Up until a few years ago, “non-heart-beating donor” transplants were a very problematic option, but today they may offer a genuine solution to the donor organ shortage. The first such successful liver transplant in London was performed by Paolo Muiesan, today a surgeon at Birmingham’s Queen Elizabeth Hospital and a member of Aspen’s “Italian talent abroad” group. Now that the number of donors is decreasing – explained Muiesan in an interview with the Aspen Italia website team – clinical research is focusing on developing new equipment to improve the use of organs even in suboptimal conditions.
You were the first surgeon to introduce “non-heart-beating donor” liver transplants to England. What results is this type of operation yielding, and what developments in clinical research lie ahead?
We started with what was considered a cutting-edge initiative and slowly built up a successful track record, obtaining excellent results. It all started in 2002, when I was at King’s College Hospital in London. We thought it might be possible to also perform transplants of livers from “non-heart-beating donors”, that is, from non-brain-dead donors who have suffered cardiac death. It was a complex procedure, with a few precedents in the area of kidney transplantation and some prior experiences in the United States.
We started from scratch, following the team that was already exploring this type of procedure for kidney transplants, and we’re now working on a line of research focusing on machines capable of reconditioning, evaluating and possibly even improving the functioning of marginal organs. Of particular interest in this regard is the ECMO (or Extracorporeal Membrane Oxygenator), a device designed to keep people with poor lung function alive. We use it in a completely different way, deploying it as a bypass to restore abdominal circulation of oxygenated blood after death from circulatory arrest. The fact that the head is not supplied with blood avoids raising ethical issues.
Another possibility we are currently exploring in Birmingham is the use of a very complex machine, developed in Oxford. It’s a piece of kit that might seem to come straight out of a James Bond film, but it’s capable of maintaining an oxygenated blood flow in the liver outside the body. In conjunction with King’s College Hospital, we’re preparing to embark on the first 20 pilot cases in the world.
Can this type of transplant resolve the problem of donor shortage?
We must first of all consider that the number of useful donors has declined over the years due to several factors which have reduced mortality, such as the spread of antihypertensive drugs, and the increased use of seat belts. We have thus found ourselves faced with increasingly less ideal donors, whose organs need to be put in better functioning state.
When we started to carry out “non-heart-beating donor” transplants at King’s, we were the first in England to do so, and were performing around 5 such operations a year. Then when I moved to Queen Elizabeth, which along with King’s is one of the leading centers for volume of transplants in Europe, the goal was to cover 10% of cases with this type of procedure, but we’ve now reached 30%. We’ve exceeded our target, but we don’t necessarily see this as a good thing. The risk is that there is a potential substitution phenomenon, and that hence the increase in the availability of “cardiac-death donor” organs has led to a half-hearted search for possible brain-death donations. In point of fact, this latter process, while offering greater chances of success, involves longer lead times.
The risks that such substitution entails emerge from a study we are in the process of publishing: slightly worse results are obtained from livers explanted from “non-heart-beating” donors. Furthermore, it is worth noting that donation after brain death allows the removal of four or five organs per donor, whilst the average from cardiac-death donors remains – despite the many advances made – at 2.5 organs, that is, the kidneys in almost all cases, and sometimes also the liver and lungs. It is for this reason that cardiac-death donation requires an increase – rather than a substitution of – donors.
Is it currently possible for such operations to be performed in Italy? How can we go about raising the profile of Italian excellence in clinical research and medicine?
The most active team carrying out this type of procedure is in Pavia, where kidney transplants are performed. They were among the first to use the ECMO process, and every now and then I find myself working with them. For instance, we’ve just put in a joint research proposal with them for a project that required an overseas Italian partner.
I think there’s a need in Italy to rationalize resources and facilities, because clinical research of a certain caliber can only be conducted in very large organizations. This would enable greater prominence to be accorded to those centers producing fine work and already well-known in the international arena. Another very important aspect concerns the need for a change in mentality: the collaborative and competitive culture that exists in the United Kingdom and the United States – whereby efforts are supported up to a certain level, after which they come into competition with those of others – is a winning formula. Research centers do their utmost to attract the best talent, the crème de la crème. A similar interest in attracting the most capable people needs to fostered in Italy, by breaking down fears of competition and cultivating greater independence among young people.
I believe that a cultural shift of this nature in Italy can also be brought about by attracting people who have lived abroad for a considerable period. But first of all, there is need for courage to carry out a systematic program of reforms. I am convinced that this courage will emerge: the reduction in available funding will effectively lead to a need to ensure things run better – and this will help bring about a mini-revolution even in our field of endeavor.
