It’s no secret that availability of organs for transplantation in the US pales in comparison to demand. Many die each year waiting for an organ. The systems that oversee transplantation define rules which allow one to “wait in line.” You get an organ based on the seriousness of your condition, your place in line, and whether you can persuade a living donor to participate. (For a living donor, this assumes it’s a “non-vital” organ – eg: one of the donor’s two kidneys, liver, etc. Obviously a living donor cannot donate his heart.)

For heart transplants, the majority come from donors declared brain dead. Brain-dead means the irreversible function of brain activity. The heart is still beating. There’s still blood pressure and circulation.


Many years ago, I took care of an elderly patient who, several years earlier, had received a heart transplant from a 20 year old. I can’t recall specifically how old my patient was, but, I believe he was in his mid-70’s. This patient suffered a severe brain injury and was clinically brain dead. While he was in his 70’s, his transplanted heart was in its 20’s. So, his transplanted heart was much younger than he was.


Now that he was brain dead, the organ procurement organization approached the family to see if they would consent to allowing his heart to be donated to another recipient. (Sounds like “re-gifting”.) Their rationale was that the heart was a young, healthy heart. The family said yes.


I was always curious as to whether the recipient was aware that this was a “doubly-used” heart. And, if aware, did he care? What choices did he have? Would he lose their place in queue if he took a pass waiting for a “less used” heart? Or would he just lose access to that heart and he would resume his place in line for the next available heart? I don’t know the answers to any of these questions. I’m guessing he was thankful to receive any heart and was ecstatic that one became available. At the end of the day, the heart’s age was reasonably young and likely would function as well as any other young heart. Of course, there’s no way to know for sure.


A thornier issue involves a different type of donor. While most transplanted hearts come from patients who are brain dead, a small number come from donors after circulatory death (“DCD”). In response to the limited number of organs available for transplantation, many centers are now using such DCD to expand their potential pool of organs.


Procedures vary from institution to institution. Candidates include patients being supported systemically, their condition is irreversible, and withdrawal of life support will likely result in heart stopping and circulation collapsing within one hour. If the family gives consent, the patient is taken to the OR and support is withdrawn. If the patient survives the hour, he goes back to the ICU.


Assuming the heart stops and blood pressure collapses, the team allows two minutes to elapse (as there are no case reports of any heart in such circumstances becoming functional in such unsupported potential donors after two minutes). If there’s no change after two minutes, the patient is declared dead, and the heart is harvested.


Arguably, a heart that has stopped beating for two minutes might not be as robust as one that came from a brain-dead donor. Back to informed consent. Does the recipient of a DCD heart even know whether his new heart will be coming from a patient whose circulation arrested and heart stopped? Does he care? Does it matter?


I had never heard of DCD until recently. On first blush, it would seem to trigger significant ethical challenges. But, apparently ethicists have tackled this topic for years. Their conclusion is that it is ethical to withdraw supportive care from a patient who will not recover. And organs are only harvested after a patient is declared dead. A good discussion of these issues is summarized in a NEJM article from 2008, the Dead Donor Rule and Organ Transplantation.


It’s unfortunate more organs are not available to help potential recipients avoid death. I imagine potential recipients don’t believe they have much choice and most will take the next available candidate heart regardless of the circumstances.