HOPE for children: successful pediatric DCD heart transplantation using hypothermic oxygenated perfusion

BACKGROUND: The number of children referred for advanced heart failure management is increasing and with it the demand for heart transplant. However, transplantation rates have declined and waiting list mortality is up to 25%. While donation after circulatory death (DCD) heart recovery has increased adult transplant activity significantly, barriers have prevented the same in pediatrics. In the UK and Belgium, we have adopted hypothermic oxygenated perfusion (HOPE) to address this inequity. METHODS: Preclinical: A porcine DCD-HOPE model was developed to simulate neonatal and infant heart recovery, preservation, and transplantation, including functional assessment. CLINICAL: Hearts were recovered from 6 pediatric donors (3 DCD and 3 donation after brainstem death), aged 16 months-13 years), preserved with HOPE and transplanted. For small donors, this required a pediatric research cannula and surgical techniques, such as arch augmentation. RESULTS: In the preclinical model, porcine infant hearts could be successfully recovered, perfused, and transplanted with good cardiac output postbypass. In the clinical series, hearts from donors as small as 9 kg were successfully recovered, perfused, and transplanted. For the DCD cohort, median functional warm ischemic time was 19 minutes and there was no severe primary graft dysfunction. Survival at follow-up (median 287.5 days) was 100% and echocardiograms showed normal systolic function. CONCLUSIONS: There is great need to facilitate DCD heart recovery for infants and neonates. We have reported our outcomes from the world's first and smallest pediatric DCD-HOPE heart transplants and demonstrated that HOPE provides the long-awaited solution for pediatric DCD donation down to even neonatal donors. We call upon clinicians and policymakers to support DCD-HOPE to provide equity for child donors and recipients.