(189) A Change of Heart: Psychiatric Considerations in the First Porcine to Human Cardiac Xenotransplantation

Abstract: Background/Significance: Xenotransplantation has been regarded as a solution to the limited number of human organs available for the exceeding amount of people who need them (Woodruff, 1965), however there is little guidance available regarding the selection and management of appropriate candidates. We herein report the first human recipient of a cardiac xenotransplantation, and the involvement of the consultation-liaison (CL) psychiatrists during the process.

Case: Mr. B is a 57-year-old male with a cardiac history of atrial fibrillation and mitral valve regurgitation, and a reported psychiatric diagnosis of schizophrenia, who was admitted to the hospital in cardiogenic shock. He was referred for standard heart transplantation and ventricular assist device (VAD) evaluations, however, his surgical team and CL psychiatry determined that he was at high risk for post-transplant complications. Mr. B’s clinical condition deteriorated, and he was emergently placed on ECMO. With no other option for survival, he was presented with the unusual opportunity for experimental cardiac xenotransplantation. Concerns about his vulnerability as a reported psychiatric patient led to three additional demands for psychiatrists to evaluate his capacity to consent for the procedure. All three CL psychiatrists found the patient to have capacity. Mr. B survived for two months after the transplant. He subsequently succumbed to organ rejection and multi-system organ failure.

Discussion: This case describes the first living person to undergo xenotransplantation of a genetically modified porcine heart. It brings up issues of equity and vulnerability, and the complicated issue of why this patient was selected for an experimental procedure in the face of being deemed high-risk. Additionally, the issues of informed consent that were raised have not yet been encountered, as the only other human subject to have received a xenotransplantation was brain dead (Cooper, 2021). Out of concern for a spurious report of mental illness, three capacity evaluations were hastily requested in an ad hoc attempt to address conflicts of interest and potential exploitation of a vulnerable patient. We propose developing a multidisciplinary team for xenotransplantation, with CL psychiatry involvement from the earliest stages to stratify risk and vulnerability, clarify psychiatric diagnoses, and assess potential psychiatric consequences both pre- and post-transplant.

Conclusion/Implications: Without a formal, multidisciplinary team to evaluate and develop care plans for future xenotransplantation recipients, the difficulties that arose in this case are very likely to recur with new and unforeseeable variations. As xenotransplantation continues to be developed, unanticipated difficulties are a certainty, and prospective, proactive involvement of psychiatric services will be necessary.

References:

Woodruff MFA: Ethical Problems in Organ Transplantation. Brit Med J 1965; 1:1457-1460.

Cooper DKC: Genetically engineered pig kidney transplantation in a brain-dead human subject. Xenotransplantation. 2021; 28(6):e12718.