A new method of retrieving hearts from organ donors means the line between life and death in the hospital is surprisingly blurry, and the donor may experience some trace of consciousness or pain when the organ is harvested. This has sparked debate as to whether there is.
This new approach has divided major hospitals in New York City and beyond. The method is backed by New York University Langone Health in Manhattan, which in 2020 became the first hospital in the U.S. to try the new method. But NewYork-Presbyterian Hospital, which has the city’s largest organ transplant program, rejected the technique after its ethics committee reviewed the issue.
If this method were more widely adopted, it would greatly increase the number of hearts available for transplantation and save lives.
The reason is that most heart donors currently belong to a small category of deceased. Often donors are declared brain dead after a traumatic event such as a car accident. But until transplant teams can retrieve their organs, they remain on life support, with their hearts beating and blood circulating to carry oxygen to their organs.
Transplant surgeons say the new technique greatly expands the possibilities for patients who are not brain dead but are in a coma and whose families have taken them off life support because there is little chance of recovery. When these patients’ hearts stop, they are declared dead. However, hearts are rarely recovered from these donors because they are often damaged by oxygen deprivation during the death process.
Surgeons discovered that by restoring blood flow to the heart, the heart healed significantly, making it suitable for transplantation.
But there are two aspects of this procedure that make some surgeons and bioethicists uncomfortable.
Some ethicists and surgeons argue that the first problem stems from the traditional definition of death: when the heart stops and blood circulation irreversibly stops. Because the new procedure involves restarting blood flow, critics say it essentially invalidates previous death declarations.
But that may be a minor problem compared to the additional steps the surgeon takes. Surgeons use metal clamps to cut off blood flow from the resuscitated heart to the donor’s head, restricting blood flow to the brain and preventing any chance of brain activity returning. Some doctors and ethicists argue that this is a tacit admission that the donor may not be legally dead.
“This is kind of creepy,” Dr. V. Eric Thompson, a longtime heart surgeon and transplant specialist, said during a recent panel discussion about the procedure at Yale School of Medicine.
As a legal matter, there are two different ways to determine whether someone has died. In addition to circulatory death, there is also brain death. If the brain stops functioning completely, a person may be declared dead even though the heart is still beating.
In contrast, the new set of donors belong to the first category and are not brain dead. You may blink if you touch your eyeballs. When the breathing tube is removed, the patient may gasp.
For them, death is not immediate. It could be five minutes or 50 minutes after life support is removed and doctors declare blood circulation has stopped.
New York University Langone is using a new procedure that uses a heart-lung bypass machine to replace 300 transplants in these patients who otherwise would not have received a transplant, said Dr. Nader Moazami, a transplant surgeon who oversaw the first surgery at the facility. It is said that nearly one heart was recovered. Vanderbilt Medical Center in Nashville adopted the procedure shortly after NYU Langone and has performed many more since.
However, some medical groups are directly opposed to this.The American College of Physicians announced that arteries in the brain would be clamped to ensure brain death while restarting circulation. It seems to be in violation “Dead Donor Rule” – A basic tenet of organ transplantation in the United States that ensures that organ acquisition is not the cause of donor death.
Dr. Robert Trugue, a bioethicist at Harvard Medical School who attended the Yale panel, said this new technology holds great promise in increasing the number of donor hearts available. However, he felt that his supporters minimized ethical and legal issues.
“I’m a little concerned that there’s a little bit of gaslighting of the general public among some transplant experts,” Dr. Truog said during a panel discussion last month.
Dr. Moazami, a surgeon at New York University Langone, said much of the criticism comes from ethicists who spend little time with patients on organ transplant waiting lists.
“You can sit in your office worrying about the ethics of something, but you can face patients who have family members who are dying, who are waiting for an organ, who are not scheduled for a transplant. “I’ve never had to go into a room where I can’t get the organ. If I don’t get the organ, the patient is going to die,” Dr. Moazami said in an interview. “If you’ve ever had that experience in your life, you would never say what I’m doing is unethical.”
The debate surrounding this procedure (also known as NRP, short for normothermic regional perfusion) is how to define death, where to mark the moment between death and life, and what doctors are allowed to do in the final stages. It reflects early medical and legal debates that touched on matters such as: Minutes.
Some experts even point to the possibility of prosecution.
“An ambitious district attorney has convincingly argued that the doctors who followed the NRP protocol also intended to irreversible brain function that had not permanently ceased, thereby ensuring the patient’s death. Two transplant experts: Alexandra Glazier, a lawyer who runs an organ donation network, and Alexander Capron, a bioethicist and professor at the University of Southern California, wrote an opinion piece last year in the Journal of the American Society of Transplantation. wrote.
There are currently 103,327 people on the nationwide transplant waiting list, and approximately 17 people die each day while waiting. Most are waiting for a kidney or liver transplant.
Heart transplants are rare, with only about 3,500 performed each year. Every year, about 20% People on the waiting list for a new heart either die or get too sick and are taken off the list.
Scientific advances may one day ease the shortage of organs available for transplantation. The solution could be genetically modified pig organs. human organs grown inside an animal.Or maybe it’s an organ. raised from scratch In the lab.
But until then, access to donor hearts will be needed to expand the number of heart transplants.
TransMedix, a Massachusetts company, sells a machine that pumps oxygenated blood to the heart outside the body, avoiding ethical controversy. When the heart is removed from the donor, Tupperware-like container, through which blood circulates. However, the device can be expensive to use.
The NRP procedure is cheaper. Dr. Moazami’s team performed the test for the first time on January 20, 2020, on a 43-year-old donor with end-stage liver disease.
Due to the accumulation of toxins in his body, he fell into a coma. With the permission of his family, his life support was removed. After five minutes, the man’s breathing became labored. At 14 minutes his heart stopped. Ten minutes later, Dr. Moazami’s team cut open his chest, tightened the artery to his brain, and began pumping blood to his body using a bypass machine. This device is the same device routinely used in open heart surgery.
Eventually, the heart resumed beating on its own. After about 30 minutes, a surgeon removed it and implanted it.
Dr Moazami learned about the procedure from cases in the UK, and surgeons in Cambridge began trying it in 2015.
Dr. Moazami does not deny the ethical concerns of his critics. He noted that new scientific research raises complex questions about what happens to the brain after death. He points to a Yale University experiment that restored cellular activity in parts of the brains of dead pigs.
He said the artery would have to be clamped to the brain as a precaution to reduce the chance that any trace of sensation or consciousness, no matter how remote, would remain once blood circulation resumed in the donor.
“The brain remains a ‘black box,'” said a group of ethicists and surgeons at New York University Langone, including Dr. Moazami. I wrote it last year.