2023-05-16 09:31:47
In Padua, the cardiac surgery team led by Professor Gino Gerosa managed to successfully recondition and transplant an organ beyond the limits experienced so far worldwide. The person who received it is fine
For the first time in Italy we were able to carry out a heart transplant
taken from a heart failure donor. But we can add that we have also subverted a paradigm worldwide, demonstrating that it is possible to transplant a heart that has remained stationary after 44 minutes of anoxic arrest and started working again like a practically normal heart. This is how Professor Gino Gerosa, director of the Gallucci Heart Surgery Center of the Aou of Padua comments on the extraordinary result obtained. The heart was taken from the Treviso hospital at 10 on 11 May It is implanted in a 46-year-old congenital heart patient who has already been operated on twice and is awaiting a transplant. The intervention ended at 9 in the evening and throughout, between Treviso and Padua, about thirty were involved among physicians, cardiac surgeons, anesthesiologists, perfusion technicians, nurses and social and health workers.
What the Italian law says
For the possibility of obtaining organs for transplantation to be verified, the potential donor must be deceased. A person’s death can be determined by neurological criteria (known as “brain death”) and by cardiac criteria. Beyond the manner in which the death of an individual is ascertained, it is important to reiterate that death is unique and coincides with the total and irreversible cessation of all brain functions. In fact, to determine death by cardiological criteria o
It is necessary to observe a complete absence of heartbeat and circulation for at least the necessary time because we have with certainty the encephalic necrosis such as to determine the irreversible loss of all encephalic functions.
In Italy, donation with a stopped heart can only take place after a doctor has certified the death by performing an electro-cardiogram for at least 20 minutes (in most European countries this 5 minute observation window) . This is considered the time of anoxia, after which it is considered vi certainly an irreversible loss of brain functions and therefore the death of the individual. Once death has been confirmed, organ harvesting from a heart-stopping donor for the purpose of transplantation looks like a complex procedure from an organizational point of viewstarting from the territorial health emergency system and the teams of doctors and health workers involved in the various procedures.
Like the donation of organs and tissues on subjects whose death has been ascertained with neurological criteriai (so-called brain death), even that with a stopped heart strictly regulated by the Law of 29 December 1993 n. 578 and by the DM 11 April 2008 n. 136 which updates the DM 22 August 1994 n. 582.
The situation abroad
The donor in cardiac arrest (Dcd) has already been used in Italy and kidney, liver and lung transplants have been performed. Donor heart transplant DCD while abroad had already been done. In Australia, for example, St Vincent’s Hospital in Sydney had 43 with a one-year survival of 98% and in the UK, the Royal Papworth Hospital in Cambridge had 79 with a one-year survival of 91% — explains Professor Gerosa – . With this substantial difference that in Australia the “no touch period”, then the recording of the ECG of 2 minutes and in the United Kingdom of 5 minutes. Due to the times imposed by law, in Italy it has always been believed that heart transplantation from a donor with a stopped heart could not have been used, because already in the United States, when they reach 30 minutes of ischemic time, they consider they have obtained the range. Because we have 20 minutes of ECG we have to add another 20 minutes of warm ischemia time i.e. when the heart is stopping it is a situation in which the patient is not ventilated and the heart is therefore suffering. now known and supported by the literature how much the time spent in the absence of a circle affects the deterioration and quality of the intended organs to explantation, therefore a prolonged no-touch period negatively affects the possibility of donation.
So actually we have to wait at least 40 minutes. I would not say that a world first: we have subverted a paradigm of medicine that was impossible to do in Italy due to the 20-minute electrocardiographic assessment. By performing the first heart transplant in Italy with the current legislation, we have instead demonstrated that even with 40 minutes of ischemia the heart can tolerate. And when we reperfused it we were able to restart it and pump it adequately, explains Professor Gerosa.
Clearly first an evaluation of this heart is made to decide if it is suitable for a transplant. So true that the first time in Italy as a heart transplant in a DCD donor. But he subverted a paradigm worldwide by demonstrating that you can transplant a heart that has remained stationary in normothermia, that is, inside the patient’s chest. Not that the patient was chilled to protect this heart. No one would have thought a heart after 44 minutes of anoxic arrest could restart and be reconditioned in such a way as to be able to pump with a 70% ejection fraction, with a practically normal heart.
Get ready for some time
How was this possible? We had prepared. For several months we had been working both in the experimental and clinical fields, developing a technique to be able to manage the donor before cardiac arrest and then the reperfusion of this heart – replies the heart surgeon – . And she actually proved to be effective. After having perfused the heart for about two hours, always inside the cadaveric donor, we evaluated its pump function. It was extremely satisfactory, so we took the organ, transported it to Padua and transplanted.
The conditions of the recipient
In what condition is the patient who received the organ? in good condition. You have an uneventful postoperative course, identical to that of a heart transplant patient with a brain dead donor – says Professor Gerosa –. The heart works very well. It must be taken into account that the patient is an adult congenital heart disease, who has already been operated on twice. You know that the risk of death at transplant for a subject in these conditions between 20 and 30%, therefore high risk. It is a 100-kilo patient, so being able to find a brain-dead donor is an almost desperate feat, given that she had been on the transplant waiting list for two years and her condition was deteriorating significantly. Luckily this donor was compatible not only in terms of blood type but also in terms of the donor’s weight.
A new opportunity
International data tell us that the use of hearts from this type of donor could lead to a 30% increase in the number of heart transplants, and this could certainly improve the satisfaction of patients waiting for a transplant. He underlines it the director of the National Transplant Center (Cnt), Massimo Cardilloregarding the operation carried out in the Padua hospital where the first heart transplant was carried out from an organ that had ceased all electrical activity for 20 minutes.
The intervention carried out in Padua – says Cardillo – definitely a new opportunity which arises from the experience that has already been made for years in Italy in the use of donor organs with the assessment of cardiac death. We used to use liver and kidneys and now we are able to use hearts too, thanks to the technology and experience of centers such as the one in Padua which have performed hundreds of heart transplants. This type of intervention, he clarified, has already been carried out abroad for some time and experience is very consolidated; now Italy is also leaving and this is very positive. In Italy there is an assessment of death with very strict criteria and this made the use of these organs technically a little more complex. Today, however, we manage to do it and it will be of great benefit to patients.
The director of the NTC then recalled how in our country today there are 600 patients who are waiting for a heart transplant and about 250 operations are performed every year, therefore the need is not currently satisfied: We have long waiting times and unfortunately many waiting patients die and do not make it to the transplant. It is therefore important to use all organs and hearts available from deceased donors”. “Obviously – concludes Cardillo – I reiterate that i
l It is an important concept that citizens confirm their consent to organ donation which can be expressed during life in various ways and the renewal of the identity card. This is the only way we can guarantee patients waiting to receive the care and therapy they need.
May 15, 2023 (change May 16, 2023 | 09:31)
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