Identifying potential heart donors among newborns undergoing circulatory determination of death

doi:10.1016/j.healun.2010.09.016

The Journal of Heart and Lung Transplantation

Volume 30, Issue 4, April 2011, Pages 389-394

https://doi.org/10.1016/j.healun.2010.09.016 Get rights and content

Background

Infants younger than 1 year old have the highest heart transplant wait-list mortality. Transplantation from donors after circulatory determination of death (DCDD) is an innovative new option for these patients. We examined the potential for heart donation in neonatal intensive care unit (NICU) patients undergoing elective withdrawal of life support.

Methods

Medical records of all patients who died between June 2003 and June 2008 in our 84-bed NICU were reviewed. The mode of death among potential organ donors (weight > 2.5 kg) was categorized into 4 groups: Died despite cardiopulmonary resuscitation (CPR), do not resuscitate (DNR) status, brain death, or withdrawal of life support. Patients undergoing planned life-support withdrawal were evaluated for DCDD potential.

Results

Of 266 NICU deaths during the study period, 117 patients weighed more than 2.5 kg at the time of death, of whom 15 (13%) died despite CPR, and 33 (28%) were DNR. No brain deaths occurred; consequently, no conventional organ donation resulted. Of 69 infants (59%) who died after withdrawal, 53 were excluded as potential donors due to active infection, cardiac dysfunction, or congenital heart disease. Among the remaining 16, median time from withdrawal to death was 31 minutes (range, < 1–310 minutes). Five infants (4.3% of deaths in babies > 2.5 kg) died within 30 minutes, had good cardiac function, and could have been potential DCDD heart donors.

Conclusions

Among NICU patients withdrawn from life support during a 5-year period, 4.3% would have been suitable heart donors after circulatory determination of death. Implementing a NICU DCDD program could markedly expand the donor pool and reduce short-term wait-list mortality for infant heart transplantation.

Section snippets

Methods

This study was approved by the Institutional Review Board (IRB) at Loma Linda University and by the research committee at OneLegacy.

Study cohort

From a total of 5466 NICU discharges, 266 deaths were recorded, with 117 babies weighing more than 2.5 kg at the time of death. Of these, 15 (13%) died despite CPR, in 33 (28%) a DNR order was in place at the time of death, and 69 (59%) died after withdrawal of life support. There were no brain deaths during the study period.

Patients undergoing withdrawal of life support

The 69 NICU patients withdrawn from life support were aged 1 day to 225 days and weighed 2500 to 7495 grams at the time of death; of these, 53 had at least one medical

Discussion

The data from our study examining the potential for infant heart donation from NICU donors after circulatory determination of death showed that 4.3% of babies heavier than 2.5 kg undergoing an elective withdrawal of life-support in our NICU would have been eligible as heart donors. The shortage of suitably size-matched organs for transplantation is highlighted by the high wait-list mortality in infants and children. DCDD is being implemented nationwide to try to increase the availability of

Disclosure statement

Presented as an abstract at the 2009 Organ Donation Congress, Berlin, Germany, October 5–7, 2009.

The authors thank Ladawna Tigard for her assistance in searching the NICU admissions database.

This work was supported in part by Health Resources and Services Administration contract 234-2005-370011C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial

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Cited by (23)

Neonatal heart transplant outcomes: A single institutional experience
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Citation Excerpt :
One study found that 4.3% of patients in the neonatal intensive care unit who were withdrawn from life support may have been appropriate donors and suggests implementation of a DCD program to increase donor availability.18 Given the increased mortality rate in infants compared to adults on the transplant list, a DCD program may create a notable source of donors.20 Importantly, to ensure compassionate treatment of the donor while optimizing organ preservation, there have been renewed ethical discussions to reconsider the dead-donor rule and include patients with severe irreversible brain damage to be used as brain dead donors rather than DCD donors.19
Neonatal orthotopic heart transplantation was introduced in the 1980s as a treatment for complex congenital heart disease. Progress in single-ventricle palliation and biventricular correction has resulted in a decline in neonatal heart transplant volume. However, limited reports on neonatal heart transplants have demonstrated favorable outcomes. We report the long-term outcomes of patients with neonatal heart transplants at our institution spanning nearly 30 years.
A retrospective analysis of neonatal heart transplants and neonates listed for transplant was performed at Children's Hospital Colorado. Primary outcomes were early and late survival. Secondary outcomes were rejection episodes, retransplantation, and development of cardiac allograft vasculopathy or post-transplant lymphoproliferative disease.
A total of 21 neonates underwent orthotopic heart transplantation at our institution. Among these, 10 neonates were transplanted from 1991 to 2000, 8 neonates were transplanted from 2001 to 2010, and 3 neonates were transplanted from 2011 to 2020. The average age of these patients was 17 days, and the average weight was 3.43 kg. Early survival was 95.2%. Survival at 1 and 5 years was 85.7% (confidence interval [CI], 61.9%-95.2%) and 75% (CI, 45.6%-85.5%), respectively. Of eligible patients, the 10-year and 20-year survival was 72.2% (CI, 45.1%-85.3%) and 50% (CI, 25.9%-70.1%), respectively.
Our institution reports favorable outcomes of neonatal heart transplantation. These results should be considered within the context of outcomes for patients awaiting transplant and the limited donor availability. However, the successful nature of these procedures suggest it may be necessary to reevaluate the indications for neonatal heart transplantation, particularly where risk of mortality and morbidity with palliative or corrective surgery is high.
Potential of neonatal organ donation and outcome after transplantation
2023, Pediatric Transplantation
Implementation of a neonatal donation protocol in the neonatal intensive care unit: A single-center experience
2022, Pediatric Transplantation
Eligible neonatal donors after circulatory determination of death (Maastricht type III): A national survey of level III NICUs
2022, Pediatric Transplantation
Neonatal donation: are newborns too young to be recognized?
2021, European Journal of Pediatrics
Potential heart, liver, and kidney donation after circulatory determination of death in a neonatal intensive care unit
2021, Neonatology

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Featured articleIdentifying potential heart donors among newborns undergoing circulatory determination of death

Background

Methods

Results

Conclusions

Section snippets

Methods

Study cohort

Patients undergoing withdrawal of life support

Discussion

Disclosure statement

Am J Transpl

Am J Transpl

Am J Transpl

Am. J Transpl

J Heart Lung Transpl

Non Heart Beating Organ Transplantation: Medical and Ethical Issues in Procurement

American College of Critical Care Medicine, Society of Critical Care Medicine: recommendations for nonheartbeating organ donation

Crit Care Med

The circulatory-respiratory determination of death in organ donation

Crit Care Med

Policy statement—pediatric organ donation and transplantation

Pediatrics

Survival following liver transplantation from non-heart-beating donors

Ann Surg

AHA Scientific statement: indications for heart transplantation in pediatric heart disease

Circulation

United Network of Organ Sharing2006 OPTN/SRTR annual report, Table 11

Pediatric heart transplantation after declaration of cardiocirculatory death

N Engl J Med

Featured article
Identifying potential heart donors among newborns undergoing circulatory determination of death