Sixteen-Hour Ex Vivo Donor Heart Perfusion During Long-Distance Transportation for Heart Transplantation.

To the Editor,

As we know, the organ care system (OCS) is an alternative method of donor organ preservation to the cold storage standard of care. It provides ex vivo heart perfusion and preservation in a warm, beating, near‐physiologic functioning state. By shortening cold ischemia time, it might allow for distant procurement 1.

To our knowledge, there was a case report of a successful heart transplant after 10‐h out‐of‐body time using OCS 2. We report a case of 16‐h cross‐clamp to cross‐clamp time for cardiac transplant. Our recipient was a 48‐year‐old, 181‐cm, and 65‐kg male with dilated cardiomyopathy. He had New York Heart Association class IV symptoms and underwent implantation of a HeartMate3 left ventricular assist device. Clinical status was complicated by drive line infection necessitating urgent enlisting for heart transplantation. A suitable donor heart became available. Poor weather conditions prevented donor transfer by medical or commercial aircraft, nor by ambulance; consequently the allograft was transported by a passenger train. Travel time on a return journey approximated 12 hours (>500 km).

The donor heart procurement took place as per conventional and company protocols for the OCS. Upon arrival at our center, the donor heart is arrested with approximately 1 L of normothermic blood cardioplegia, as opposed to cold Custodiol, and is disconnected from the OCS for implantation into the recipient. For cardioplegia, we used blood and crystalloid solution at the ratio of 1:5. In the OCS, in order to protect and improve donor heart function, the allograft was conditioned with levosimendan 45μg/kg and hemofiltration (Medos Medizintechnik AG, Heilbronn, Germany), which can lead to a significant reduction in circulating inflammatory mediators, blood loss, and transfusion requirements 3.

Total ischemia time was 68 min and perfusion was 955 min. This resulted in a total cross‐clamp to cross‐clamp time of 1023 min. Mean venous lactate at the start of perfusion was 8.2 mmol/L, and at the end of perfusion was 6.8 mmol/L. The perfusate was continuously run through a hemofiltration of 250–300 mL/h via an arteriovenous shunt.

There was a total cardiopulmonary bypass time of 387 min with 219 min of warm reperfusion. Due to the high dose requirement of inotrope support, ECMO was connected.

ECMO was weaned off and the patient decannulated 44 h later. The recipient was extubated 72 h after, discharged from the hospital 24 days after the transplant with normal biventricular function. The recipient is over 7 months post‐transplant with no evidence of rejection or cardiac dysfunction.

We report the longest ex vivo allograft perfusion time for a successful human cardiac transplant to be added to a global learning curve of long runs using OCS.