‘There is little guidance available regarding the selection and management of appropriate recipients‘
One of the posters from CLP 2022 traces the involvement of C-L psychiatrists in the adoption of an animal organ transplanted into a human.
A Change of Heart: Psychiatric Considerations in the First Porcine to Human Cardiac Xenotransplantation, from a team led by Nithya Cherukuru, MD, reported the first human recipient of a cardiac porcine xenotransplantation.
Xenotransplantation has been regarded as a solution to the limited number of human organs available for the exceeding amount of people who need them. However, as the research team commented, there is little guidance available regarding the selection and management of appropriate recipients.
“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,” say the presenters.
“As xenotransplantation continues to be developed, unanticipated difficulties are a certainty, and prospective, proactive involvement of psychiatric services will be necessary.”
Chair of the Oral Papers & Posters Subcommittee, Michael Marcangelo, MD, FACLP, describes xenotransplantation as one of the fastest-moving frontiers in organ transplantation. But issues raised in the research point to ethical and clinical concerns about the care of the patient. “As new technologies are developed, C-L Psychiatry will surely be asked to participate to determine a patient’s capacity and suitability for new procedures,” says Dr. Marcangelo.
Case study
The research team quote the case of 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 hospital in cardiogenic shock. He was referred for standard heart transplantation and ventricular assist device evaluations. However, his surgical team and C-L Psychiatry determined that he was at high risk for post-transplant complications.
The patient’s clinical condition deteriorated, and he was emergently placed on extracorporeal membrane oxygenation. With no other option for survival, he was presented with the unusual opportunity for experimental cardiac xenotransplantation.
Concerns about his vulnerability led to additional demands for psychiatrists to evaluate his capacity to consent for the procedure. Three C-L psychiatrists found the patient to have capacity. The patient survived for two months after the transplant but subsequently succumbed to organ rejection and multi-system organ failure.
The case “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,” say the research team. “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.
“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.”
Recommendation
The research team recommends a multidisciplinary team for xenotransplantation, with C-L Psychiatry involvement from the earliest stages to stratify risk and vulnerability, clarify psychiatric diagnoses, and assess potential psychiatric consequences both pre- and post-transplant.
“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,” they say. “As xenotransplantation continues to be developed, unanticipated difficulties are a certainty, and prospective, proactive involvement of psychiatric services will be necessary.”