Correspondence

Case 15-2009: A Man with Coma after Cardiac Arrest

N Engl J Med 2009; 361:724-725August 13, 2009

Article

To the Editor:

Kotton et al. (May 14 issue)1 present the case of a 25-year-old man with cardiac arrest. The initial rhythm was ventricular fibrillation. Despite successful resuscitation, brain death was declared and the heart was procured for transplantation. Although no structural abnormalities were identified on echocardiography or cardiac catheterization, primary ventricular fibrillation has many causes that are not readily diagnosed,2 and when idiopathic it has a high rate of recurrence.3 Therefore, the suitability of the donor's heart for transplantation needs to be determined by means of a thorough anatomical and electrophysiological assessment, which may be difficult to perform under the time constraints of donor evaluation. An implantable cardioverter–defibrillator should be considered for the recipient.

Paul J. Hauptman, M.D.
Saint Louis University School of Medicine, St. Louis, MO
hauptmpj@slu.edu

3 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 15-2009). N Engl J Med 2009;360:2118-2125
   Full Text | Web of Science | Medline

2. 2

   Wever EF, Robles de Medina EO. Sudden death in patients without structural heart disease. J Am Coll Cardiol 2004;43:1137-1144
   CrossRef | Web of Science | Medline

3. 3

   Champagne J, Geelen P, Philippon F, Brugada P. Recurrent cardiac events in patients with idiopathic ventricular fibrillation, excluding patients with the Brugada syndrome. BMC Med 2005;3:1-1
   CrossRef | Medline

To the Editor:

In Case 15-2009, the discussion focused mainly on the patient's colonic schistosomiasis and its implications for the recipients of his transplanted organs. Little was said about why this otherwise healthy 25-year-old man was seen to have had seizurelike movements and to have collapsed, without pulse or respirations. Examination by emergency medical personnel approximately 7 minutes after his collapse disclosed ventricular fibrillation. Later, urinalysis revealed the presence of cannabinoids and cocaine metabolites. An echocardiogram revealed no abnormalities and a normal ejection fraction, and a cardiac catheterization revealed no coronary artery disease. The most likely assumption seems to be that the patient died from a cocaine-induced arrhythmia. My question is whether the discussants agree, and whether the patient's schistosomiasis could have potentiated this fatal arrhythmia.

David L. Keller, M.D.
Providence Healthcare West, Torrance, CA

To the Editor:

The discussion of donor assessment by Kotton et al. suggests that exclusion criteria from the Centers for Disease Control and Prevention (CDC) (Table 3 of the article) are used to reduce the likelihood of transmission of the human immunodeficiency virus (HIV). In fact, the CDC's criteria do not have an exclusionary function but define a group of donors considered to have a high risk for transmission of HIV. The policy of the United Network for Organ Sharing does stipulate that transplantation centers must disclose this organ-specific information to potential recipients at the time the organ is offered, presumably during a discussion of informed consent.1 The CDC's criteria were devised in 19942 in an effort to exclude donors with an unacceptably high risk of transmitting HIV. Fifteen years later, rising waiting-list mortality, improved prospective detection of infectious agents with nucleic acid testing, growing uncertainty regarding the effectiveness of the criteria, and the problem of promoting social bias against homosexual men have cast doubt on the importance of the criteria.3

Daniel S. Kamin, M.D.
Sandra Burchett, M.D.
Heung Bae Kim, M.D.
Children's Hospital Boston, Boston, MA
daniel.kamin@childrens.harvard.edu

3 References

1. 1

   Acquired immune deficiency syndrome (AIDS), human pituitary derived growth hormone (HPDGH), and reporting of potential recipient diseases or medical conditions, including malignancies, of donor origin. Richmond, VA: United Network for Organ Sharing, 2009. (Accessed July 23, 2009, at http://unos.org/PoliciesandBylaws2/policies/pdfs/policy_16.pdf.)
   

2. 2

   Guidelines for preventing transmission of human immunodeficiency virus through transplantation of human tissue and organs. MMWR Recomm Rep 1994;43:1-17
   

3. 3

   Halpern SD, Shaked A, Hasz RD, Caplan AL. Informing candidates for solid-organ transplantation about donor risk factors. N Engl J Med 2008;358:2832-2837
   Full Text | Web of Science | Medline

Author/Editor Response

Kamin et al. are correct that the CDC criteria have been used to define donors at higher risk for transmission of HIV. The criteria are generally considered to be outdated and less useful now than at the time they were developed, as the authors suggest.

Revision of these guidelines has been a work in progress for some time. Further guidance in this realm would help the clinicians involved with transplantation maximize the numbers of organs transplanted and minimize both the number of transplant-related infections and the mortality among patients on the transplantation waiting list.

Hauptman and Keller express concern about the use of this donor's heart. The cause of his ventricular fibrillation was presumed to be a cocaine overdose. Without further medical history, the surgeons involved in the case did not believe that placement of an implantable cardioverter–defibrillator for the recipient was indicated. Potentiation of this fatal arrhythmia by the donor's schistosomiasis also seems extremely unlikely. Given his epidemiologic history, myocarditis due to Trypanosoma cruzi could have been a risk factor for this arrhythmia, although his serologic screening for this disease was negative.

Camille N. Kotton, M.D.
Nahel Elias, M.D.
Francis L. Delmonico, M.D.
Massachusetts General Hospital, Boston, MA