Consensus Statement Paper
ISHLT consensus statement on donor organ acceptability and management in pediatric heart transplantation

https://doi.org/10.1016/j.healun.2020.01.1345Get rights and content

The number of potential pediatric heart transplant recipients continues to exceed the number of donors, and consequently the waitlist mortality remains significant. Despite this, around 40% of all donated organs are not used and are discarded. This document (62 authors from 53 institutions in 17 countries) evaluates factors responsible for discarding donor hearts and makes recommendations regarding donor heart acceptance. The aim of this statement is to ensure that no usable donor heart is discarded, waitlist mortality is reduced, and post-transplant survival is not adversely impacted.

Section snippets

What is the waitlist mortality?

Current waitlist mortality varies by country, region, and institution. Published reports from large national and international datasets have consistently reported waitlist mortality between 17% and 30%. These include Japan (30%),2 Australia (22% mortality with 7% delisted for clinical deterioration),4 Eurotransplant (18%),5 and the United States of America (US, 17%).1 A contemporary survey of international organ procurement organizations (OPOs) showed waitlist mortality rates of 13% to 25% (

What is the current donor discard rate?

There is no standard definition of organ discard across organizations or countries, making it difficult to quantify and make comparisons. Organs may be discarded because potential organ donors were not evaluated for organ donation or were evaluated without assessing the heart, the heart was evaluated but not offered (or not reassessed for suitability to offer), an accepted organ was retrieved but not transplanted, or a donor heart was offered but not accepted for transplantation. The first 3

How much do donor characteristics affect outcomes?

The impact of donor characteristics and comorbidities on pediatric heart transplant outcomes remains challenging because of the low quality of available evidence. The literature, however, is consistent in that recipient factors far outweigh donor factors in influencing short- and long-term outcomes. The term marginal donor is often used but donor quality assessment is imprecise,16 hard evidence lacking, and the variety of criteria used to define a marginal donor for the most part is not

Can we improve donor management?

Management of pediatric donors primarily focuses on measures to mitigate the pathophysiologic responses to brain death.104, 105, 106 A recent consensus statement by the Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations made recommendations for both adult and pediatric donors.105 Early, targeted management of the potential donor can increase the number of available donor hearts without a deleterious effect on post-transplant

How do recipient and donor interactions affect outcomes?

Limited data exist on the interplay between the recipient and donor variables but do suggest there is likely a combination of factors at play.25,116, 117, 118, 119 Recipient factors appear to influence transplant outcomes more64 and has been clearly shown in adults (Table 2).118 Despite this evidence, it is common for physicians to accept marginal donors for recipients who are at higher risk. Examples are a patient deemed too sick to continue to wait, for example, on ECMO, not a ventricular

Behavioral science, programmatic, and regulatory influences

Behavioral science and the psychology of decision making provide insights into human behavior and explain why choices often deviate from rational predictions.125, 126, 127 There are several key concepts in behavioral economics and decision psychology that apply to decision making in transplantation.

Conclusions and recommendations

  • 1.

    The most important donor information is the echocardiographic measurement of EF. When normal, most other donor factors become irrelevant.

  • 2.

    It is reasonable to consider donor hearts when the EF is abnormal and/or with focal segmental wall motion abnormalities, but no strong recommendations can be made. Consideration of other factors may play a role in decision making, including the wishes of the recipient or family.

  • 3.

    There are notable differences in echocardiographic interpretations between local

Disclosure statement

The authors have no conflicts of interest to disclose. This manuscript received no funding.

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    Endorsed by the International Pediatric Transplant Association, Pediatric Heart Transplant Society, and The Transplantation Society

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