Near-fatal Transplant Mistake Being Investigated, Network Looks Into How Girl Got Organs That Were Not CompatibleFeb 21, 2003 | USA TODAY An inquiry is underway into the mismatched heart and lung transplant that nearly killed a Mexican girl. The mistake is raising questions about the integrity of the nation's organ transplant system.
Jesica Santillan, 17, underwent a second heart and lung transplant Thursday after the botched transplant two weeks earlier. She is blood type O, and the donor heart and lungs she received in the first operation were blood type A. That mismatch triggered rejection by her immune system.
The United Network for Organ Sharing (UNOS) has begun a physician review of what breakdowns in the organ transplant system led to the mistake. Long the center of controversy over the fairness of the transplant system, UNOS matches donor organs to the 80,000 people awaiting organ transplants nationwide.
Duke University Medical Center says the second operation went well, though Jesica remains in critical condition. Doctors gave her little chance of surviving without the second transplant of well-matched donor organs, a heart and lungs that became available late Wednesday. ''We hope we can use this event, as tragic as it has been, to emphasize the need for donor organs,'' says William Fulkerson, chief executive officer of Duke Hospital. Duke blames the organ mismatch on human error.
Statements from the principals in this controversy do not clarify who was at fault and exactly how Jesica got the first set of organs without being a match for them.
UNOS' standard procedure is to distill its master list of potential recipients to separate those who match a donated organ or organs based on blood type, other medical compatibility conditions and time on the waiting list. The organization says in this case, Jesica was not on the list of patients who matched the first set of organs.
Carolina Donor Services (CDS), one of 63 regional organ procurement organizations, works with UNOS, hospitals and surgeons to get transplant organs to patients in counties near Duke. CDS said the first set of organs entered the national system through the New England Organ Bank in Boston.
CDS says it offered the organs to Duke surgeons for two patients who appeared on the UNOS match list, but the surgeons declined the organs. One of the surgeons, whose name CDS did not disclose, then contacted the organization, requesting the organs for an operation Feb. 7 on a patient who was not on the match list.
A New England Organ Bank spokesman told the Boston Herald on Wednesday that the organization had sent paperwork listing the correct organ blood type to Duke.
Transplant surgeon James Jaggers, who performed both surgeries, has said he was contacted about the organs by CDS, not the other way around.
Heart-lung transplants are rare. There are 197 people nationwide on the waiting list. Most, like Jesica, suffer from heart defects that have damaged their lungs. An additional 3,869 people wait for a heart transplant, and 3,821 people wait for a lung transplant.
At every step in the transplant process, blood type should be checked along with factors such as body size, immune system status, medical urgency and logistics.
''Certainly, there is pressure on organ procurement organizations to proceed down the list and get the organs placed as quickly as possible,'' says transplant surgeon Kenneth McCurry of the University of Pittsburgh Medical Center
About 56 transplants occur daily. ''This kind of mishap happens very rarely,'' McCurry says. ''A lot of people work hard to make sure it doesn't happen, and this may very well lead to more changes to make sure it doesn't happen again.''