Doctor carries a heart in a box.
A doctor is ready to board the plane with an organ donation. © Keystone Switzerland

When speed becomes a matter of survival: Organ transplants are not just medical achievements; they are also a race against time. Advanced transport technology and precise organization are real lifesaving factors in a complex process.

For one person it seems outrageous, for another simply an impossibility. The idea of transplanting organs as spare parts from the body of one human into that of another was considered pure utopia for a long time. But since the first successful organ transplant involving a human heart, on December 3, 1967, by the South African surgeon Christiaan Barnard, it has been clear: Even this central organ, so essential for life, can survive the rigors of being transplanted into a foreign organism. Since that time, it is almost as if organ transplants have simply standard procedure in medicine.

According to estimates by the World Health Organization, (WHO), more than 80,000 kidneys, 26,000 livers, 6,500 hearts and 4,700 lungs are transplanted yearly around the world. An organizational masterpiece. Because every transplant is a race against time, even today. In Germany alone, more than 10,000 people are currently awaiting a donor organ. For some organs, there are three times as many patients as transplants waiting for the procedure. Furthermore, the size and properties of the donor organ have to suit the potential recipient.


Delivering sensitive load: a logistic masterstroke

Often there are also great geographical distances between donors and patients. Organs almost always need to be transported, and often across country borders. That not only costs money but also valuable time which, in the worst case, can lead to donor organs, which are already scarce, becoming unusable. The longer the delicate tissue is without blood circulation, the more damage occurs in the cells, worsening the chances are that the organ will survive the transplant to carry out its function in the recipient's body for as long as possible.

Nobody can plan exactly when the countdown for an organ will begin. Because nobody knows ahead of time when a potential organ donor will die from an accident, stroke or heart attack. The only thing that is certain: As soon as the person arrives at the intensive care unit in a hospital, and the clinical signs of brain death are evident, the clock starts ticking. During the period before the organ is removed, the circulation of the potential donor deteriorates.

"At brain death, it is not only the total functioning of the brain that is extinguished," says Undine Samuel, chief physician at the German Organ Transplantation Foundation (DSO). All reflexes located in the brain stem and involuntary breathing stop at the same time. Acute asphyxiation can occur within a very short time which can cause massive damage to the organ tissues.

If an organ donation is being considered, doctors have to do everything they can to keep the donor's heart beating and maintain all metabolic life-supporting functions. Parallel to all this, another important process has begun shortly after the determination of brain death: namely the protocol that makes it possible to coordinate all steps in the organ donation today so that, ideally, they are completed within 24 hours of the donor being pronounced dead.

This would, of course, be impossible if the physicians and hospitals involved were not supported in almost all countries in the world by centralized national or international coordination offices, such as the DSO in Germany or the Organización Nacional de Trasplantes (ONT) in Spain. Their employees navigate the participating physicians through all the steps of an organ donation, find a suitable recipient, organize the transport and coordinate the collaboration with the transplant centers. Up to 150 people can be working together across several hundreds of kilometers or more.


Steps of an organ transplantation:

  • Step 1: Two specially qualified doctors must independently pronounce brain death.
  • Step 2: Perhaps the most difficult: the legal clarification of the situation. It is simple if the patient had an organ donor ID or made it known in a will that he or she wished to donate an organ. However, neither is usually available. If the prospective donor's family agrees, a careful medical history is established and a thorough medical checkup is carried out. One reason is to protect the future recipient from diseases such as AIDS, hepatitis or cancer being transmitted. Another is that important donor traits, such as blood type and immunological factors like HLA markers, can be determined by the examination. Whether the recipient's organism can accept the foreign organ depends significantly on these things.
  • Step 3: If, at the end of these several hours, all medical and legal requirements for an organ donation have been clarified, a coordinator for the DSO transmits the results of the examination regarding the donor, blood type and tissue traits to the office that is responsible for searching for a suitable donor. In Central Europe it is the Eurotransplant Foundation with headquarters in Leiden, Holland.
  • Step 4: Employees there go through the list of all of the potential recipients. Which patient is suitable for the donor's organ? Body size, weight, girth and age of the deceased are relevant, as well as the general condition of the organ. At the end, four principles are decisive for allocating an organ.

First, the chances of success for the transplant. These primarily depend on the tissues matching. The advantage of Eurotransplant's transnational cooperation is evident here: Because it covers a large area, 135 million people living in seven countries, it is possible to match almost every foreign donor organ to a suitable recipient.

A second and third criteria for allocating an organ are the urgency of a transplant for the individual patient and the waiting time. Finally, the so-called national organ transplant account balance plays a role. It ensures that countries with a high rate of organ donation, such as Belgium, Croatia and Austria, do not constantly deliver organs to countries with a low rate, such as Germany.

As soon as a suitable patient is found, both the recipient and the responsible transplant center are informed. They are not only responsible for preparing the transplant surgery on site. They are also the ones who send their surgeons to remove the organ from the donor in the hospital. Undine Samuel emphasizes:

Our primary goal is to keep the time after the removal during which the organ will have no circulation as brief as possible.

This so called cold ischemia time for highly fragile tissue such as heart and lung is particularly critical. All organs are rinsed with a chilled preservative solution before removal and then packed in well-insulated boxes. This type of handling prevents blood clotting in the organ and ensures that most (damaging) enzyme reactions in the cells are halted through the chilling.

But even with perfect refrigeration and careful transport, the heart, for example, cannot be without circulation for more than four to six hours. Otherwise there is a danger that the organ will cause massive problems in the recipient's body as soon as it is connected to the circulatory system. Livers or kidneys are different because, as a rule, they can still be successfully transplanted from 12 to 24 hours later, providing they were expertly stored.


Transport of cooler cans mostly by airplane

The DSO, for example, has formed a network of cooperating partners across Germany to ensure transport. Depending on how quickly the organ must get to the recipient, and how far the hospital is from the donor's hospital, the organ cooler can be transported by car or chartered airplane, and even in some cases, by helicopter or train.

A heart transplant, for instance, in which the donor is in Hamburg and the recipient in Munich, cannot be done without air transport. Thirty to 35 percent of the organs are thus transported by air. In individual cases, transnational cooperation can make it possible that an organ is sent by airplane, for instance from Frankfurt to Zagreb and then with a helicopter to one of the five Croatian transplant centers. That has a price. A single organ transport can cost up to 16,000 euros. The transplant pioneer Christiaan Barnard, a South African surgeon at Groote Schuur Hospital in Cape Town, never would have imagined all this. He clearly had the advantage when it came to logistics during his bold first transplantation of a human heart.

His donor, a 25-year-old bank employee named Denise Ann Darvall, suffered a fatal brain injury during a traffic accident on December 2, 1967. At the same time, a 54-yearold grocer named Louis Washkansky, who later become the recipient, lay dying in Barnard's hospital after having suffered three severe heart attacks. Barnard recognized a unique opportunity. After a neurosurgeon pronounced Darvall brain dead, her body was connected to a heart-lung machine and cooled down to 16 Celsius and within two minutes her heart was removed. Three hours later, it was already in Washkansky's chest: Denise Darvall had been lying in the adjacent operating room during the entire procedure.

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