New Report Sparks Controversy About Cardiac Transplantation in Infants

A controversial article published August 14 by the New England Journal of Medicine questions the length of time that should elapse between cardiocirculatory death and organ retrieval in infant patients.

Previously established guidelines stated a suitable period of time must elapse between cardiac cessation and organ retrieval to ensure that auto resuscitation will not occur in hearts eligible for cardiocirculatory death donation. The Institute of Medicine recommended in 1997 that five minutes should elapse between cardiac death and organ retrieval. The guidelines were revised in 2000 when the Institute suggested, “The empirical data available indicate that cardiopulmonary arrest becomes irreversible with a shorter time interval—60 seconds or less” but “existing empirical data cannot confirm or disprove a specific interval at which the cessation of cardiopulmonary function becomes irreversible.” The 2000 report clearly leaves much of the decision up to the surgeon’s discretion, and in some cases, a wait-period shortened to around two minutes has been reported.

The study in the New England Journal of Medicine details three successful heart transplant cases in infants that had a donation made after cardiac circulatory death. The doctors in these cases withdrew life support from three prospective infant donors with neurological damage but not to the extent that they met brain-death criteria. All had normal cardiac function with life support, but with consent from the parents, life support was removed and cessation of cardiac activity occurred after an average of 18 minutes. In the first patient, the elapsed time between cardiac cessation and organ retrieval was extended to three minutes. In the last two patients, this time was shortened to 75 seconds. All three surgeries and transplants were successful.

It was the Journal’s intention to raise serious debate about the ethical and legal limits to infant heart transplantation, and its website has published three Perspective articles and a Web debate alongside the report so they may represent all sides of this divisive issue. Some argue that because cardiac death had not been properly met, the organ transplantation should never have occurred. On the other side, some say with informed consent, this study indicates a promising hope for survival in infants desperately needing hearts.

What do you think of the New England Journal of Medicine report? Does the current cardiac death criteria need to be revised? How can we educate parents to make a more informed decision when it comes to the delicate situation of removing a child from life support?