Donor heart injury caused by liver needle biopsy during multi-organ procurement surgery: A case report

Abstract

BACKGROUND

Thoracic organ procurement procedures have been standardized for decades, and serious organ injury during procurement is considered rare. However, when injuries do occur, they may result in irreversible loss of transplantable organs.

CASE SUMMARY

We report a rare case of unintentional donor heart injury caused by transdiaphragmatic liver core needle biopsy using a Tru-Cut–type device during multi-organ procurement. Two puncture injuries were identified on the inferior wall of the heart adjacent to the posterior descending coronary artery. Although there was no active bleeding and gross ventricular function appeared preserved, the proximity to a coronary branch raised concern for potential coronary injury and re-bleeding following systemic heparinization. After multidisciplinary discussion among the cardiac procurement team, recipient transplant team, and the organ procurement organization, the donor heart was declined intraoperatively.

CONCLUSION

This case highlights a preventable mechanism of procurement-related cardiac injury and underscores the importance of coordination, timing, and situational awareness among procurement teams to minimize avoidable donor organ loss.

Key Words: Transplantation; Heart; Organ procurement; Donor injury; On-site decline; Case report

Core Tip: Organ procurement injuries during multi-organ recovery are considered rare, but they can result in irreversible loss of otherwise transplantable organs and may be underreported in national registries. We describe an unusual case in which a liver core needle biopsy performed during abdominal procurement caused transdiaphragmatic puncture injury to the donor heart, leading to intraoperative heart decline at the donor hospital. This case highlights a preventable mechanism of donor heart loss and emphasizes the importance of coordination, timing, and protective strategies among procurement teams to avoid avoidable organ injury.

INTRODUCTION

The procurement procedure for thoracic organ transplantation has been standardized and safely performed by cardiothoracic surgeons for many decades. Pasque and colleagues established a systematic approach to thoracic organ procurement that has contributed to improved safety and reproducibility of heart and lung recovery procedures[1]. Despite these advances, procurement-related organ injury remains a recognized complication of multi-organ recovery, with potential consequences for organ utilization and transplant outcomes.

According to a national analysis of deceased donor organ procurement injuries in the United States, procurement-related injuries occur in approximately 0.3% of recovered organs, with cardiac injury being particularly rare[2]. However, the clinical impact of procurement-related injury extends beyond thoracic organs. Ten years of national quality monitoring data from the Netherlands demonstrated that procurement-related injury to abdominal organs is not uncommon and can adversely affect transplant outcomes, including increased organ discard and compromised graft function[3]. Similarly, multicenter data from the United States showed that procurement-related injury contributes to reduced organ availability and loss of potentially transplantable grafts across multiple organ systems[4]. These findings suggest that the burden of procurement-related injury may be underestimated when focusing solely on registry-reported post-transplant outcomes.

Here, we describe a rare case of donor heart injury caused by liver core needle biopsy during multi-organ procurement. This case highlights an underrecognized and potentially preventable mechanism of procurement-related cardiac injury and underscores the importance of coordination and timing among procurement teams.

CASE PRESENTATION

Chief complaints

The donor was a 36-year-old male with a history of heavy alcohol use who suffered brain death following a drug overdose.

History of present illness

The donor heart, lungs, liver, and kidneys were initially accepted for transplantation.

History of past illness

The donor had a history of heavy alcohol use.

Personal and family history

No significant personal or family history was noted.

Physical examination

No remarkable findings.

Laboratory examinations

No remarkable findings.

Imaging examinations

No remarkable findings.

FINAL DIAGNOSIS

The donor heart was declined intraoperatively.

TREATMENT

The abdominal procurement team performed a laparotomy and obtained multiple core needle biopsies from two lobes of the liver using a Tru-Cut–type device prior to the arrival of the cardiac procurement team. Thoracic exposure was initiated approximately 30 minutes after completion of the liver biopsy. No hemodynamic instability or overt bleeding was reported immediately following the biopsy.

Upon pericardiotomy, the cardiac surgeons noted a moderate amount of bright arterial blood within the pericardial sac. Two puncture injuries, each measuring approximately 1-2 mm in diameter, were identified on the inferior wall of the heart, located within a few millimeters of the posterior descending coronary artery (PDA). The puncture sites appeared to extend through the epicardium into the superficial myocardial layer, without evidence of full-thickness ventricular perforation. One small distal branch of the PDA showed evidence of focal injury, although there was no active bleeding at the time of inspection. No gross transmural myocardial defect or pericardial tamponade was observed, and global ventricular contractility appeared preserved (Figure 1). In addition, two puncture defects were noted in the diaphragm, consistent with a transdiaphragmatic needle trajectory from the upper abdomen into the pericardial space.

Figure 1 Intraoperative photograph showing two puncture injuries on the inferior wall of the heart (arrowheads) adjacent to the posterior descending coronary artery (arrow). The injured branch of the posterior descending coronary artery is indicated. The relative positions of the puncture sites are consistent with a transdiaphragmatic needle trajectory from the upper abdomen.

The operative field was irrigated and carefully inspected for ongoing hemorrhage. Given the proximity of the puncture sites to a coronary artery and concern for potential coronary injury, thrombosis, or re-bleeding following systemic heparinization during implantation, the cardiac procurement surgeons immediately communicated these findings to the recipient heart transplant team and the organ procurement organization.

OUTCOME AND FOLLOW-UP

After multidisciplinary discussion at the donor hospital, the donor heart was declined intraoperatively and was not reallocated.

DISCUSSION

We report a rare but consequential case of unintentional donor heart injury during multi-organ procurement caused by liver core needle biopsy. Although procurement-related injuries are uncommon, their impact is substantial when they result in loss of transplantable organs[2].

The discard rate for donor hearts recovered for transplantation in the United States has been reported to be approximately 1%[5]. However, this figure does not include hearts declined intraoperatively at the donor hospital, as occurred in this case. Thus, the true burden of donor heart loss related to procurement injury may be underestimated. We previously reported that on-site decline of donor lungs occurs in nearly 8% of cases, suggesting that intraoperative organ decline represents a meaningful and underappreciated contributor to donor organ loss across organ systems[6].

Procurement-related organ injury and intraoperative decline are not limited to cardiac transplantation. Intraoperative injury to other abdominal organs, including the kidney and liver, has also been reported as a cause of organ discard or delayed graft function, further underscoring that procurement-related injury represents a cross-organ challenge rather than an organ-specific issue[7]. Collectively, these observations highlight that preventable procurement-related injury can have downstream consequences on transplant utilization and outcomes across multiple organ systems.

In this case, the cardiac injury was most likely caused by transdiaphragmatic passage of the liver biopsy needle prior to thoracic exposure. The injury may have been preventable had the pericardium been opened before liver biopsy, allowing direct visualization of the heart and recognition of needle trajectory. Alternatively, deferring liver biopsy until after thoracic organ assessment or modifying biopsy technique may reduce the risk of similar injuries.

Previous studies have reported procurement-related organ injury rates of approximately 0.3%, with cardiac injury being particularly rare[2]. Nevertheless, even a single preventable cardiac injury represents a significant loss given the persistent shortage of donor hearts. This case underscores the need for heightened awareness among procurement surgeons regarding the potential for thoracic injury during abdominal procedures, particularly when core needle biopsy is performed.

Beyond the technical and procedural aspects, preventable procurement-related organ injury also raises important ethical considerations. The intraoperative loss of an otherwise transplantable donor heart may impose an additional emotional burden on the donor family, who consented to donation with the expectation that organs would be used to save lives. Moreover, such losses have direct consequences for candidates on the transplant waiting list, potentially prolonging waiting times or contributing to waitlist mortality. From a broader perspective, preventable organ injury represents a stewardship issue within organ allocation systems, underscoring the ethical responsibility of procurement teams to minimize avoidable loss of scarce donor organs through careful coordination and adherence to safe procurement practices.

From a practical standpoint, several specific preventive measures may reduce the risk of similar injuries. First, when liver biopsy is clinically necessary during multi-organ procurement, the biopsy needle should be advanced with a caudal and superficial trajectory, avoiding cranial angulation toward the diaphragm and pericardium. Second, a malleable retractor or manual shielding should be placed posterior to the liver to physically protect the diaphragm and inferior pericardium during needle advancement. In addition, we recommend establishing mandatory communication checkpoints between the abdominal and thoracic procurement teams prior to any liver biopsy, including explicit confirmation of thoracic exposure status and agreement on biopsy timing. Deferring liver core needle biopsy until after thoracic organ assessment and pericardiotomy, whenever feasible, may further reduce the risk of unrecognized cardiac injury. Awareness that transdiaphragmatic needle passage can occur, even during open procurement, is critical to preventing irreversible donor organ loss.

This report has several limitations inherent to a single-case description. First, the exact needle gauge used for the liver core biopsy was not documented in the operative record, limiting precise characterization of the biopsy technique. Second, only standard intraoperative photographs were available, and high-resolution images or preoperative cross-sectional imaging demonstrating the spatial relationship between the liver, diaphragm, and heart were not obtainable. Third, preoperative cross-sectional imaging demonstrating the spatial relationship between the liver and heart at the time of procurement was not available in this case, which limits direct visualization of the presumed needle trajectory. Despite these limitations, the anatomical findings and operative context strongly support a transdiaphragmatic biopsy-related cardiac injury, and the case highlights an important, preventable mechanism of donor heart loss during multi-organ procurement.

CONCLUSION

We describe a rare case of donor heart injury caused by liver needle biopsy during multi-organ procurement that resulted in on-site decline of the donor heart. This case highlights a preventable mechanism of procurement-related cardiac injury and emphasizes the importance of careful coordination, timing, and situational awareness during multi-organ procurement. Procurement teams should recognize that liver core needle biopsy performed prior to thoracic exposure carries a risk of serious cardiac injury and should implement concrete procedural safeguards, including careful selection of needle gauge, controlled caudal needle trajectory, physical shielding of the diaphragm, and mandatory communication between abdominal and thoracic teams, to avoid irreversible loss of donor organs.