MUSC Surgeons Perform First DCD Heart Transplant in South Carolina

Donor heart on perfusion machine

Increased access to organs by use of ex vivo perfusion technology expected to increase transplant volume for patients in need

by Shawn Oberrath

As the old song goes: It’s a quarter to three, there’s no one in the place — except a fully staffed heart transplant team, persevering into the early morning and bubbling with anticipation of their role in a historic moment.

The ready room awaits, the patient is prepared in the OR, and the organ’s inbound flight draws ever nearer with its cargo.

Working through a Saturday night this past October, cardiothoracic surgeons at MUSC transplanted the first heart in South Carolina obtained by donation after circulatory death (DCD). They worked in partnership with Transmedics, a medical device company that created an ex vivo perfusion machine to keep organs functional and healthy during their journey from donor to recipient.

Two surgeons performing open-heart transplant surgery 
Fellow Krishna Bhandari, M.D. (left), and lead surgeon Arman Kilic, M.D. (right), performed the first DCD heart transplant at MUSC. Credit: Scott Garrand

Arman Kilic, M.D., surgical director of the MUSC Heart Failure and Heart Transplant Program, led the surgical team, and he explained that organs obtained by DCD have previously posed challenges because of questions about functional quality, ethical considerations and logistical issues.

“With the Transmedics system we can now safely use DCD organs,” he said. “And we can also use the system to utilize brain-dead donors that have high risk criteria.”

Because there is a severe gap between supply and demand for donor organs — about 3,500 heart transplants were performed in the U.S. this year, but the waitlist grew by more than 4,300 patients in the same period — access to more organs stands to close that gap significantly. Projections anticipate a national increase of 20-30% with this new technology.

Ryan Tedford, M.D., medical director of heart transplantation at MUSC, predicts this effect at MUSC as well.

“MUSC already offers a premier advanced heart failure center,” he said. “We transplanted almost 60 hearts last year, and we expect continued growth this year with the use of DCD hearts.”

For patients who are not candidates for transplantation, MUSC offers many other life-sustaining options as well. For example, the surgical team implanted 49 left ventricular assist devices (LVADs), or heart pumps, in the past year.

The machine in the night

From the moment the heart arrived, it was obvious that something new was occurring. Gone were the days of just being able to transport a cold heart on ice. On the perfusion machine, the heart pulsated with life and warmth under conditions that mimicked human physiology.

The machine pumped a blend of the donor’s blood plus a few additives to keep the heart preserved and nourished during its time outside the body, and it kept the organ warm at a normal body temperature.

Donor heart in perfusion machine 
The Transmedics perfusion machine keeps donor organs nourished and oxygenated during transport. Credit: Scott Garrand

As Kilic and fellow Krishna Bhandari, M.D., prepared the recipient to receive the new heart, other members of the team found a moment to visit the ready room, eager to see the lifesaving organ in its suspended state.

The team included a procurement surgeon, the Transmedics team, surgeons and residents, an anesthesiologist and the entire OR staff. And amid their complicated logistical efforts and individual tasks, each team member’s face lit up as they saw the tangible result for the first time.

“This first case required a team effort across the board to work out the logistics and make the process as smooth as possible,” said Kilic. “I am really proud of our team. They pulled it off beautifully.”

Zubair Hashmi, M.D., a cardiothoracic surgeon at MUSC, retrieved and secured the donor organ along with the Transmedics team, and he was delighted with the difference that the machine provided.

“Instead of a still, inert organ, we were able to keep the heart beating and perfused with oxygen and nutrients throughout the journey,” Hashmi said. “We could analyze its function and really see its vitality.”

One of the benefits of the ex vivo system is that the organ can be assessed while it is being perfused. For example, physicians can measure lactate levels to make sure that the organ is appropriate for transplantation.

Two surgeons discuss an upcoming procedure 
Arman Kilic, M.D. (left), led the transplant team, and Zubair Hashmi, M.D. (right), procured and transported the donor organ. Both collaborated to assess the case and the organ prior to transplantation. Credit: Scott Garrand

In addition, by keeping the organ perfused and warm, the machine allows more time to gain access to organs. With the traditional method of keeping a heart cooled on ice, the maximum safe travel time is around four hours, which limits the distance a donated organ can travel for transplantation.

But with the Transmedics system, donated hearts can come from much longer distances, and Kilic shared that some centers have successfully transplanted organs donated on one side of the country and then transported to the other.

There are even conversations about a move to daytime transplants. Many transplant surgeries take place overnight, but with ex vivo perfusion it may be possible to hold donor organs overnight and perform surgeries the next morning — allowing OR staff to follow a less rigorous schedule.

According to Kilic, more data is needed before this can happen because there are limits to the length of time an organ can spend on the system. But the option is tantalizing if it becomes feasible.

Even so, with the machine humming along through the night, Kilic felt a little less rushed during removal of the native heart from the recipient. “An added benefit of this approach was that there was less urgency to have everything ready when the donor organ hit MUSC as compared to a more traditional case,” he said.

The heart of the matter

The first heart transplant with a DCD heart at MUSC was performed in a male patient with heart failure and ventricular tachycardia, which can be a fatal arrhythmia. He was being supported with a mechanical pump, but even with that help he was in persistent end-stage heart failure and needed a transplant.

When the DCD donor organ became available, the team at MUSC was able to work with Transmedics to obtain the heart, place it on the perfusion machine and bring it to MUSC for a successful transplant.

Once the donor heart was on-site and accepted for transplant, the operation proceeded as usual for a heart transplant. After the donor organ was sewn in and Kilic removed the vessel clamp to allow blood flow, the heart restarted and had a normal rhythm within a few seconds.

“We were able to come off the bypass machine with excellent function,” said Kilic. “The heart function was stellar from the beginning.”

According to Kilic, using DCD organs can avoid some of the negative effects of brain death on donor organ quality. And he said that the Transmedics system is designed to mimic the human body, which likely contributes to better organ function right away.

The patient went on to have an excellent postoperative recovery, and he became the earliest discharge at MUSC following heart transplant. He continues to do well on follow-up and is likely to be one of many similar stories as ex vivo perfusion gains traction and usage at heart centers throughout the country.

“When I saw how well the heart functioned and how good the outcome was, I was very happy for the patient,” Kilic said. “And I’m excited that the Transmedics system will allow us to expand our patients’ access to more donors.”