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An approach to induction of tolerance to pig cardiac xenografts in neonates

There is a continuing need for donor hearts for infants with complex congenital heart defects. The transplantation of hearts from neonatal pigs would be an alternative to human organs, particularly if donor‐specific immunological tolerance could be achieved. The great majority of infant humans do not make natural (preformed) antibodies against triple‐knockout (TKO) pigs (that do not express any of the three known pig antigens against which humans have natural anti‐pig antibodies). The transplantation of a heart from a TKO pig into an infant would therefore minimize any risk of early antibody‐mediated rejection, and, with adequate immunosuppressive therapy, prolonged graft survival may well be achieved. Total host thymectomy (commonly carried out at the time of orthotopic heart transplantation in this age group) ± residual T‐cell depletion and donor‐specific pig thymus tissue transplantation might induce T‐cell tolerance and allow immunosuppressive therapy to be discontinued (if there is in vitro evidence of T‐cell and B‐cell nonresponsiveness to donor‐specific pig cells). Even if tolerance were not achieved, with continuing immunosuppressive therapy, the graft would likely “bridge” the patient until a suitable allograft became available or be associated with prolonged xenograft function.