USING UNSUITABLE HEARTS FOR TRANSPLANTATION

Donor availability is the single most limiting factor in heart transpl antation. From a consecutive series of 100 heart donors, there were 21 which fell well outside our minimum criteria on initial inspection: m ean arterial pressure (MAP) more than 60 mm Hg, central venous pressur e (CVP) less than 12 mm Hg, pulmonary capillary wedge pressure (PCWP) less than 12 mm Hg, left ventricular stroke work index (LVSWI) more th an 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. Fol lowing full invasive monitoring another 14 donors fell outside our cri teria; 5 had a mean LVSWI of 12.4 g.m. and 9 had a mean PCWP of 19.6 m m Hg. Following the institution of our hormone-based pharmacological r esuscitation regime 30 of these donors yielded 19 transplantable heart s and 11 transplantable heart-lung blocks. The other five were not use d due to left ventricular hypertrophy (2), inotrope dependency (2) and persistent poor function (1). Twenty-five of the 30 recipients of the se organs (83.3%) are alive and well, 4-25 months post transplant. Fou r 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 da ys from tamponade (heart). Aggressive and focussed donor management ha s helped us to maintain our levels of transplant activity, without com promising the outcome - a 30-day mortality of 16.2% in 1989, 11.8% in 1990 and 6.8% in 1991. We contend that full haemodynamic monitoring is necessary to avoid the use of poorly functioning hearts whilst provid ing objective data in those donors where cardiac function may appear i nadequate on superficial examination. This policy has allowed an expan sion of our donor pool by approximately 30%.