Canadian Journal of Cardiology 30 (2014) 1460.e1e1460.e2 www.onlinecjc.ca

Case Report

Successful Recycling of a Previously Transplanted Heart: Another Option for Limited Resources John C. Mullen, MD, MSc,a Emily J. Kuurstra, BSc,a Mohamad S. Burhani, MD,a Srujan Ganta, MD,a and Lucille Lalonde, MDb a

Division of Cardiac Surgery, University of Alberta Hospital, Edmonton, Alberta, Canada b

Department of Cardiology, University of Alberta Hospital, Edmonton, Alberta, Canada

ABSTRACT

  RESUM E

We report a case of successful reuse of a previously transplanted heart. The organ was retransplanted 16 days after the initial transplantation into a 60-year-old man who had previously received a left ventricular assist device.

sentons un cas de re utilisation re ussie d’un cœur ayant de jà Nous pre te  transplante . L’organe a e  te  retransplante  16 jours après la transe plantation initiale chez un homme de 60 ans qui avait auparavant reçu un dispositif d’assistance ventriculaire gauche.

Although many patients with end-stage heart failure are benefiting from developments such as ventricular assist devices (VADs), heart transplantation remains the gold standard treatment for such patients. Because of the scarcity of the donor pool, alternative tactics such as the liberalization of donation criteria, the use of marginal donors, and ex vivo donor heart perfusion techniques are increasingly being used. Although rare, reuse of a previously transplanted heart may be considered when the opportunity arises.

The second recipient was a 60-year-old male ex-smoker (40 pack-years) with a past history of heavy alcohol use and hypertension and a recent history of myocardial infarction. He received 2 drug-eluting stents but experienced a severe low cardiac output state and recurrent episodes of ventricular tachycardia and fibrillation. The patient was transferred to our institution and received a Levitronix (CentriMag; Levitronix LLC, Waltham, MA) LVAD and RV assist device. One month later, after the recovery of the right ventricle, the patient received a HeartWare LVAD. He experienced 2 episodes of transient ischemic attack, at 4 and 6 months postoperatively, despite an adequate anticoagulation level and antiplatelet regimen. He was therefore listed urgently for transplantation. The patient had a lymphocytotoxic screen 1 month before transplantation that showed only 6% class I panel reactive antibodies and no class II panel reactive antibodies. Given this urgent status, the previously transplanted (marginal) heart was accepted for retransplantation. The patient was made aware of the exceptional distribution and consented to proceed with the transplant. The recycled heart was transplanted into the second recipient 16 days after the initial transplantation. There were minimal adhesions on re-entry of the chest of the initial recipient. After cardioplegic preservation and removal, the heart was prepared on the back table (Fig. 1), and all donor tissues from the first recipient were removed. The recycled heart was reimplanted with bicaval anastomoses. Total donor ischemic time was 295 minutes. The second recipient spent 10 days in the intensive care unit. Cardiac function recovered quickly, and the postoperative course was relatively smooth apart from a left hemothorax that required chest tube insertion, and mild renal dysfunction.

Case Presentation The original donor was an 18-year-old man who died of fulminant hepatic failure caused by drug/alcohol toxicity. His heart was transplanted at another transplant centre into the first recipient, a 59-year-old man with known ischemic cardiomyopathy, who was bridged for transplantation with a HeartWare left ventricular assist device (LVAD) (HeartWare, Framingham, MA). Fourteen days after the uneventful transplantation, the first recipient had a subarachnoid hemorrhage that progressed to herniation and brain death. The previously transplanted heart showed continued good function with moderate right ventricular (RV) dysfunction, and the donor was not receiving any inotropic agents. Received for publication June 17, 2014. Accepted July 4, 2014. Corresponding author: Dr John C. Mullen, Division of Cardiac Surgery, University of Alberta Hospital, 2D2.18 WMC, 8440 112 Street, Edmonton, Alberta T6G 2B7, Canada. Tel.: þ1-780-407-6327; fax: þ1-780-407-6752. E-mail: [email protected] See page 1460.e2 for disclosure information.

http://dx.doi.org/10.1016/j.cjca.2014.07.003 0828-282X/Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Mullen et al. Recycled Heart Transplantation

Figure 1. View of the recycled heart’s aorta and pulmonary artery during back table preparation before the second transplantation.

The moderate RV dysfunction resolved completely before discharge on postoperative day 22. All biopsy samples to date have been negative for rejection. The patient is alive and doing well 15 months postoperatively. Comment There have been 5 reported cases in the literature involving the reuse of a previously transplanted heart.1-5 The transplantation of 1 heart into 2 subsequent recipients raises several concerns, such as RV dysfunction, immune response, and ultimate success. The procedure involves subjecting the allograft to a second ischemic period, which could be especially damaging to RV function. This case involved the longest retransplantation ischemic period reported to date (295 minutes); other ischemic times ranged from 193-231 minutes.1-3 Despite initial moderate RV dysfunction, there was relatively quick normalization in our patient. The fact that the allograft is exposed to 2 hosts (and thus additional immune components) raises concern that the

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second recipient may be at risk of experiencing a more substantial immune response. We attempted to minimize this by excising all tissue belonging to the first recipient from the donor heart. Our recipient experienced no episodes of rejection using our standard triple-therapy immunosuppression regimen. Similarly, there have been no major instances of rejection reported in the literature.1-5 Nemec et al.1 suggest that continuing administration of the original immunosuppression may have a positive effect. Chronic exposure of an organ to immunosuppressive drugs may modify its immunogenicity. Treating an organ with immunosuppressive agents before transplantation might reduce the risk of rejection. The timing between transplantation procedures may be crucial in cases involving the reuse of previously transplanted hearts. In all reports,1-5 the first recipients experienced brain death from intracranial events, and the hearts were retransplanted < 16 days after the initial transplantation procedure. If the time was > 2 or 3 months after the initial transplantation, the risk could be substantially increased because of adhesion formation and the risk of repeated sternotomy. Furthermore, after a prolonged period, the donor heart may already have experienced some degree of rejection. It is noteworthy that the functional outcome was excellent in short-term follow-up (10 months-2 years) for each reported case of recycled heart transplantation (including this one).1-5 One patient died 10 months after retransplantation; however, this was the result of acute myelogenous leukemia.3 Because of the constant shortage of donor hearts, any additional donor that can be identified represents a valuable contribution. Recycling a heart can be considered when the opportunity arises based on standard acceptance criteria. Additional consideration should be given for predicted prolonged ischemic time and for longer implantation times in the initial recipient. Disclosures The authors have no conflicts of interest to disclose. References 1. Nemec P, Bedanova H, Ostrizek T. Successful re-use of the transplanted heart. Ann Thorac Surg 2010;90:1337-8. 2. Simir SA, Fontana GP, Czer LS, Schwarz ER. Heart allograft transplanted twice. Eur J Cardiothorac Surg 2008;34:918-9. 3. Planinc M, Mihaljevic T, Jarret CM, Smedira NG, Starling RC. One heart in 3 patients. Ann Thorac Surg 2012;94:143-4. 4. Pasic M, Gallino A, Carrel T, et al. Brief report: reuse of a transplanted heart. N Engl J Med 1993;328:319-20. 5. Meiser BM, Uberfuhr P, Reichenspurner H, et al. One heart transplanted successfully twice. J Heart Lung Transplant 1994;13:339-40.

Successful recycling of a previously transplanted heart: another option for limited resources.

We report a case of successful reuse of a previously transplanted heart. The organ was retransplanted 16 days after the initial transplantation into a...
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