2.1 Donation request

A 46-year-old man diagnosed with amyotrophic lateral sclerosis approached our center with a request for euthanasia. His medical history was otherwise unremarkable. The patient spontaneously and explicitly expressed his wish to donate his organs, and of the utmost importance to him, his heart. He was thoroughly examined by multiple independent specialists who confirmed the poor prognosis and that the patient's wish for euthanasia met the criteria of Belgian law. The patient's request was eventually accepted. We aimed for a strict separation between euthanasia and organ donation procedures. The patient's wish was to be admitted to the hospital only one day before euthanasia for a routine work-up. The DCD practical modalities following euthanasia including premortem administration of heparin, postmortem central cannulation, and initiation of TA-NRP, were explained and agreed to by the patient. The heart was allocated to a suitable 65-year-old female recipient with a left ventricular assist device (LVAD) in a distant center (University Hospitals) through Eurotransplant.

2.2 The euthanasia procedure

The euthanasia procedure was carried out in the presence of his relatives, in a private room. Loss of consciousness was induced using a combination of sufentanil 10 mcg, propofol 400 mg, and diazepam 100 mg. Once the patient became unresponsive, a bolus of 30.000 IU of heparin was given before induction of circulatory arrest by injection of 40 mEq potassium chloride. The clinical determination of cardiocirculatory arrest was based on the disappearance of heart sounds, femoral, and carotid arterial pulses, and was associated with the appearance of bilateral fixed mydriasis at 8 mm.

2.3 Organ procurement

According to our local DCD protocol, the no-touch period started at the time of the circulatory arrest. The patient was transported to the operating room during the 5-min no-touch period. The patient was then moved onto the operating table. Death was declared at the end of the 5-min no-touch period, shortly after his positioning. Surgical skin preparation and draping were performed.

A rapid sternotomy was performed followed by clamping of all three supra-aortic vessels. A two-stage venous cannula was placed into the right atrium, and an arterial cannula was placed into the ascending aorta prior to the initiation of mechanical lung ventilation. Cannulas were connected to a cardiopulmonary bypass (CPB) circuit (Figure 1) and in situ TA-NRP was initiated after a warm ischemic interval of 17 min. Within 86 s of in situ reperfusion, the DCD heart spontaneously reverted to sinus rhythm (SR). We observed a rapid decrease in serum potassium and lactate after the initiation of TA-NRP, and the arterial pH gradually returned to normal (Figure 2). A femoral arterial line was inserted to allow measurement of the arterial pressure. Given the rapid and spontaneous reversion to SR, in addition to the excellent contractility of both ventricles observed on the transoesophageal echocardiography images,⁶ no inotrope infusion was required. After 42 min of TA-NRP, contractility sufficiently recovered to solely support regional perfusion of the thorax and the abdomen. There was a 52-minute preparation interval between cessation of TA-NRP and cross-clamping to allow the cold flush of the heart, the lungs, and the abdominal organs (Table 2).

Cardiectomy was carried out in a standard fashion. After procurement, the heart graft was stored on ice. The kidneys, lungs, pancreas, and liver were also recovered and successfully transplanted.

2.4 Transplantation

The heart was implanted using a bicaval technique with an implantation time of 49 min. The total ischemic time was 184 min (including the 17 min of warm ischemia prior to the onset of TA-NRP).

Thirty minutes after the onset of reperfusion, a hemodynamic stable situation was reached with moderate inotropic support and the patient could be weaned off CPB. The driveline from the LVAD was removed. Forty-five minutes after stopping CPB, the hemodynamic situation slowly deteriorated reflected by an increased inotropic support need and signs of right ventricular failure on echocardiography. The decision was made to start peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO), resulting in improved hemodynamics. However, 1 h after installation of the VA-ECMO, the hemodynamic situation deteriorated further (increased inotropic and vasopressor support, declining mean arterial pressure). An Impella CP (Abiomed) was placed to further support the systemic circulation and unload the left ventricle. In the hours that followed in the intensive care unit, the hemodynamic situation continued to deteriorate with a clinical picture that was dominated by progressive hypotension responding to volume expansion, abdominal distention, and hemoglobin loss. Abdominal ultrasound revealed a significant intraperitoneal hemorrhage. A laparotomy was performed visualizing important bleeding of the right superior epigastric artery where the driveline was extracted.

On postoperative day (POD) six, the recipient was weaned from all mechanical circulatory support. On POD fourteen, the patient was extubated. She was subsequently transferred to the ward on POD twenty-seven. Grade 1R acute cellular rejection (ACR, ISHLT 2004) was diagnosed on routine biopsy 1 month after heart transplantation. The patient went home in good health on POD 65 and is currently doing well 225 days after her transplantation. On follow-up, the left ventricular ejection fraction was 60% with a cardiac output of 4.7 L/min. The last biopsy showed no signs of ACR (grade 0 [ISHLT 2004]).