He had three months to live.
At the age of 41, Anthony Donatelli lay in a hospital bed waiting for a donor.
As if in an agonizing nightmare, every day, every hour, every minute that passed was a countdown to what had seemed inevitable until then.
In spite of everything, Donatelli was still hopeful of staying alive.
“Thinking about my children, I never gave up,” the American told BBC Mundo from San Diego, California.
He had amyloidosis, a rare disease that occurs when certain abnormal proteins accumulate in the body and form deposits. His only alternative was the appearance of a donor who could provide him with three compatible organs.
Until that day came. In February of last year, Donatelli became the first person in the world to receive a triple heart, liver and kidney transplant, using a technique called PRN (normothermic regional perfusion).
Today he is enjoying every moment with his family, and although some days are more difficult than others, he is back to swimming and surfing the Atlantic waves.
“I just came home from running,” says Donatelli, now retired from the military and on the mend.
“I have an amazing life,” says this father of two children, ages 4 and 7.
In charge of one of the organ transplants Donatelli received, the heart transplant, was Victor Pretorius, surgical director of Heart Transplantation at the University of California, San Diego Health System.
“We used innovative technology that has allowed us to obtain organs that historically would have been discarded,” says the physician.
The debate in the U.S. medical community about life and death
Not everyone agrees with that view.
Some physicians oppose the PRN technique, especially for heart transplantation, because it circulates the dead person’s oxygenated blood inside his or her body until the organ starts beating again.
These are donors with irreversible catastrophic brain damage who are kept alive artificially with the aid of life support.
With the family’s consent, the doctors performing PRN disconnect life support; cardiorespiratory arrest occurs and, after waiting at least five minutes, the patient is declared dead.
Then, with the help of a machine, the doctors pump the donor’s blood to reactivate the functioning of the heart and lungs. This allows them to assess whether the organ is suitable for transplantation and also to prevent it from deteriorating.
As it is a race against time, the procedure is done as quickly as possible.
Although PRN has been practiced for several years in countries such as Australia, the United Kingdom, Spain, France, Portugal, Italy and Sweden, the debate “for ethical reasons” has taken off in the United States.
According to its detractors, restarting the cardiac activity of the deceased is like bringing the dead back to life.
Concern reached such a point that the American College of Physicians issued a public statement in April 2021 calling for a pause in the implementation of PRN for raising “profound ethical questions regarding the determination of death.”
“PRN resuscitates the patient,” the document notes.
The central argument is that restarting blood circulation reverses what had been declared irreversible: the patient’s death.
Some organ procurement organizations (OPOs) agree with this position.
The president and executive director of one of these organizations, Alexandra Glazier, told BBC Mundo that for them what is essential in this discussion is that the rights of the deceased donor be respected.
She says that her organization, New England Donor Services, is currently in the process of implementing the PRN only for abdominal organ transplants.
The idea is “to avoid further circulation in the donor’s body and thus avoid restarting the heart,” says Glazier.
“You don’t bring a dead man back to life.”
Brendan Parent, Nader Moazami, Arthur Caplan and Robert Montgomery, medical specialists at New York University (NYU), published in 2022 in the American Journal of Transplantation a response to claims made by the American College of Physicians criticizing the procedure.
In it they state that pumping blood to the thoracic organs does not change the fact that the heart will not restart on its own.
The PRN technique, they argue, does not change the circumstances that led the family and medical team to conclude that there is no longer the possibility of a meaningful life for the catastrophically brain-damaged patient declared dead from cardiopulmonary arrest.
PRN “does not resuscitate the patient,” say the professionals. The procedure pumps blood into the dead donor’s organs, but does not revive him or her.
It is an “honest, transparent and respectful” organ recovery because the death was declared “in an ethical manner”.
Speaking to BBC Mundo, physician Nader Moazami, explains that when a person has died of cardiorespiratory arrest (also called circulatory death), the best way to assess whether his or her heart is suitable for transplantation is to restore circulation while the organ is still in the donor’s body.
Moazami, surgical director of Heart Transplantation and Mechanical Circulatory Support at NYU Langone Health, explains that since they began using the technique in 2020, previously nonviable hearts have been recovered.
Restoring circulation, he argues, is simply another method of organ retrieval.
“It has nothing to do with bringing a patient back to life, it’s not resuscitating the donor, because resuscitation, by definition, means you’re going to restore longevity or quality of life.”
The decision about the patient’s death, he adds, occurs when the family decides to withdraw life support.
“You don’t bring a dead person back to life. People like to play with words, but that’s not the case.” he notes. “PRN is completely ethical.”
While the debate continues in the United States, the technique continues to advance in developed countries.
Pilot plans are currently underway in nations such as Switzerland, the Netherlands, Norway and Canada.
So far, according to publicly available information, it has not been used in Latin America.