**7. Heart procurement surgery**

Although it is a system unique to Japan, after each organ procurement team has completed the evaluation of the transplanted organ at the intensive care unit of the donor hospital, the donor hospital administrator/attending physician, operating department nurse, anesthesiologist (respiratory and cardiological management doctor), each organ procurement team, JOT Cos, et al. have gathered together to hold a meeting on organ procurement surgery. After self-introduction, the procedure for procurement of each organ, line of resection (pulmonary artery and vein, aorta, and superior and inferior vena cava), drainage method, dosage and timing of drugs (antibiotics, heparin, and steroid), organ transport method and scheduled hospital

departure time are confirmed. As a result, a very smooth procurement operation is performed. As a result of this meeting, the procurement surgery start time is determined, which in turn determines the recipient's surgery start time. At the same time, we are reaffirming our respect for the donor and her family. A cardiologist assists with cardiorespiratory management during the surgical excision.

In Europe and the United States, surgeons perform surgery in the order of arrival at the donor hospital, but in that case, the heart extraction is often started later, which sometimes makes the donor's hemodynamics unstable and results in giving up heart extraction. In Japan, all procurement teams perform surgery together after arrival. When the surgery start time is decided, consent for organ donation is obtained from the donor's family again, and the donor is transported to the operating room. At this time, it is customary for the entire procurement team to greet the donor and his/her family at the entrance of the operation department to show the utmost respect to the donor and his/her family. After a JOT Co finally confirms that the donor's family has agreed to the donation, all members observe a moment of silence before starting the operation. After all the organs have been removed, the chest and abdomen are closed in the clinically usual way, and the operation is discontinued after a moment of silence. Doctors accustomed to organ donation in Europe and the United States may think that it is not necessary to go that far, but the author thinks that it will continue as a custom that was born from the unique culture of Japan that respects the "heart". As the author mentioned to Co in the U.S.A., Southern California recently observed a moment of silence at the beginning of an operation. When transporting the heart, a cooler box is used to ensure that the heart functions better, and the cooler box is wrapped in a cloth and transported as if it was the donor's remains. This might be not enough to convey our gratitude to the donors and their families who donated their hearts, but we hope to convey our gratitude. Sometimes, for families who want to say goodbye to their hearts in the box for the last time, we arrange a moment of farewell to their hearts just before the heart board an emergency vehicle or helicopter. Because the heart has a short safe tolerance time, it is often airlifted by helicopter or airplane, arriving at the transplant hospital within 3 hours, within 4 hours the donor's heart is beating again, and within 1 hour the heart pulsation becomes stronger and the recipient can be weaned from the heart-lung machine. At that point, in most cases, the donor's family is still staying at the donor hospital, so the recipient Co at the transplant hospital will inform the JOT of the withdrawal from cardiopulmonary bypass so that the information will be available to the donor family. After knowing that the loved one's heart was beating strong in the recipient's body and knowing that the recipient's family was grateful, the donor family made their way home. We believe that it will reduce the grief of the family.
