Using "unsuitable" hearts for transplantation

Donor availability is the single most limiting factor in hearttransplantation. From a consecutive series of 100 heart donors, there were21 which fell well outside our minimum criteria on initial inspection: meanarterial pressure (MAP) more than 60 mm Hg, central venous pressure (CVP)less than 12 mm Hg, pulmonary capillary wedge pressure (PCWP) less than 12mm Hg, left ventricular stroke work index (LVSWI) more than 15 g.m. oninotropes less than 5 mcg/kg per min. Of these 13 out of 21 had a MAP lessthan 55 mm Hg, 6 out of 21 a CVP more than 15 mm Hg and 2 out of 21 were oninotropes at more than 20 mcg/kg per min. Following full invasivemonitoring another 14 donors fell outside our criteria; 5 had a mean LVSWIof 12.4 g.m. and 9 had a mean PCWP of 19.6 mm Hg. Following the institutionof our hormone-based pharmacological resuscitation regime 30 of thesedonors yielded 19 transplantable hearts and 11 transplantable heart-lungblocks. The other five were not used due to left ventricular hypertrophy(2), inotrope dependency (2) and persistent poor function (1). Twenty-fiveof the 30 recipients of these organs (83.3%) are alive and well, 4-25months post transplant. Four early deaths occurred; one arrhythmia (heart),one acute respiratory distress syndrome (heart), one cerebrovascularaccident (heart lung) and one infection (heart, lung and liver). One deathoccurred at 90 days from tamponade (heart). Aggressive and focussed donormanagement has helped us to maintain our levels of transplant activity,without compromising the outcome--a 30- day mortality of 16.2% in 1989,11.8% in 1990 and 6.8% in 1991.