Authors: Wenman A et al.
Source: A & A Practice, 19(11):e02084, November 2025,
This case report explores a rare and ethically complex scenario in pediatric cardiac anesthesia and transplantation: whether to proceed with heart transplantation after intraoperative cardiac arrest occurring before cardiopulmonary bypass. The authors describe a 12-year-old patient undergoing a second heart transplant for severe graft failure who experienced profound hemodynamic collapse and required 25 minutes of high-quality cardiopulmonary resuscitation prior to successful initiation of bypass. Despite the clinical stabilization that followed, the event created immediate uncertainty about neurologic viability, end-organ injury, appropriate stewardship of a scarce donor organ, and the ethical justification for proceeding.
The case highlights a critical gap between regulatory frameworks and real-world practice. Although organizations such as OPTN and UNOS outline broad ethical principles for organ allocation—justice, beneficence, and utility—they do not offer explicit guidance for extraordinary intraoperative events like pre-bypass cardiac arrest. This left the care team to weigh evolving clinical data, consult national experts, and communicate transparently with donor agencies while making a time-sensitive decision.
Clinically, several factors supported proceeding with transplantation. Objective indicators suggested high-quality CPR with preserved cerebral perfusion, recovery of urine output, and improving cerebral oximetry after initiation of bypass. Pediatric surgical-cardiac patients who arrest in the operating room are known to have higher survival rates than other hospitalized children requiring CPR, which reinforced the plausibility of meaningful neurologic recovery. Logistically, donor heart procurement was already underway, and reallocation to another recipient was not feasible. Ethically, the absence of viable alternative life-sustaining options for the patient, combined with prior evidence of compliance and strong family support, strengthened the argument for beneficence.
The discussion also addresses broader ethical tensions unique to pediatric transplantation, including retransplantation in children, long-term outcomes, and resource allocation. The authors note that while pediatric recipients face higher long-term risks of sudden cardiac death, denying transplantation on this basis alone would ignore the obligation to care for vulnerable patients already committed to the transplant pathway. The case underscores persistent inequities and lack of stratification in pediatric transplant listing criteria compared with adult frameworks.
Ultimately, the patient underwent successful transplantation without neurologic deficit and recovered well, validating the multidisciplinary decision-making process. The authors argue that cases like this illustrate the urgent need for clearer guidance from transplant oversight bodies while affirming the importance of individualized, ethically grounded clinical judgment when protocols fall short.
Key Points
• Intraoperative cardiac arrest before cardiopulmonary bypass poses a rare but profound ethical dilemma in pediatric heart transplantation.
• Existing transplant regulations provide ethical principles but lack specific guidance for extraordinary intraoperative events.
• Objective markers of high-quality CPR and end-organ recovery are critical when assessing neurologic viability.
• Pediatric retransplantation introduces unique ethical and resource-allocation challenges not fully addressed in current policies.
• Multidisciplinary consultation and transparent communication with transplant agencies are essential when navigating such scenarios.
Thank you to A & A Practice for allowing us to summarize and discuss this important and thought-provoking case.