Left ventricular assist devices have become an important therapeutic option as a mechanical circulatory support system in the treatment of end-stage heart failure. Organ transplants from brain dead donors on mechanical circulatory support are rare. In the literature, many successful solid-organ transplants have been reported using these donors. However, to our knowledge, this is the first report of successful solid-organ transplant from a child donor with a nonpulsatile ventricular assist device.

Key words : Brain dead donor, End-stage heart failure, Mechanical circulatory support

Introduction

The number of patients on organ transplant wait lists has increased around the world.1 In Turkey, there are almost 1000 children waiting for organ transplant. Organ shortages remain the major limitations in pediatric transplant procedures, and transplant centers are now evaluating high-risk donors. With organ shortages and increased mortality of patients on wait lists, every potential organ donor should be carefully evaluated. We report the first case of visceral organ transplant from a pediatric donor whose cardiac function was supported by a nonpulsatile left ventricular assist device (LVAD).

Case Report

A 9-year-old girl was admitted to the emergency department with right hemiparesis. The patient had implantation of the Hearth Mate II (Thoratec Corp) LVAD 6 months earlier as a bridge to heart transplant because of severe dilated cardiomyopathy. The patient had also received anticoagulation therapy with warfarin. Brain computed tomography (CT) angiogram demonstrated a thrombus in the terminal of the left internal carotid artery and ipsilateral middle cerebral artery. A noncontrast brain CT scan showed acute ischemia. The patient was transferred to the pediatric intensive care unit, and her anticoagulation therapy was switched to low-molecular-weight heparin. The interventional radiology department determined that the patient was not suitable for the thrombectomy procedure. Laboratory tests were in normal ranges, activated partial thromboplastin time was 38 seconds, and international normalized ratio was 2.8.

On day 2 of hospitalization, the patient suddenly became unresponsive, and an examination revealed anisocoria. After intubation, an emergency brain CT was performed that demonstrated enlargement of ischemic areas and a large subarachnoid hemorrhage. Despite decompressive craniectomy and medical treatment, on day 6 of hospital admission, brain death was confirmed; her family consented to visceral organ and eye donation.

The liver recipient was a 7-year-old girl with autoimmune hepatitis. After transplant, graft function quickly improved and the patient was discharged home 1 week after transplant without complications. The kidney recipients were a 15-year-old boy and a 17-year-old girl who were diagnosed with vesicoureteral reflux and chronic glomeru­lonephritis, respectively. Both kidney recipients were discharged home 3 weeks after transplant with no health concerns. The intestinal recipient, a 1-year-old girl with microvillus inclusion disease, died on day 3 after transplant.

Discussion

Early after development of cardiopulmonary support systems, those donors on extracorporeal membrane oxygenation and on cardiac assisted devices have been considered to be high-risk solid-organ donors. Concerns with regard to these donors include noncardiac organ dysfunction because of nonpulsatile perfusion.

In the literature, many successful solid-organ transplant procedures have been reported using these donors. In 2004, Rayhill and associates reported the first successful organ transplant from an adult donor who was supported by an LVAD.² In 2009, Misra and associates reported the first successful transplant of a left lateral segment graft from a pediatric donor who was supported by a Berlin Heart pulsatile ventricular assist device.³ To our knowledge, this is the first report of a successful solid-organ transplant from a child donor who had nonpulsatile LVAD support.

Left ventricular assist devices have become an important therapeutic option in the treatment of end-stage heart failure as a bridge to transplant and a bridge-to-recovery. Because of organ shortages, there are often long waits for deceased donors, especially in developing countries like Turkey. Longer wait times for heart transplant have resulted in increases in the number of patients with long-term LVAD complications.⁴

Radovancevic and associates suggested that long-term nonpulsatile support may not be inferior to pulsatile support and can be used efficiently and safely to maintain adequate renal function in patients who are receiving long-term LVAD support.⁵ Patel and associates reported the first case of a successful solid-organ transplant from a donor who had continuous-flow LVAD treatment for 22 months.⁶ Results from a successful case report reported that nonpulsatile cardiac assist devices are not a contraindication to visceral organ donation.7

References:

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