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Echocardiographic evaluation of potential cardiac transplant donors
J
THoRAc CARDIOVASC SURG
1988;95:1003-7
Echocardiographic evaluation of potential cardiac transplant donors Since the initiation of the UTAH Cardiac Transplant Program, echocardiography has been used to evaluate 74 potential donors including 65 of 71 hearts ultimately used for transplantation. Of these 65 donors, 46 had normal studies, nine had pericardial effusions, five had mild septal hypokinesia with otherwise normal function, four had equivocal mitral valve prolapse, and only one heart could not be visualized. All transplants were successful and aU donor hearts exhibited satisfactory hemodynamic function immediately after transplantation, including the hearts that were mildly abnormal before transplantation. These hearts included 21 (29%) that could have been excluded by conventional screening criteria. Nine potential donor hearts with grossly abnormal echocardiograms were not used for transplantation, including eight hearts with severe hypokinesia and one heart with significant mitral and tricuspid regurgitation. Inspection or histologic analysis confirmed the presence of severe dysfunction or morphologic damage in those hearts subjected to these additional measures. We conclude that echocardiographic screening is a useful method of evaluating potential cardiac transplant donors. It can identify potential donors that would otherwise have been excluded and it can identify potential donors with severe cardiac dysfunction without the need for direct surgical inspection.
Edward M. Gilbert, MD, Steven K. Krueger, MD, June L. Murray, RN, Dale G. Renlund, MD, John B. O'Connell, MD, William A. Gay, MD, Michael R. Bristow, MD, PhD, Salt Lake City, Utah, and the UTAH Cardiac Transplant Program*
Cardiac transplantation has become a common and accepted treatment modality for selected patients with severe heart failure. As of March 31, 1986, there were 83 heart transplant programs in the United States,' and this number is growing. It is estimated that 1002 heart transplants were performed in 1986.2 With such volume, the donor supply has become one of the limiting steps in the performance of cardiac transplantation. Thus it is desirable to identify as many suitable donors as possible. It is equally important to exclude potential donors with dysfunctional hearts that would be expected to fail immediately. Because of the possibility of significant cardiac dysfunction in subjects dying of trauma, it has been current practice to exclude potential donors with chest trauma, From the UTAH Cardiac Transplant Program. Salt Lake City. Utah. Received for publication April 17. 1987. Accepted for publication June 17. 1987. Address for reprints: Michael R. Bristow. MD. Division of Cardiology. University of Utah Medical Center. Salt Lake City. UT 84132. "For listing of members of the UTAH Cardiac Transplant Program. see end of article.
prolonged hypotension or hypoxemia, cardiac arrest, or donors receiving high-dose catecholamines.>' Direct inspection during harvesting has been the definitive method of identifying cardiac dysfunction. These methods of donor selection may exclude some hearts that have normal function. Also, failure to identify dysfunction in the heart before surgical harvest results in wasted effort and expense. Thus additional means of evaluation of potential cardiac transplant donors is needed. Echocardiography is widely available and provides an accurate, noninvasive assessment of cardiac function. From the initiation of the UTAH (Utah Transplantation Affiliated Hospitals) Cardiac Transplant Program in March 1985 through Feb. 20, 1987, echocardiography has been used to evaluate cardiac function in 74 potential donors, including 65 of the 71 hearts that have been used for transplantation. In this report we describe the effectivenessof echocardiography in the screening of potential cardiac transplant donors. Methods The criteria for a potential heart donor were as follows: formal declaration of brain death, less than 45 years of age, good prior general health, no evidence of active infection, and
1003
The Journal of Thoracic and Cardiovascular Surgery
1 0 0 4 Gilbert et af.
74
SCREENED REJECTED
9 65
ACCEPTED
46
NORMAl EFFUSION
9
HYPOKINESIA EOUIVOCAL MVP UNINTERPRETABLE
Fig. 1. Echocardiographic findings of all 74 screened donors. MVP, mitral valve prolapse.
negative hepatitis B surface antigen and human immunodeficiency virus (HIV) antibody tests. To exclude occult coronary artery disease, we subjected men older than 35 years of age and women older than 40 years of age with coronary risk factors to coronary angiograms before final acceptance as a cardiac donor. In each patient not excluded by primary screening, a secondary screen was performed to obtain the following information: (1) cause of brain death; (2) if caused by trauma, the nature of the trauma and whether specific chest injury occurred; (3) dosages and duration of medications, in particular vasoactive drugs; (4) vital signs, including invasive hemodynamic measurements if available; (5) volume status and whether diabetes insipidus was present; (6) chest x-ray film; (7) arterial blood gases; (8) electrocardiogram; (9) echocardiogram. Two-dimensional echocardiograms were performed and analyzed by a cardiologist at the referring hospital. Whatever dose of inotropic/pressor agent deemed necessary for blood pressure support (minimal acceptable systolic pressure was 90 mm Hg) was used. Acceptable echocardiographic findings were (I) a normal echocardiogram, (2) mild septal hypokinesia and otherwise normal function, (3) equivocal mitral valve prolapse without evidence of significant mitral regurgitation, and (4) small pericardial effusion. Potential donors with any other echocardiographic abnormalities were excluded. Donors who were not excluded underwent open surgical inspection of the hearts before harvest. When possible, donors who had exclusions on the echocardiograms were directly inspected to assess the validity of the echocardiographic findings. All hearts with normal or near normal function by direct inspection were ultimately transplanted. All transplants performed between March 8, 1985, and Feb. 20, 1987, are included in this investigation.
Fig. 2. Parasternal long-axis two-dimensional echocardiogram from potential donor who would have been excluded by conventional criteria A, End-diastolic frame; B, end-systolic frame. There is normal left ventricular contractility and a percent fractional shortening of 0.30. This heart was transplanted and functioned well. eM, I ern; Ao, aorta; IVS, interventricular septum; LA, left atrium; LV, left ventricle.
Results Since the initiation of the UTAH cardiac transplant program, transplantation has been performed at a rate of 0.70 transplants per week and at a rate of 1.04 transplantation per week for the last 9 months of the study. The median ischemic time (cross-clamp on to cross-clamp oft) for the donor hearts was 152 minutes (range 50 to 260 minutes). The 12-month actuarial
survival rate for all patients receiving transplants was
96%. A total of 74 potential donors were screened by echocardiography, including 65 of the 71 hearts that were used for transplantation. Of these 65 donor hearts, 46 were found to have normal echocardiograms, nine had small pericardial effusions, five had mild septal
Volume 95 Number 6
Cardiac transplant donors
June 1988
hypokinesia with otherwise normal function, four had equivocal mitral valve prolapse, and only one subject had an uninterpretable echocardiogram. Six potential donors were not screened by echocardiography because of equipment malfunction, lack of echocardiographic equipment at the harvest site, protocol violation, or because no qualified echocardiographer was available at the time of donor screening. All transplant operations were successful, and with the exception of one subject who died on postoperative day 7, all were successfully weaned from inotropic drips within 7 days. Fig. I illustrates the distribution of echocardiographic findings of all screened donors. One patient's postoperative echocardiogram revealed a biscupid aortic valve that was not detected on pretransplant echocardiographic screening or by direct surgical inspection. In one donor heart harvested from a site where echocardiographic evaluation was not available, the postoperative echocardiogram met criteria for Ebstein's anomaly and Doppler evaluation showed moderate tricuspid regurgitation, findings that were not apparent on direct surgical inspection at the time of graft harvest. Of the 65 donor hearts successfully transplanted, 21 (29%) would have been excluded by clinical criteria alone because of the presence of serious chest trauma, history of prolonged hypotension (systolic blood pressure <70 mm Hg for 2: I hour's duration), cardiac arrest, or prolonged administration of high-dose catecholamines (2:5 ~g/kg/min of dopamine for 2:5 hours' duration). However, since echocardiographic screening revealed normal cardiac function, all 21 underwent direct surgical inspection and were harvested for transplantation. The two-dimensional echocardiogram of one of these subjects is illustrated in Fig. 2. Table I outlines the clinical exclusion criteria for these 21 patients. If a more liberal dopamine dose of more than 10 ~g/kg/min for 5 hours or more is used as a clinical exclusion, 18 potential donor hearts (25%) would have been excluded by clinical criteria alone. Nine potential donor hearts were found to have grossly abnormal echocardiograms on screening and were not used. Seven had global hypokinesia and one had marked septal hypokinesia and mitral valve prolapse. The mean left ventricular percent fractional shortening of these eight hearts was 0.15 ± 0.09 (mean ± standard deviation). One of these hearts with global dysfunction had direct evaluation by inspection and palpation during kidney harvest and was found to be markedly hypokinetic; the others were excluded by echocardiographic screening alone. The ninth excluded
I005
Table I. Donors with exclusionary clinical criteria Donor No.
Catecholamines
1 2 3 4 5 6
Chest trauma
Cardiac arrest
Hypotension
* *
*
*
*
7
*
8 9
10 11 12 13 14 15 16
* * *
17
18 19
20 21
* * * *
* *
* * *
donor heart had normal left ventricular function (percent fractional shortening = 0.38) but had significant mitral and tricuspid regurgitation on Doppler flow analysis. Direct inspection and palpation were performed to further assess graft suitability and to confirm the accuracy of the echocardiographic findings. This patient had had head trauma and had no external signs of chest injury. However, direct inspection revealed mediastinal hemorrhage and cardiac contusion with resultant valvular insufficiency and the graft was not used. Among the potential donors excluded on the basis of a markedly abnormal echocardiogram were four potential grafts from subjects with isolation brain injury (gunshot wound or intracranial hemorrhage) that would not have been excluded by conventional screening criteria. The two-dimensional echocardiogram of one of these subjects is illustrated in Fig. 3. Autopsy of a second donor excluded because of isolated brain injury revealed necrotic myocardial fibers in the interventricular septum on staining with antibody directed against complement (C3) without other abnormalities.
Discussion Echocardiography is a useful noninvasive means of evaluating cardiac function. Since it is available in most hospitals where organ retrieval occurs, it can be applied
1 0 0 6 Gilbert et al.
Fig. 3. Parasternal short-axis two-dimensional echocardiogram at the level of the papillary muscles from a donor who would have been acceptable by conventional clinical criteria. A, End-diastolic frame; B, end-systolic frame. There is marked left ventricular hypokinesia with a percent fractional shortening of 0.11, which excluded this potential donor. eM. I em.
to nearly all potential donors, including those screened at long distance. Diagnostic echocardiograms can be obtained from most potential donors (98% in our experience) despite these subjects being maintained on mechanical ventilation. Since valvular insufficiency may be present, Doppler evaluation should be performed whenever possible. Donor hearts found to be acceptable by echocardiographic screening function well upon transplantation.
The Journal of Thoracic and Cardiovascular Surgery
Hearts found to have mild septal hypokinesia, equivocal mitral valve prolapse, or pericardial effusion without other abnormalities can be successfully transplanted. The cause of pericardial effusions and mild septal hypokinesia observed in some donor hearts is unknown. Mechanical ventilation and fluctuating fluid and metabolic status may account for some of these findings. Although pericardial effusion may occur in cardiac trauma, we did not consider a small effusion an exclusion in the absence of wall motion abnormalities suggestive of contusion. Careful inspection at harvest is especially important when these or other minor echocardiographic abnormalities are present. Echocardiographic screening can identify donor hearts that otherwise would have been excluded for transplantation by conventional criteria of graft evaluation. As many as 29% of our donor grafts may not have been harvested if screening echocardiograms had not revealed normal cardiac function. These hearts have all functioned successfully on transplantation. It is extremely important to identify these grafts, since the rate of transplantation is usually limited by donor availability. We identified nine donors with significant myocardial or valvular dysfunction by echocardiography, including four hearts that would not have been excluded by conventional criteria. Presumably, these four hearts would have been either used unsuccessfully or excluded by direct inspection after the harvest team had been transported to the retrieval site. Thus echocardiographic screening of potential donors may reveal unexpected cardiac dysfunction. There may be multiple causes for ventricular dysfunction in the setting of head injury. Significant traumatic cardiac injury may escape detection by conventional methods of patient evaluation and can be present in the absence of chest trauma." Histologic evidence for nontraumatic myocardial damage has been demonstrated in patients with acute head injury? and subarachnoid hemorrhage.'? Patients with subarachnoid hemorrhage have been found to have significant left ventricular wall motion abnormalities by two-dimensional echocardiogram in the absence of prior heart disease or cardiac risk factors. II In this report myocardial damage was also observed histologically in one of our subjects with isolated brain injury who had global left ventricular dysfunction on echocardiographic screening. A final, practical benefit of echocardiographic screening is that the low incidence of false positiveidentification of suitable donors eliminates unnecessary and costly transport of the surgical team to the harvest site. On the other hand, since the predictive value of echocardiography is so high, all grafts that meet echocardiographic criteria
Volume 95 Number 6
Cardiac transplant donors
June 1988
are likely to be accepted after direct inspection, which leads to a low threshold for mobilization of the transplant team for distant organ harvest.
8.
REFERENCES 1. Casscells W. Heart transplantation: recent policy developments. N Engl J Med 1986;315:1365-8. 2. Kaye MP. The registry of the international society for heart transplantation: fourth official report-l 987. J Heart Transplant 1987;6:63-7. 3. Griepp RB, Stinson EB, Clark DA, Dong E, Shumway NE. The cardiac donor. Surg Gynecol Obstet 1971; 133:792-8. 4. Painvin GA, Frazier OH, Chandler LB, Cooley DA, Reece IJ. Cardiac transplantation: indications, procurement, operation, and management. Heart Lung 1985; 14:484-9. 5. Reemtsma K, Hardy MA, Drusin RE, Smith CR, Rose EA. Cardiac transplantation-s-changing patterns in evaluation and treatment. Ann Surg 1985;202:418-23. 6. Dougherty JE, Rossi MA, Nino AF, Low HBC, Schweizer R T. Heart transplantation: 1985 perspective. Conn Med 1985;49:345-9. 7. Baumgartner WA, Borkon M, Achuff SC, Baughman
9.
10.
11.
I007
KL, Traill TA, Reitz BA. Heart and heart-lung transplantation: program, development, organization, and initiation. J Heart Transplant 1985;4:197-202. Sutherland GR, Amacher AL, Sibbald WJ, Driedger AL. Heart injury in head-injured adolescents. Childs Nerv Syst 1985;1:219-22. McLeod AA, Neil-Dwyer G, Meyer CHA, Richardson PL, Cruickshank J, Bartlett J. Cardiac sequelae of acute head injury. Br Heart J 1982;47:221-6. Greenhoot JH, Reinchenbach DO. Cardiac injury and subarachnoid hemorrhage, a clinical, pathological and physiological correlation. J Neurosurg 1969;30:521-31. Parker S, Tator CH, Pollick C. LV wall motion abnormalities in subarachnoid hemorrhage: echocardiographic study [Abstract). Circulation 1986;74(Pt 2):II153.
Physician members of the UT AU Cardiac Transplant Program John B. O'Connell, MD, William A. Gay, Jr., MD, Dale G. Renlund, MD, Kent W. Jones, MD, Michael R. Bristow, MD, PhD, Nelson A. Burton, MD, S. V. Karwande, MD, J. Lee Burke, MD, Donald L. Lappe, MD, Jeffrey A. Laser, MD, Sherman G. Sorensen, MD, Donald B. Doty, MD, Jeffrey Anderson, MD, Richard Sutton, MD, Thea Tsgaris, MD, and Edward M. Gilbert, MD
THoRAc CARDIOVASC SURG
1988;95:1003-7
Echocardiographic evaluation of potential cardiac transplant donors Since the initiation of the UTAH Cardiac Transplant Program, echocardiography has been used to evaluate 74 potential donors including 65 of 71 hearts ultimately used for transplantation. Of these 65 donors, 46 had normal studies, nine had pericardial effusions, five had mild septal hypokinesia with otherwise normal function, four had equivocal mitral valve prolapse, and only one heart could not be visualized. All transplants were successful and aU donor hearts exhibited satisfactory hemodynamic function immediately after transplantation, including the hearts that were mildly abnormal before transplantation. These hearts included 21 (29%) that could have been excluded by conventional screening criteria. Nine potential donor hearts with grossly abnormal echocardiograms were not used for transplantation, including eight hearts with severe hypokinesia and one heart with significant mitral and tricuspid regurgitation. Inspection or histologic analysis confirmed the presence of severe dysfunction or morphologic damage in those hearts subjected to these additional measures. We conclude that echocardiographic screening is a useful method of evaluating potential cardiac transplant donors. It can identify potential donors that would otherwise have been excluded and it can identify potential donors with severe cardiac dysfunction without the need for direct surgical inspection.
Edward M. Gilbert, MD, Steven K. Krueger, MD, June L. Murray, RN, Dale G. Renlund, MD, John B. O'Connell, MD, William A. Gay, MD, Michael R. Bristow, MD, PhD, Salt Lake City, Utah, and the UTAH Cardiac Transplant Program*
Cardiac transplantation has become a common and accepted treatment modality for selected patients with severe heart failure. As of March 31, 1986, there were 83 heart transplant programs in the United States,' and this number is growing. It is estimated that 1002 heart transplants were performed in 1986.2 With such volume, the donor supply has become one of the limiting steps in the performance of cardiac transplantation. Thus it is desirable to identify as many suitable donors as possible. It is equally important to exclude potential donors with dysfunctional hearts that would be expected to fail immediately. Because of the possibility of significant cardiac dysfunction in subjects dying of trauma, it has been current practice to exclude potential donors with chest trauma, From the UTAH Cardiac Transplant Program. Salt Lake City. Utah. Received for publication April 17. 1987. Accepted for publication June 17. 1987. Address for reprints: Michael R. Bristow. MD. Division of Cardiology. University of Utah Medical Center. Salt Lake City. UT 84132. "For listing of members of the UTAH Cardiac Transplant Program. see end of article.
prolonged hypotension or hypoxemia, cardiac arrest, or donors receiving high-dose catecholamines.>' Direct inspection during harvesting has been the definitive method of identifying cardiac dysfunction. These methods of donor selection may exclude some hearts that have normal function. Also, failure to identify dysfunction in the heart before surgical harvest results in wasted effort and expense. Thus additional means of evaluation of potential cardiac transplant donors is needed. Echocardiography is widely available and provides an accurate, noninvasive assessment of cardiac function. From the initiation of the UTAH (Utah Transplantation Affiliated Hospitals) Cardiac Transplant Program in March 1985 through Feb. 20, 1987, echocardiography has been used to evaluate cardiac function in 74 potential donors, including 65 of the 71 hearts that have been used for transplantation. In this report we describe the effectivenessof echocardiography in the screening of potential cardiac transplant donors. Methods The criteria for a potential heart donor were as follows: formal declaration of brain death, less than 45 years of age, good prior general health, no evidence of active infection, and
1003
The Journal of Thoracic and Cardiovascular Surgery
1 0 0 4 Gilbert et af.
74
SCREENED REJECTED
9 65
ACCEPTED
46
NORMAl EFFUSION
9
HYPOKINESIA EOUIVOCAL MVP UNINTERPRETABLE
Fig. 1. Echocardiographic findings of all 74 screened donors. MVP, mitral valve prolapse.
negative hepatitis B surface antigen and human immunodeficiency virus (HIV) antibody tests. To exclude occult coronary artery disease, we subjected men older than 35 years of age and women older than 40 years of age with coronary risk factors to coronary angiograms before final acceptance as a cardiac donor. In each patient not excluded by primary screening, a secondary screen was performed to obtain the following information: (1) cause of brain death; (2) if caused by trauma, the nature of the trauma and whether specific chest injury occurred; (3) dosages and duration of medications, in particular vasoactive drugs; (4) vital signs, including invasive hemodynamic measurements if available; (5) volume status and whether diabetes insipidus was present; (6) chest x-ray film; (7) arterial blood gases; (8) electrocardiogram; (9) echocardiogram. Two-dimensional echocardiograms were performed and analyzed by a cardiologist at the referring hospital. Whatever dose of inotropic/pressor agent deemed necessary for blood pressure support (minimal acceptable systolic pressure was 90 mm Hg) was used. Acceptable echocardiographic findings were (I) a normal echocardiogram, (2) mild septal hypokinesia and otherwise normal function, (3) equivocal mitral valve prolapse without evidence of significant mitral regurgitation, and (4) small pericardial effusion. Potential donors with any other echocardiographic abnormalities were excluded. Donors who were not excluded underwent open surgical inspection of the hearts before harvest. When possible, donors who had exclusions on the echocardiograms were directly inspected to assess the validity of the echocardiographic findings. All hearts with normal or near normal function by direct inspection were ultimately transplanted. All transplants performed between March 8, 1985, and Feb. 20, 1987, are included in this investigation.
Fig. 2. Parasternal long-axis two-dimensional echocardiogram from potential donor who would have been excluded by conventional criteria A, End-diastolic frame; B, end-systolic frame. There is normal left ventricular contractility and a percent fractional shortening of 0.30. This heart was transplanted and functioned well. eM, I ern; Ao, aorta; IVS, interventricular septum; LA, left atrium; LV, left ventricle.
Results Since the initiation of the UTAH cardiac transplant program, transplantation has been performed at a rate of 0.70 transplants per week and at a rate of 1.04 transplantation per week for the last 9 months of the study. The median ischemic time (cross-clamp on to cross-clamp oft) for the donor hearts was 152 minutes (range 50 to 260 minutes). The 12-month actuarial
survival rate for all patients receiving transplants was
96%. A total of 74 potential donors were screened by echocardiography, including 65 of the 71 hearts that were used for transplantation. Of these 65 donor hearts, 46 were found to have normal echocardiograms, nine had small pericardial effusions, five had mild septal
Volume 95 Number 6
Cardiac transplant donors
June 1988
hypokinesia with otherwise normal function, four had equivocal mitral valve prolapse, and only one subject had an uninterpretable echocardiogram. Six potential donors were not screened by echocardiography because of equipment malfunction, lack of echocardiographic equipment at the harvest site, protocol violation, or because no qualified echocardiographer was available at the time of donor screening. All transplant operations were successful, and with the exception of one subject who died on postoperative day 7, all were successfully weaned from inotropic drips within 7 days. Fig. I illustrates the distribution of echocardiographic findings of all screened donors. One patient's postoperative echocardiogram revealed a biscupid aortic valve that was not detected on pretransplant echocardiographic screening or by direct surgical inspection. In one donor heart harvested from a site where echocardiographic evaluation was not available, the postoperative echocardiogram met criteria for Ebstein's anomaly and Doppler evaluation showed moderate tricuspid regurgitation, findings that were not apparent on direct surgical inspection at the time of graft harvest. Of the 65 donor hearts successfully transplanted, 21 (29%) would have been excluded by clinical criteria alone because of the presence of serious chest trauma, history of prolonged hypotension (systolic blood pressure <70 mm Hg for 2: I hour's duration), cardiac arrest, or prolonged administration of high-dose catecholamines (2:5 ~g/kg/min of dopamine for 2:5 hours' duration). However, since echocardiographic screening revealed normal cardiac function, all 21 underwent direct surgical inspection and were harvested for transplantation. The two-dimensional echocardiogram of one of these subjects is illustrated in Fig. 2. Table I outlines the clinical exclusion criteria for these 21 patients. If a more liberal dopamine dose of more than 10 ~g/kg/min for 5 hours or more is used as a clinical exclusion, 18 potential donor hearts (25%) would have been excluded by clinical criteria alone. Nine potential donor hearts were found to have grossly abnormal echocardiograms on screening and were not used. Seven had global hypokinesia and one had marked septal hypokinesia and mitral valve prolapse. The mean left ventricular percent fractional shortening of these eight hearts was 0.15 ± 0.09 (mean ± standard deviation). One of these hearts with global dysfunction had direct evaluation by inspection and palpation during kidney harvest and was found to be markedly hypokinetic; the others were excluded by echocardiographic screening alone. The ninth excluded
I005
Table I. Donors with exclusionary clinical criteria Donor No.
Catecholamines
1 2 3 4 5 6
Chest trauma
Cardiac arrest
Hypotension
* *
*
*
*
7
*
8 9
10 11 12 13 14 15 16
* * *
17
18 19
20 21
* * * *
* *
* * *
donor heart had normal left ventricular function (percent fractional shortening = 0.38) but had significant mitral and tricuspid regurgitation on Doppler flow analysis. Direct inspection and palpation were performed to further assess graft suitability and to confirm the accuracy of the echocardiographic findings. This patient had had head trauma and had no external signs of chest injury. However, direct inspection revealed mediastinal hemorrhage and cardiac contusion with resultant valvular insufficiency and the graft was not used. Among the potential donors excluded on the basis of a markedly abnormal echocardiogram were four potential grafts from subjects with isolation brain injury (gunshot wound or intracranial hemorrhage) that would not have been excluded by conventional screening criteria. The two-dimensional echocardiogram of one of these subjects is illustrated in Fig. 3. Autopsy of a second donor excluded because of isolated brain injury revealed necrotic myocardial fibers in the interventricular septum on staining with antibody directed against complement (C3) without other abnormalities.
Discussion Echocardiography is a useful noninvasive means of evaluating cardiac function. Since it is available in most hospitals where organ retrieval occurs, it can be applied
1 0 0 6 Gilbert et al.
Fig. 3. Parasternal short-axis two-dimensional echocardiogram at the level of the papillary muscles from a donor who would have been acceptable by conventional clinical criteria. A, End-diastolic frame; B, end-systolic frame. There is marked left ventricular hypokinesia with a percent fractional shortening of 0.11, which excluded this potential donor. eM. I em.
to nearly all potential donors, including those screened at long distance. Diagnostic echocardiograms can be obtained from most potential donors (98% in our experience) despite these subjects being maintained on mechanical ventilation. Since valvular insufficiency may be present, Doppler evaluation should be performed whenever possible. Donor hearts found to be acceptable by echocardiographic screening function well upon transplantation.
The Journal of Thoracic and Cardiovascular Surgery
Hearts found to have mild septal hypokinesia, equivocal mitral valve prolapse, or pericardial effusion without other abnormalities can be successfully transplanted. The cause of pericardial effusions and mild septal hypokinesia observed in some donor hearts is unknown. Mechanical ventilation and fluctuating fluid and metabolic status may account for some of these findings. Although pericardial effusion may occur in cardiac trauma, we did not consider a small effusion an exclusion in the absence of wall motion abnormalities suggestive of contusion. Careful inspection at harvest is especially important when these or other minor echocardiographic abnormalities are present. Echocardiographic screening can identify donor hearts that otherwise would have been excluded for transplantation by conventional criteria of graft evaluation. As many as 29% of our donor grafts may not have been harvested if screening echocardiograms had not revealed normal cardiac function. These hearts have all functioned successfully on transplantation. It is extremely important to identify these grafts, since the rate of transplantation is usually limited by donor availability. We identified nine donors with significant myocardial or valvular dysfunction by echocardiography, including four hearts that would not have been excluded by conventional criteria. Presumably, these four hearts would have been either used unsuccessfully or excluded by direct inspection after the harvest team had been transported to the retrieval site. Thus echocardiographic screening of potential donors may reveal unexpected cardiac dysfunction. There may be multiple causes for ventricular dysfunction in the setting of head injury. Significant traumatic cardiac injury may escape detection by conventional methods of patient evaluation and can be present in the absence of chest trauma." Histologic evidence for nontraumatic myocardial damage has been demonstrated in patients with acute head injury? and subarachnoid hemorrhage.'? Patients with subarachnoid hemorrhage have been found to have significant left ventricular wall motion abnormalities by two-dimensional echocardiogram in the absence of prior heart disease or cardiac risk factors. II In this report myocardial damage was also observed histologically in one of our subjects with isolated brain injury who had global left ventricular dysfunction on echocardiographic screening. A final, practical benefit of echocardiographic screening is that the low incidence of false positiveidentification of suitable donors eliminates unnecessary and costly transport of the surgical team to the harvest site. On the other hand, since the predictive value of echocardiography is so high, all grafts that meet echocardiographic criteria
Volume 95 Number 6
Cardiac transplant donors
June 1988
are likely to be accepted after direct inspection, which leads to a low threshold for mobilization of the transplant team for distant organ harvest.
8.
REFERENCES 1. Casscells W. Heart transplantation: recent policy developments. N Engl J Med 1986;315:1365-8. 2. Kaye MP. The registry of the international society for heart transplantation: fourth official report-l 987. J Heart Transplant 1987;6:63-7. 3. Griepp RB, Stinson EB, Clark DA, Dong E, Shumway NE. The cardiac donor. Surg Gynecol Obstet 1971; 133:792-8. 4. Painvin GA, Frazier OH, Chandler LB, Cooley DA, Reece IJ. Cardiac transplantation: indications, procurement, operation, and management. Heart Lung 1985; 14:484-9. 5. Reemtsma K, Hardy MA, Drusin RE, Smith CR, Rose EA. Cardiac transplantation-s-changing patterns in evaluation and treatment. Ann Surg 1985;202:418-23. 6. Dougherty JE, Rossi MA, Nino AF, Low HBC, Schweizer R T. Heart transplantation: 1985 perspective. Conn Med 1985;49:345-9. 7. Baumgartner WA, Borkon M, Achuff SC, Baughman
9.
10.
11.
I007
KL, Traill TA, Reitz BA. Heart and heart-lung transplantation: program, development, organization, and initiation. J Heart Transplant 1985;4:197-202. Sutherland GR, Amacher AL, Sibbald WJ, Driedger AL. Heart injury in head-injured adolescents. Childs Nerv Syst 1985;1:219-22. McLeod AA, Neil-Dwyer G, Meyer CHA, Richardson PL, Cruickshank J, Bartlett J. Cardiac sequelae of acute head injury. Br Heart J 1982;47:221-6. Greenhoot JH, Reinchenbach DO. Cardiac injury and subarachnoid hemorrhage, a clinical, pathological and physiological correlation. J Neurosurg 1969;30:521-31. Parker S, Tator CH, Pollick C. LV wall motion abnormalities in subarachnoid hemorrhage: echocardiographic study [Abstract). Circulation 1986;74(Pt 2):II153.
Physician members of the UT AU Cardiac Transplant Program John B. O'Connell, MD, William A. Gay, Jr., MD, Dale G. Renlund, MD, Kent W. Jones, MD, Michael R. Bristow, MD, PhD, Nelson A. Burton, MD, S. V. Karwande, MD, J. Lee Burke, MD, Donald L. Lappe, MD, Jeffrey A. Laser, MD, Sherman G. Sorensen, MD, Donald B. Doty, MD, Jeffrey Anderson, MD, Richard Sutton, MD, Thea Tsgaris, MD, and Edward M. Gilbert, MD