Case Studies
Case studies showcase real-world applications of policies and innovations, offering insights into improving outcomes and efficiency. They enhance problem-solving skills, highlight best practices, and engage through storytelling for education and transparency.
Expanding the Donor Heart Pool: Dobutamine Challenge in 12 Donors with Reduced LVEF
Patricia
Raval
, DMSc, PA-C, CCAPP
, Lead APP Donor Mgmt and Support Team
, Perfusion Solution Inc
The Challenge
A persistent shortage of donor hearts limits transplantation. Many organs are declined due to initial assessment demonstrating reduced cardiac function and left ventricular ejection fraction (LVEF <50%). In both brain-dead donors (BDD) and donation after circulatory death donors (DCD), myocardial dysfunction may be reversible; however, generally accepted, standardized evaluation strategies remain limited. We evaluated whether a short-term, low-dose dobutamine protocol could facilitate rehabilitation and reassessment of cardiac function in marginal donors with suspected reversible dysfunction. Efficacy was examined in available OPO post-transplant recipient outcomes.
The Approach
We conducted a case series of 15 donors managed by the Donor Management and Support Team (DMaST; Perfusion Solution Inc). in collaboration with the local OPO, LifeLink of Florida. All donors demonstrated initial LVEF ≤50% with global hypokinesis. A proprietary, low-dose dobutamine challenge protocol was implemented, followed by repeat transthoracic echocardiography performed off inotropic support. Post-transplant recipient data were obtained through the OPO in coordination with recipient transplant centers.
The Results
Following dobutamine challenge, 9 of 15 donors (60%) demonstrated recovery of left ventricular function sufficient to support heart allocation. Among these donors, 2 did not proceed to cardiac transplantation: one due to coronary artery disease identified on subsequent cardiac catheterization and one due to hemodynamic instability requiring expedited operative management that precluded cardiac allocation. Complete post-transplant data were available for 6 of the 7 heart transplant recipients; all demonstrated preserved graft function, absence of rejection, and survival to hospital discharge. Data collection is ongoing for the remaining recipient.
Insights & Lessons Learned
In this case series, a short-term, low-dose dobutamine challenge was associated with improvement in left ventricular function in selected donors with suspected reversible myocardial dysfunction, permitting consideration for heart transplantation in donors initially deemed unsuitable. Early recipient outcomes demonstrated preserved graft function and survival to hospital discharge. Incorporation of a structured dobutamine challenge into donor management protocols for appropriately selected donors may represent an opportunity to expand the donor heart pool. Larger, multi-OPO studies are warranted to validate this approach.