World-first paediatric heart transplant technique boosts number of life-saving operations for children in the UK

Great Ormond Street Hospital (GOSH) and Royal Papworth Hospital (RPH) have collaborated to introduce a world-first paediatric heart transplant technique that has successfully expanded the donor pool and increased the number of transplants for eligible children in the UK by 50%.

The donation after circulatory death (DCD) heart transplant programme was previously only available to adults. For the first time ever, using a portable organ perfusion system called the TransMedics heart Organ Care System (OCS), the technique has now been made available for children, paving the way for six life-saving heart transplants for young patients at GOSH in 2020.

It is the biggest and most successful paediatric DCD heart transplant programme in the world.

DCD refers to the retrieval of organs for transplantation from a patient whose death is diagnosed and confirmed using cardio-respiratory criteria. This means that the donation to transplantation process can start after the heart has stopped beating, death is confirmed and organ donation consented to by the patient’s family.

Using the OCS, doctors are able to reanimate the heart, medicate it and keep it beating outside of a human body, keeping it healthy whilst it is transported to the recipient patient. This not only allows DCD hearts to be used – immediately widening the donor pool – it also allows them to be transported further and gives surgeons and nurses time to assess an organ's function and apply medication to the heart if required.

The first adult DCD heart transplant in Europe was performed at RPH in 2015. Prior to this, heart transplants had only been possible using the DBD (donation after brain-stem death) technique.

The collaboration between RPH in Cambridge – whose team retrieves the heart – and GOSH, whose team implants the organ, represents the first-ever use of the DCD technique in paediatric transplantation anywhere in the world.

Across Britain there is a shortage of suitable donors, which means that the number of children who would benefit from organ transplantation exceeds the number of organs available. Children face longer than average wait times due to the difficulty of finding the right match and because the consent rate for paediatric organ donation is much lower than the national average for adults.

For children who can receive adult-sized hearts, the DCD heart programme is a promising solution to reducing the waiting time.

Speaking on the significance of the programme, Jacob Simmonds, Consultant Cardiologist and Transplant Physician at GOSH, said: “In early 2020 we had more children at GOSH on the transplant list than I’d ever seen in my 16 years working at the hospital.

“Every day a child waits there is a bigger likelihood that they may get too ill even for transplantation, or worse. Although medical advances have come far, for some children with heart failure an organ donation is truly their only hope.

“With the DCD heart programme we have unlocked more opportunities for donation, essentially doubling the number of transplants done at GOSH in eligible patients weighing over 20kg. It’s game-changing and work is already underway to make the technique suitable for our much younger and smaller patients.

“Ultimately, though, this still relies on families having conversations around their organ donation wishes, and then of course the bravery to consider making this precious, life-saving gift at a time of unimaginable tragedy.”

Mr Marius Berman, Consultant Cardiothoracic Transplant Surgeon at Royal Papworth Hospital, said: “We have taken our experience of performing DCD heart transplants on adults during the past five years and collaborated with GOSH to introduce this programme into clinical use within paediatric transplantation.

“No one else in the world is currently doing this. It’s been an incredible multi-institutional and multidisciplinary team effort to make this possible, involving everyone from the specialist nurses in organ donation and retrieval, transplant coordinators,, physicians and surgeons. Above all, none of this would be possible without the generosity of every donor and their families.

GOSH and RPH are national transplant centres, playing leading roles in providing paediatric and adult transplant care respectively for patients from all over the UK. They are also two of the largest heart and lung transplant centres in their fields across Europe.

GOSH currently has 24 children waiting for a heart transplant, and between 2014 and 2019 the average waiting time was 282 days. Despite the COVID-19 pandemic, the heart and lung transplant service at GOSH continued operating. Last year the clinical team performed a record 24 heart transplants at the hospital, boosted by the six DCD hearts.

John Forsythe, Medical Director for Organ Donation and Transplantation at NHS Blood and Transplant, said: “We have supported the DCD heart programme from the early research stages. It means some people can donate their hearts, as well as other organs, where it wouldn’t have been possible in the past, giving life to patients on the waiting list. This new technology is a significant step forward in heart transplantation in the UK and, indeed, the rest of the world.

“It has been great to see heart transplants continuing during this pandemic and incredible that lots more children have received a heart compared to the previous year, thanks in part to this collaboration.”

The DCD paediatric heart programme has yielded positive outcomes so far, with patients getting discharged home on average 13.5 days after transplantation. This is almost 50% shorter than published data from international centres.

Speaking about this, Dr. Simmonds said: “The donation and transplantation process are incredibly complex and when it comes to children it’s also very emotional - for all of the families and the clinical teams involved. For children waiting around the UK and the world, the success of this programme will have huge significance - that even in this time of international crisis with a pandemic, there is still hope. It’s taken five years to get to this point with the DCD technique, but this is absolutely a step in the right direction.”

The OCS machine is currently the only medical device capable of making DCD heart transplantation a clinical reality. Although this technology limits donation to donors who weigh at least 50kg – all six recipients under the programme so far are aged between 12 and 16 - the teams at RPH and GOSH are working together to develop a new machine that will enable DCD heart donation from even smaller infants, opening up a new dawn of transplantation for babies and young children, where donors are the most scarce.

The first DCD adult heart transplant in Europe was performed by Royal Papworth Hospital, funded by Royal Papworth Charity, in 2015. The Cambridge-based cardiothoracic hospital has the largest and most successful adult DCD heart transplant programme in the world, with 86 of the nearly 200 operations performed there – that’s more than 40% of the global total. Adult DCD heart transplants have only been performed in five countries; the UK, the USA, Belgium, Austria and Australia.

DCD paediatric heart transplants are even rarer. Although a very small number have been performed worldwide, the collaboration between RPH and GOSH is the first time ever that a paediatric DCD heart transplant has been performed where the non-beating heart is removed from the donor’s body before being transferred onto the OCS where it is reanimated and then transported for implantation into the recipient potentially hundreds of miles away.