The transplant in asystole and from a donor with an incompatible blood group to baby Naiara opens up hope for other children who are waiting for a heart.
Talking about miracles in the world of science is not always well seen. There are those who think – not without reason – that a disservice is being done to the scientific method when this word is used to describe an extraordinary event such as saving a life. But doctors are also capable of talking about a “miracle” when a donor’s heart starts beating again on the receiver’s chest. Those who are in charge of one of these interventions know very well what they have to do and what to expect, but they still admit that it is fantastic to see it. Extraordinary. It is hard to imagine, therefore, the feeling that must invade a medical team when the patient whose life they have managed to extend is a two-month-old baby.
Naiara is that latest “miracle” that has been announced this week and has made history: the first baby in the world to successfully receive a heart stopped e incompatible. However, this achievement has not only saved the little girl’s life, but has given hope to children who, like her, are born needing another heart. Unfortunately, it is the youngest babies who have the most difficulty receiving one of these organs.
The Gregorio Marañón Hospital is responsible for the success of this feat. It is a very powerful center in this area: half of the infant heart transplants performed each year throughout Spain are done in this center. In the last five years, he has performed a total of 41 transplants, seven of which were carried out last year, despite the Covid pandemic. Of all these cases, 35% were patients under one year of age. In other words, every year in Spain about 15 children need a heart transplant.
Naiara’s mother arrived at the Corazón Infantil del Marañón area when she was still carrying her in her womb. During the pregnancy, the doctors had observed that the girl’s heart was not working properly and the situation was getting worse. The best option for Naiara then was to be born prematurely in her 34th week., when a pregnancy can last until week 42. It was still too early to be able to operate.
Despite doctors fearing for the baby’s life on several occasions, Naiara’s diseased heart held out until she was ready for a transplant. Her chance to live came with the heart of another baby who had just passed away and was similar in age and size to the little girl. “24 hours before, Naiara had gotten much worse and, if he didn’t get a heart, he probably wouldn’t be here today“, explains Manuela Camino, head of the Pediatric Heart Transplant Unit at Hospital Gregorio Marañón.
The baby was doubly lucky: not only did she receive the transplant on time, but only three years ago the intervention that saved her would not have been possible. Her donor had a blood group incompatible with hers and before 2018 she could not have opted for this heart. On this date, the incompatible AB0 program was implemented: “The criteria for organ distribution in children weighing less than 15 kilograms changed and now those who urgently need a heart wait less because they are not penalized for having an incompatible blood group,” says Camino a THE SPANISH.
little chance of survival
The younger the child who needs a heart, the more difficult it is to get one. In Spain babies hardly die and, although this is of course a positive thing, the organs for these patients are scarce. The incompatible AB0 program, therefore, gave these children more opportunities, but it would not have been enough to save Naiara. The baby also received a heart in asystole; that is, it was standing when the doctor checked its validity. This type of transplant has already been performed on adults, but Naiara was the first child patient in the world to obtain it.
Whereas before transplants were obtained from brain-dead people whose organs continued to function, now it is possible to transplant a heart that has been stopped for a few minutes. “The doctor must revive that heart with a kind of hydraulic pump that we usually use in the operating room. After pumping blood to the heart and body, the heart starts beating again“, comments Juan Miguel Gil Jaurena, head of Pediatric Cardiac Surgery at the Gregorio Marañón Hospital.
In other words, saving Naiara was possible due to the combination of the benefits of the incompatible AB0 program and the first transplant in asystole to a baby. This advance opens the door to hope for other very young children who urgently need a heart in the future. “We are accepting organs that were not accepted before and that increases the probability of transplanting 50% more patients. This brings us closer to the ideal: that every child under one year of age who needs a heart receives one“, explains Constancio Medrano, director of the Children’s Heart area of the Gregorio Marañón Hospital.
A coordinated job
The day of Naiara’s transplant, a team of doctors left the Gregorio Marañón at three in the afternoon to collect the donor’s heart. When he was stopped, the first task was to restore his heartbeat by connecting him to an extracorporeal circulation pump directed by a perfusionist. “Amazingly, in less than a minute it started beating again.. Although it is true that younger children better withstand this degree of aggression”, recalls Gil Jaurena.
Medrano compares the day in which a transplant is performed with a Formula 1 race: “At each stop there is a series of people who know very well what to do and where to stand.” When the group that has gone to check the validity of the donation heart gives its approval, the Gregorio Marañón team must begin the operation so as not to waste time. Thus, one team returned with the heart preserved in cold while the other began the operation at eight in the evening.
“It is very important that the transplant recipient enters the operating room in advance. The operation can be delayed if there is a setback when bringing the organ, but if it arrives cold-preserved and the intervention has not started, that time adds up unnecessarily”, explains Gil Jaurena. The heart for Naiara arrived at Gregorio Marañón around eleven at night and the operation ended at five in the morning with the organ already beating inside the girl’s chest.
The heart that Naiara now wears stood on ice for four hours, to which must be added the time it spent standing in the donor. Gil Jaurena explains that one of the team’s biggest concerns—apart from the difficulty of operating on a three-kilogram patient—was that all that time would make the heart finally did not beat as they expected. Fortunately, Manuela Camino tells EL ESPAÑOL that Naiara is recovering favorably: “She had a normal postoperative period after heart surgery and ischemia. It wasn’t much for how small she is.”
Naiara will need to take immunosuppressive drugs to prevent rejection of her new heart and, if all goes well, have regular check-ups. “If you exceed the first year, the average life expectancy of a transplanted organ is 20 years. For an adult it is a good prognosis, but many things have to be optimized so that they become many more in a baby”, explains Medrano. These professionals hope that in the next two decades the possible scientific advances will take place to improve this forecast, and everything invites us to think optimistically.
Advances in Pediatric Cardiology come later than for adults for two main reasons: the first is that cardiac operations in children are less frequent —represent 10% of those performed in adults— and the second is that they are more complicated cases because the vast majority are due to congenital diseases and the instruments must be adapted to the small size of these patients. To get an idea, professionals point out that Naiara’s heart was the size of a plum.
In any case, the Children’s Heart area of the Gregorio Marañón Hospital has been a space in which several pioneering milestones have been achieved in recent years: the first incompatible AB0 transplant, placement of valves by catheterization, the practice of fetal cardiology… These experts look to the future with hope and, above all, in the fields of genetics, cell therapy and, of course, new technologies like 3D printing.
Naiara’s time in the Children’s Heart area has not ended: it began in her mother’s womb and will continue until she transitions to adult medicine. The hospital follows the cases of these children and their possible needs in any aspect of health, but also assists their families. “To have an area like this you need a lot of support. It could not be achieved without a public health system, without a management model such as the National Transplant Organization (ONT) and a society as aware of these interventions as the Spanish one”, Camino concludes.