Using "unsuitable" hearts for transplantation.

Donor availability is the single most limiting factor in heart transplantation. From a consecutive series of 100 heart donors, there were 21 which fell well outside our minimum criteria on initial inspection: mean arterial pressure (MAP) more than 60 mm Hg, central venous pressure (CVP) less than 12 mm Hg, pulmonary capillary wedge pressure (PCWP) less than 12 mm Hg, left ventricular stroke work index (LVSWI) more than 15 g.m. on inotropes less than 5 mcg/kg per min. Of these 13 out of 21 had a MAP less than 55 mm Hg, 6 out of 21 a CVP more than 15 mm Hg and 2 out of 21 were on inotropes at more than 20 mcg/kg per min. Following full invasive monitoring another 14 donors fell outside our criteria; 5 had a mean LVSWI of 12.4 g.m. and 9 had a mean PCWP of 19.6 mm Hg. Following the institution of our hormone-based pharmacological resuscitation regime 30 of these donors yielded 19 transplantable hearts and 11 transplantable heart-lung blocks. The other five were not used due to left ventricular hypertrophy (2), inotrope dependency (2) and persistent poor function (1). Twenty-five of the 30 recipients of these organs (83.3%) are alive and well, 4-25 months post transplant. Four early deaths occurred; one arrhythmia (heart), one acute respiratory distress syndrome (heart), one cerebrovascular accident (heart lung) and one infection (heart, lung and liver). One death occurred at 90 days from tamponade (heart). Aggressive and focussed donor management 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.