Andersons pediatric cardiology 1783
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FIG.67.15 Percentageofpatientsbridgedwithmechanicalcirculatory
supporttohearttransplantation.ECMO,Extracorporealmembrane
oxygenation;LVAD,leftventricularassistdevice;RVAD,rightventricular
assistdevice;TAH,totalartificialheart;VAD,ventricularassistdevice.
(FromtheregistryoftheInternationalSocietyofHeartandLung
Transplantation.JHeartLungTransplant.2016;35(10):1185–1195.)
FIG.67.16 Percentageofpatientsbridgedwithmechanicalcirculatory
supporttohearttransplantationstratifiedbyagegroup.ECMO,
Extracorporealmembraneoxygenation;LVAD,leftventricularassist
devices;RVAD,rightventricularassistdevice;TAH,totalartificialheart;
VAD,ventricularassistdevice.(FromtheregistryoftheInternational
SocietyofHeartandLungTransplantation.JHeartLungTransplant.
2016;35(10):1185–1195.)
ManagementoftheDonorandRecipient
ConsiderationsRelativetotheDonor
Themechanismofdeath,resuscitation,andthetypeofsupportrequiredhavea
significantbearingonthesuitabilityofanorganfortransplantation.Thereis
accumulatingknowledgeontheeffectofbraindeathoncardiacfunctionandthe
bestmethodstosupportthecirculationtopreservecardiacfunctionfor
subsequentdonation.Theresponsetoacutetraumaticbraindeathcanbea
profounddecreaseinventricularfunction,withthemyocardiumoftheright
ventriclemoreaffectedthanthatoftheleft.41Whencomparedtopediatric
donorswithoutcardiacdysfunction,theproportionofprocuredheartswas
significantlylowerinthosewithcardiacdysfunction(56%vs.84%).42With
appropriate“donormanagement”andtime,greaterthan50%ofdonorswith
globalleftventriculardysfunctionand/orregionalwallmotionabnormalities
havebeenshowntoimproveenoughtoallowfororganprocurement,ashighas
82%intheonepediatricstudy.42Giventhedonor:recipientimbalanceandthe
realityofwaitlistmortality,itisimportanttoexploredonororganutilizationand
optimizeallpossiblefactorstomaximizedonororganavailability.Therapy
shouldbedirectedtowardtherestorationofintravascularvolumeand
appropriatesupportofthemyocardiumandvascularsystemtoensureoptimal
cardiacoutput.Detaileddiscussionregardingtheoptimalmanagementofthe
organdonorispublishedelsewhere,43butserialechocardiographyisessentialto
reassesssuitabilityfordonation.42
Muchemphasishasbeenplacedonthedevelopmentofbettercardioplegia
andpreservationsolutionsaswellasoptimizingtemperatureduringtransportof
theharvesteddonorheartinordertomitigatetheeffectofischemiareperfusion
onthemyocardium.44Donorischemictime,aknownriskfactorintheadult
population,remainscontroversialinchildren,withsomestudiessuggestingthat
itmaybeariskfactorforprimarygraftdysfunction.45–47However,inamore
recentanalysisofthePHTSregistry,ischemictimedidnothaveanimpacton
overallrecipientsurvival,althoughlongerischemictimesnegativelyimpacted1yearposttransplantsurvival.Analyzedbyrecipientage,longerischemictime
andagreateragedifferencebetweentherecipientanddonorimpactedearlyphasesurvivalforrecipientswhoreceivedatransplantatgreaterthan10yearsof
