Introduction

In the UK, approximately 12 children die annually while on the heart transplant waiting list. Furthermore, other children are never ‘listed’ due to the negligible chance of transplant. Concurrently, every year, children die in tragic circumstances and some become deceased organ donors. Despite the willingness of their families, very few children are able to donate their hearts due to technological, logistical and perceived ethical factors. However, emerging technology is set to change this, and we report here how we are on the precipice of changing the landscape of paediatric heart transplantation.

In the UK, controlled donation after circulatory determination of death (DCD) has been practised for over a decade, with a framework of national ethical, legal and professional guidance, with 7000 DCD donations resulting in 20 000 transplants.1 2

The DCD process in children is identical to that in adults. Most donors are mechanically ventilated following severe brain injury, with a shared decision between the parents and medical team to withdraw life-sustaining treatment (WLST) in the child’s best interest. Since the initiation of paediatric DCD in the UK, nearly 200 child donors have donated liver, kidneys, pancreas and lungs, but only a handful have been able to donate their heart.

The crucial limitation in paediatric cardiac donation in DCD has been technological, as the currently approved ex situ mechanical perfusion device (TransMedics OCS Heart (OCS)) has a lower donor weight limit of 50 kg, which precludes most child DCD donors. However, a newer device without this limitation, the XVIVO Heart Assist Transport, has now been used by one of the authors (LK) in a single, successful small child DCD heart recovery. The XVIVO system has additionally been used for donor after brain death (DBD) heart recovery from a 15 kg child.3 This early evidence supports the hope that the …