lives.

“While one of the goals in transplantation medicine is to make more organs available for people in need, it has to be done safely and effectively while also maintaining excellent long-term outcomes,” says Dr. Kaczorowski.

Dr. Kaczorowski explains that UPMC and other centers have been able to more effectively use organs from so-called "high-risk donors" when safe, and also from what is known as extended criteria donors. With careful selection criteria and protocols, some organs from individuals of advanced age or who have mildly impaired cardiac function, for example, from left ventricular hypertrophy, or those who have suffered from a prolonged cardiac arrest (and other criteria) can be successfully transplanted, thus helping to increase the pool available.

"We continue to assess high-risk donors for potential organ donation,” says Dr. Kaczorowski. “For example, in the past, anyone with hepatitis C infection would be excluded as there would be nearly a 100% chance of the recipient contracting the illness. However, with the advances in antiviral therapies for this disease that now make it curable, we can use some of these organs safely.”

Rekindling the Use of DCD Organs to Increase Availability

Donation after circulatory death (DCD), has begun to see renewed interest from the field in the last several years as a safe and effective means to increase the number of organs available for transplant, and in particular, hearts.

"DCD is not a new concept by any means," says Dr. Kaczorowski. "The very first human heart transplants performed in the mid-1960s were done with DCD donors. The concept of brain death as we now know it (and the criteria surrounding a declaration) did not exist back then. Transplant teams waited for the heart to stop and circulatory death to be confirmed, and then the organ would be removed and prepared for transplant. This still occurs today for significant portions of kidney, liver, and lung transplants.”

However, as Dr. Kaczorowski explains, over time, as the science around transplantation progressed, transplantation teams and researchers realized that, along with the understanding of brain death, if the heart (and other organs) could be kept intact in the body in these donors, you could minimize ischemic times and injury to the heart that could render it unusable. Donation after brain death became the gold standard by which outcomes could be improved.

"Essentially, the field came to appreciate that donation after brain death was optimal for heart transplantation and transplantation in general," says Dr. Kaczorowski. "But over the last several years, as technology has advanced and we have become better at preserving and perfusing organs before transplantation, assessing their function and appropriateness for transplant, there has been a renewed focus and effort related to DCD,” says Dr. Kaczorowski. “We can do it safely and effectively and at the same time work at one of the ongoing challenges with transplantation: a critical shortage of organs for patients in need. It's another tool and option, that we have to offer when appropriate."

How Does DCD Work?

For organs procured through DCD, the donor experiences a natural circulatory death. In cases involving a DCD donor, the individual experiences cardio-pulmonary arrest and is declared deceased by the team of physicians treating the patient. For ethical concerns and protocols, the transplantation team and the surgeons who will access and retrieve the patient's organs after death are not a part of the process involved in declaring the patient's death.

"When the patient's treating team declares death, there is a stand-off period of several minutes where we wait before preparing the patient and removing the donated organs,” says Dr. Kaczorowski.

From there, transplantation teams generally have two different paths for securing the organs and performing the necessary testing and assessment regimens to determine suitability for transplantation. The first is normothermic regional perfusion, and the other is direct procurement.

Direct Procurement Using the Transmedics OCS System for Hearts at UPMC

Within the last year, the heart transplantation program at UPMC has begun using the Transmedics® OCS™ Heart system, which currently is the only U.S. Food and Drug Administration-approved device capable of extracorporeal perfusion and preservation of donor hearts.

“For DCD hearts, after the patient has died, the heart is given a dose of preservation solution, and then the heart is removed from the body and placed in the OCS™ Heart device," says Dr. Kaczorowski. "The system functions by keeping the heart alive, much as it would be while in the human body. It is perfused and functioning and beating. The device gives us the time to fully assess the organ prior to transplantation, while also allowing the organ to be better preserved in the period between when it was removed from the donor and when it is transplanted into the recipient."

No one solution is likely to transform the shortage of organs for transplantation overnight or by itself. With the steady advance of medical technology and the skill of transplantation and research teams, such as exist at UPMC and the Heart and Vascular Institute, and through the continuing immense generosity of individuals who choose to donate their organs to help children and adults with life-threatening illnesses, options such as DCD can aid in increasing the availability of organs for transplantation.

"Perhaps one day we'll be able to cure or reverse many of the conditions that lead to organ failure. Or we may be able to perfect the use of artificial devices, or maybe even grow new organs from a person's cells or tissues that would be perfect anatomic and biological matches, ones that circumvent issues such as the immune response," says Dr. Kaczorowski. "Until then, we'll keep looking for safe and effective ways to make more organs available for transplant."

Learn more about the UPMC Heart and Vascular Institute and the Heart Transplantation Program.