Donor management tactics for cardiothoracic transplantation

Abstract

I n the last decade, refinement of surgical techniques, evolution of immunosuppression, and advances in infection and rejection management after heart and/or lung transplantation have produced improvements in survival rates. Because transplantation is recognised as the best therapeutic option for an expanding number of patients with end-stage heart and lung diseases, the number of patients referred for transplantation is increasing. Before 1980, less than 350 heart transplantations were performed annually worldwide. Numbers steadily increased through the 1980s to almost 4,000 per annum by 1990 (Fig l).’ Thereafter, the number of heart and lung transplantations reached a plateau and started to decline in the last few years. Conversely, in the United Kingdom alone, 100,000 new cases of heart failure are reported each year.* The limited availability ofdonor organs results in a steady increase in both waiting times and the number of patients dying while on the waiting lists. High standards of donor care are required to ensure the maximum yield of organs for transplantation from all potential donors. The active management of donors is therefore an essential part of every transplant program. Donor selection criteria have long been established.3 The absolute contraindications to organ donation remain unchanged. These include septicaemia, extracranial malignancy, hepatitis B or C, and infection with human immunodeficiency virus. A previous myocardial infarction precludes the use of the heart for transplantation. Evidence of chronic obstructive airways disease, significant lung trauma, infection, neurogenic pulmonary oedema, and previous thoracic surgery are exclusion criteria for the use of lungs for transplantation. In an attempt to increase the donor pool; many centres have relaxed the classic donor criteria. Hearts from donors aged up to 65 years have been used, as