Donation after circulatory death significantly reduces waitlist times while not changing post-heart transplant outcomes: A United Network for Organ Sharing Analysis

Donation after circulatory death heart transplantation: The French perspective

Heart transplantation is the gold standard treatment for patients with advanced heart failure in the absence of contraindications. In recent years, the shortage of heart donors has led to a resurgence in the use of hearts from donation after circulatory death (DCD) donors after withdrawal of life-sustaining treatment. In these donors, death is determined by the cessation of spontaneous circulation and respiration for≥5minutes and is confirmed by neurological criteria. Two heart procurement procedures are used, namely direct procurement and perfusion (DPP) and procurement after thoracoabdominal-normothermic regional perfusion (TA-NRP). Donor hearts procured using TA-NRP are reperfused and assessed inside the donor and preserved with static cold storage or ex situ machine perfusion. With DPP, hearts are reperfused and assessed ex situ with a perfusion machine. The ischaemic time before heart reperfusion is shorter with TA-NRP than with direct procurement followed by ex situ perfusion. The TA-NRP technique allows for the assessment of the function of the donor heart. Numerous studies have reported similar survival rates between recipients who have received hearts from DCD and donation after brain death (DBD) donors. The incidence of severe primary graft dysfunction varies according to the team's learning curve and the country. The heart utilization rate is greater with TA-NRP procurement than DPP. This article describes the two donor heart procurement techniques, provides a summary of the relevant literature on the outcomes of transplantation from DCD donors and reports the position of a working group, convened by the French national transplant agency, on donor and recipient selection.

Spanish Center's Early Experience With Donation Following Circulatory Death in Heart Transplantation

Heart transplantation using donation after circulatory death (DCD) has recently re-emerged alongside donation after brain death (DBD). This technique can potentially increase the number of available cardiac grafts. However, its clinical outcomes remain limited. We compared data from patients who received grafts from DCD versus DBD between 2012 and 2023. During this period, 131 adult patients underwent isolated heart transplantation. Of these, 25 (19%) were DCD donors. Donation after circulatory death donors were predominantly local (66% vs. 42%; p = 0.027). Donation after circulatory death graft recipients had fewer ventricular assist devices (12% vs. 35%; p = 0.025) and were less frequently urgent (12% vs. 39%; p = 0.009). Donation after circulatory death grafts had shorter myocardial ischemia and extracorporeal circulation times than DBD grafts (70 min [63.5-91] vs. 168 [83-219]; p < 0.001); (90 min [78-103) vs. 120 [96-148], p < 0.001). We observed no significant differences in the incidence of primary graft failure (16% vs. 22%; p = 0.526) or hospital mortality (8% vs. 14%; p = 0.410) between both groups. In conclusion, cardiac DCD demonstrates hospital outcomes comparable to those of cardiac DBD. Further long-term follow-up of these patients is necessary to determine their rejection, graft vascular disease, and mortality outcomes.

Early outcomes in heart transplantation using donation after circulatory death donors in patients bridged with durable left ventricular assist devices

OBJECTIVE

Donation after circulatory death heart transplantation potentially increases donor allografts, especially for patients with lower listing status. We assessed the outcomes of donation after circulatory death heart transplantation in patients bridged with durable left ventricular assist devices.

METHODS

The United Network for Organ Sharing database was queried for adult heart transplants using donation after circulatory death donors from 2019 to 2022. Patients were stratified between those with durable left ventricular assist devices and those with intra-aortic balloon pump, inotropic, or no bridging support (control group). Primary outcome was 1-year mortality. Secondary end points were hospital length of stay, stroke, pacemaker implantation, dialysis, and acute rejection before discharge.

RESULTS

A total of 160 left ventricular assist device recipients and 311 control recipients met study inclusion criteria. Recipients bridged with left ventricular assist devices were younger (55 vs 58 years, P < .001) with lower body mass index (28.3 vs 30.3, P < .001), longer waitlist times (112 vs 34 days, P < .001), longer out of body times (5.7 vs 4.6 hours, P < .001), and less frequent normothermic regional perfusion (31% vs 40%, P = .049). Patients with left ventricular assist devices commonly underwent transplantation at United Network for Organ Sharing status 3 and 4 (92%), whereas control patients underwent transplantation at status 2 (27%), status 3 (10%), status 4 (30%), or status 6 (30%). Kaplan-Meier analysis showed no difference in 1-year mortality between groups (P = .34). However, acute rejection was higher in the unadjusted left ventricular assist device cohort (26% vs 13%, P < .001). On multivariable logistic regression, left ventricular assist device was an independent predictor of acute rejection (odds ratio, 2.21, 95% CI, 1.32-3.69, P = .002).

CONCLUSIONS

Durable left ventricular assist devices may be associated with a higher risk of developing an early inflammatory response in donation after circulatory death heart transplantation; however, 1-year survival was similar between groups.

Understanding preservation time thresholds in the modern era of heart transplantation

A 4-h preservation time threshold for cardiac allografts is the current standard in heart transplantation, but novel technologies are proposed to decrease the morbidity associated with prolonged allograft storage. This study examined adult heart transplant recipients from 2000-2015 and 2020-2023 in the United States, stratified into an early (2000-2015) and modern era (2020-2023), then into standard (≤ 4 h) and prolonged (≥ 5 h) preservation time groups within each era. This study reinforced the 4-h threshold in the early era, where prolonged preservation significantly increased one-year mortality (HR 1.60, 95% CI 1.36-1.90). However, this association was no longer significant in the modern era (HR 1.14, 95% CI 0.85-1.50). A sub-analysis showed that using machine perfusion devices for allograft storage was not associated with one-year mortality (HR 1.15, 95% CI 0.79-1.70). Spline analysis demonstrated possible inflection points between 4 and 5 h and 8-9 h in the modern era, and further analysis found that 5-8 h of preservation did not increase one-year mortality (HR 1.09, 95% CI 0.80-1.47) relative to the ≤ 4 h group. In conclusion, the association between cardiac allograft preservation duration and morbidity has decreased in the modern era. Today, a 4-h preservation duration threshold may be too restrictive.

Survival after heart transplants from circulatory-dead versus brain-dead donors: Meta-analysis of reconstructed time-to-event data

BACKGROUND

Heart transplantation (HTx) using donors after circulatory death (DCD) has the potential to significantly boost overall transplant rates. This study aims to reconstruct data from individual studies comparing survival between HTx from DCD recipients and donation after brain (DBD) recipients.

METHODS

MEDLINE, Embase, Scopus, were searched up to August 2024. We included studies that reported a Kaplan-Meier summary of survival comparing DCD and DBD HTx. Digitization of the Kaplan-Meier curves and reconstruction of individual patient data followed by survival analysis that was conducted using R software.

RESULTS

Six studies including a total of 3240 patients (2242 DBD and 998 DCD) were included in the final analysis. There was no significant difference in the overall survival rates between DCD and DBD patients (Hazard Ratio (HR): 1.01, 95 % CI [0.81-1.25], P = 0.91). However, the proportional hazard assumption was violated, deeming such results inconclusive. Time-varying flexible parametric model revealed a significantly declining survival in DCD recipients 3 years after surgery. Landmark analyses further suggest this declining trend in the DCD group at the two-year landmark (HR: 1.67, p = 0.021) and the four-year mark (HR: 2.78, p = 0.002). However, data beyond 6 years is limited. Evidence comparing direct procurement and normothermic regional perfusion is scarce, with no significant survival differences observed.

CONCLUSION

This meta-analysis shows that, despite similar early survival outcomes, DCD heart transplants showed a trend towards a lower long-term survival, with the difference becoming evident around three years post-transplantation. These findings highlight the need for enhanced monitoring and optimized post-transplant care in DCD recipients. Further studies with strict and long-term follow-up are warranted to confirm these results.

The role of temporary mechanical circulatory support in heart failure

Heart failure (HF) remains a leading cause of morbidity and mortality worldwide, with acute HF (AHF) or cardiogenic shock requiring rapid intervention to prevent fatal outcomes. Advances in temporary mechanical circulatory support (tMCS) devices have revolutionized the management of advanced HF, offering temporary, durable, and individualized support options. This manuscript reviews the pathophysiology and clinical presentation of AHF, the role of multi-disciplinary Heart Teams, and the growing importance of structured care networks in managing complex cases of HF. We explore the strategic deployment of tMCS in acute settings, device options, implications for patient outcomes, and current challenges in the field. This manuscript emphasizes the importance of team-based approaches and underscores the potential of tMCS devices in stabilizing patient haemodynamics, bridging to recovery or definitive therapy, and improving survival in patients facing high-risk HF.

National Organ Procurement and Transplant Network Heart Allocation Policy: 6 Years Later

In 2014, the Organ Procurement and Transplant Network began reappraisal of the United States heart transplant allocation policy. Driven by ongoing discordance between organ supply and demand, high waitlist mortality, and increasing exception requests, the Thoracic Committee radically redesigned the priority scheme and drafted a 6-tiered algorithm, included durable device complications into policy, expanded broader sharing, and increased the number of mandatory listing variables to develop a future heart allocation score. This became the 2018 New Heart Allocation Policy. Changes in allocation priority have resulted in a significant increase in the use of temporary mechanical circulatory support in waitlisted candidates with a concomitant decrease in the number of patients bridged to transplanted with durable left ventricular assist device support. The number of exception requests continues to increase, particularly for patients listed status 2 and for multiorgan transplants. Importantly, fewer patients are being delisted for clinical improvement, suggesting missed opportunities for recovery. The current review will critically evaluate the 2018 heart allocation policy 6 years later, briefly focusing on the history of heart allocation in the United States, the current and evolving algorithms for candidate prioritization including continuous distribution, the impact of technology and innovation on transplant rates and future policy development, and the ongoing regulatory oversight and governance changes in the Organ Procurement and Transplant Network.

Donor Selection for Heart Transplantation in 2025

The number of candidates on the waiting list for heart transplantation (HT) continues to far outweigh the number of available organs, and the donor heart nonuse rate in the United States remains significantly higher than that of other regions such as Europe. Although predicting outcomes in HT remains challenging, our overall understanding of the factors that play a role in post-HT outcomes continues to grow. We observe that many donor risk factors that are deemed "high-risk" do not necessarily always adversely affect post-HT outcomes, but are in fact nuanced and interact with other donor and recipient risk factors. The field of HT continues to evolve, with ongoing development of technologies for organ preservation during transport, expansion of the practice of donation after circulatory death, and proposed changes to organ allocation policy. As such, the field must continue to refine its processes for donor selection and risk prediction in HT.

The Rapidly Evolving Landscape of DCD Heart Transplantation

PURPOSE OF REVIEW

To summarise current international clinical outcomes from donation after circulatory death heart transplantation (DCD-HT); discuss procurement strategies, their impact on outcomes and overall organ procurement; and identify novel approaches and future areas for research in DCD-HT.

RECENT FINDINGS

Globally, DCD-HT survival outcomes (regardless of procurement strategy) are comparable to heart transplantation from brain dead donors (BDD). Experience with normothermic machine perfusion sees improvement in rates of primary graft dysfunction. Techniques have evolved to reduce cold ischaemic exposure to directly procured DCD hearts, though controlled periods of cold ischaemia can likely be tolerated. There is interest in hypothermic machine perfusion (HMP) for directly procured DCD hearts, with promising early results. Survival outcomes are firmly established to be equivalent between BDD and DCD-HT. Procurement strategy (direct procurement vs. regional perfusion) remains a source of debate. Methods to improve allograft warm ischaemic tolerance are of interest and will be key to the uptake of HMP for directly procured DCD hearts.

Advancing the Scientific Basis for Determining Death in Controlled Organ Donation After Circulatory Determination of Death

In controlled organ donation after circulatory determination of death (cDCDD), accurate and timely death determination is critical, yet knowledge gaps persist. Further research to improve the science of defining and determining death by circulatory criteria is therefore warranted. In a workshop sponsored by the National Heart, Lung, and Blood Institute, experts identified research opportunities pertaining to scientific, conceptual, and ethical understandings of DCDD and associated technologies. This article identifies a research strategy to inform the biomedical definition of death, the criteria for its determination, and circulatory death determination in cDCDD. Highlighting knowledge gaps, we propose that further research is needed to inform the observation period following cessation of circulation in pediatric and neonatal populations, the temporal relationship between the cessation of brain and circulatory function after the withdrawal of life-sustaining measures in all patient populations, and the minimal pulse pressures that sustain brain blood flow, perfusion, activity, and function. Additionally, accurate predictive tools to estimate time to asystole following the withdrawal of treatment and alternative monitoring modalities to establish the cessation of circulatory, brainstem, and brain function are needed. The physiologic and conceptual implications of postmortem interventions that resume circulation in cDCDD donors likewise demand attention to inform organ recovery practices. Finally, because jurisdictionally variable definitions of death and the criteria for its determination may impede collaborative research efforts, further work is required to achieve consensus on the physiologic and conceptual rationale for defining and determining death after circulatory arrest.

Direct procurement with machine perfusion and normothermic regional perfusion in donation after circulatory death heart transplantation

BACKGROUND

Donation after circulatory death (DCD) heart transplants have increased in the United States with direct procurement with machine perfusion (DPP) and thoracoabdominal normothermic regional perfusion (TA-NRP) techniques. There remains a paucity of data examining DPP and TA-NRP outcomes. The purpose of this study was to investigate the impact of the DCD technique on post-transplant outcomes compared to donation after brain death (DBD) donors.

METHODS

Adult patients undergoing heart transplantation between December 1, 2019, and June 30, 2023, were identified in the United Network for Organ Sharing registry. DPP and TA-NRP groups were identified using time of death to an aortic cross-clamp time of 30 minutes. Categorical variables were compared using the χ2 or Fisher exact test, and continuous variables were compared using the Mann-Whitney U test. Propensity score matching was performed using a 1:3 match. One-year survival was analyzed using the log-rank test and a Cox proportional hazard regression model.

RESULTS

During the study period, there were 7338 DBD and 419 DCD heart transplants. At 1 year post-transplant, there was no difference in survival between unmatched (P = .13) and matched (P = .36) DBD and DCD heart recipients. There was an increase in acute rejection and rejection requiring treatment in DCD recipients compared to DBD recipients in the matched cohort. A total of 134 TA-NRP transplants and 242 DPP transplants were performed. One-year survival and post-transplant outcomes were similar in the DPP and TA-NRP groups. TA-NRP functional warm ischemia time (fWIT) was increased significantly during the study period.

CONCLUSIONS

In this matched cohort, DCD heart recipients experienced increased acute rejection, both treated and nontreated, compared to DBD heart recipients. Despite differences in the techniques and likely in fWIT, acute rejection, survival, and other secondary outcomes are similar with DPP and TA-NRP.

A Global Experience of Donation after Circulatory Death for Pediatric Lung Transplantation

OBJECTIVE

Donation after circulatory death (DCD) lung transplantation has increased, but there is limited data in children. We sought to characterize the international experience of pediatric DCD lung transplant (LT) in comparison to donation after brain death (DBD) to address extreme donor organ shortages in children needing LT.

METHODS

Using the International Society for Heart and Lung Transplantation (ISHLT) Thoracic Organ Transplant Registry, 1453 children (<18yo) LT recipients from January 2004 to June 2018 were identified: 34 (3%) were DCD and 1419 (97%) were DBD recipients. Post-transplant outcomes were compared between groups. Propensity score method was used to derive matched cohorts and were compared between groups.

RESULTS

DCD and DBD recipients were of similar age, with cystic fibrosis being the most frequent indication for LT in both groups (64.5% vs. 57.5%, respectively). Kaplan-Meier analysis demonstrated similar survival between DCD and DBD cohorts, whereas propensity score-matched recipients also identified similar post-transplant survival in both groups (P=0.098). Secondary analysis found that DCD LT recipients had a longer post-transplant length of hospital stay (unmatched cohorts: 36.5d vs. 20d, p=0.022; matched cohort: 26d vs. 19d, p=0.016), and shorter time to acute cellular rejection (ACR) (unmatched cohorts: 248d vs. 560d, p=0.039; matched cohorts: 248d vs. 1650d,p=0.059).

CONCLUSIONS

Due to DCD being a key contributor to the increasing number of lung transplants being performed worldwide, the results of this analysis support this organ donation approach in children requiring LT, which would increase access to donor organs. The identification of a potential shorter time to ACR needs further exploration as more DCD pediatric LTs are performed.

Consensus Statement: Technical Standards for Thoracoabdominal Normothermic Regional Perfusion

BACKGROUND

Thoracoabdominal normothermic regional perfusion (TA-NRP) has emerged as a powerful technique for optimizing organ procurement from donation after circulatory death donors. Despite its rapid adoption, standardized guidelines for TA-NRP implementation are lacking, prompting the need for consensus recommendations to ensure safe and effective utilization of this technique.

METHODS

A working group composed of members from The American Society of Transplant Surgeons, The International Society of Heart and Lung Transplantation, The Society of Thoracic Surgeons, and The American Association for Thoracic Surgery was convened to develop technical guidelines for TA-NRP. The group systematically reviewed existing literature, consensus statements, and expert opinions to identify key areas requiring standardization, including predonation evaluation, intraoperative management, postdonation procedures, and future research directions.

RESULTS

The working group formulated recommendations encompassing donor evaluation and selection criteria, premortem testing and therapeutic interventions, communication protocols, and procedural guidelines for TA-NRP implementation. These recommendations aim to facilitate coordination among transplant teams, minimize variability in practice, and promote transparency and accountability throughout the TA-NRP process.

CONCLUSIONS

The consensus guidelines presented herein serve as a comprehensive framework for the successful and ethical implementation of TA-NRP programs in organ procurement from donation after circulatory death donors. By providing standardized recommendations and addressing areas of uncertainty, these guidelines aim to enhance the quality, safety, and efficiency of TA-NRP procedures, ultimately contributing to improved outcomes for transplant recipients.

Utilization and outcomes of expanded criteria donors in adults with congenital heart disease

BACKGROUND

Use of donation after circulatory death (DCD) and hepatitis C virus (HCV) positive donors in heart transplantation have increased the donor pool. Given poor waitlist outcomes in the adult congenital heart disease (ACHD) population, we investigated waitlist outcomes associated with willingness to consider DCD and HCV+ offers and post-transplant outcomes following HCV+ and DCD transplantation for these candidates.

METHODS

Using the United Network for Organ Sharing database, we identified adult ACHD candidates and recipients listed or transplanted, respectively, between 01/01/2016 and 09/30/2023 for the HCV analysis and between 12/01/2019 and 09/30/2023 for the DCD analysis. Among candidates, we compared the cumulative incidence of transplant, with waitlist death/deterioration as a competing risk, by willingness to consider HCV+ and DCD offers. Among recipients of HCV+ (vs HCV-) and DCD (vs brain death [DBD]) transplants, we compared perioperative outcomes and post-transplant survival.

RESULTS

Of 1,436 ACHD candidates from 01/01/2016 to 09/30/2023, 37.0% were willing to consider HCV+ heart offers. Of 886 ACHD candidates from 12/01/2019 to 09/30/2023, 15.5% were willing to consider DCD offers. On adjusted analysis, willingness to consider HCV+ offers was associated with 84% increased likelihood of transplant, and willingness to consider DCD offers was associated with 56% increased likelihood of transplant. Of 904 transplants between 01/01/2016 and 09/30/2023, 6.4% utilized HCV+ donors, and of 540 transplants between 12/01/2019 and 09/30/2023, 6.9% utilized DCD donors. Recipients of HCV+ (vs HCV-) and DCD (vs DBD) heart transplants had similar likelihood of perioperative outcomes and 1-year survival.

CONCLUSIONS

ACHD candidates who were willing to consider HCV+ and DCD offers were more likely to be transplanted and had similar post-transplant outcomes compared to recipients of HCV- and DBD organs.

Donation After Circulatory Death following Withdrawal of Life-Sustaining Treatments. Are We Ready to Break the Dead Donor Rule?

A fundamental criterion considered essential to deem the procedure of vital organ procurement for transplantation ethical is that the donor must be dead, as per the Dead Donor Rule (DDR). In the case of Donation after Circulatory Death (DCD), is the donor genuinely dead? The main aim of this article is to clarify this uncertainty, which primarily arises from the fact that in DCD, death is determined based on cardiac criteria (Circulatory Death, CD), rather than neurological criteria (Brain Death, BD), and that to allow the procurement procedure, physicians reperfuse the organs in an assisted manner. To ensure that the cessation of circulation leads to the irreversible loss of brain functions, DCD regulations require that physicians wait a certain period after CD before commencing vital organ procurement. However, during this "no-touch period," the organs are at risk of damage, potentially rendering them unsuitable for transplantation. When DCD is performed on patients whose CD follows a Withdrawal of Life-Sustaining Treatment (WLST) (DCD Maastricht III category), how long should the no-touch period last? Does its existence really make sense? Does beginning the procedure of vital organ procurement immediately after WLST constitute a violation of the DDR that can be ethically justified? The discussion aims to provide arguments in support of the non-absoluteness of the DDR.

Outcomes of Heart Transplantation From Donation After Circulatory Death: An Up-to-date Systematic Meta-analysis

BACKGROUND

Donation after circulatory death (DCD) heart transplantation (HTx) significantly expands the donor pool and reduces waitlist mortality. However, high-level evidence-based data on its safety and effectiveness are lacking. This meta-analysis aimed to compare the outcomes between DCD and donation after brain death (DBD) HTxs.

METHODS

Databases, including MEDLINE, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials, were systematically searched for randomized controlled trials and observational studies reporting the outcomes of DCD and DBD HTxs published from 2014 onward. The data were pooled using random-effects models. Risk ratios (RRs) with 95% confidence intervals (CIs) were used as the summary measures for categorical outcomes and mean differences were used for continuous outcomes.

RESULTS

Twelve eligible studies were included in the meta-analysis. DCD HTx was associated with lower 1-y mortality rate (DCD 8.13% versus DBD 10.24%; RR = 0.75; 95% CI, 0.59-0.96; P  = 0.02) and 5-y mortality rate (DCD 14.61% versus DBD 20.57%; RR = 0.72; 95% CI, 0.54-0.97; P  = 0.03) compared with DBD HTx.

CONCLUSIONS

Using the current DCD criteria, HTx emerges as a promising alternative to DBD transplantation. The safety and feasibility of DCD hearts deserve further exploration and investigation.

Consensus Statement: Technical Standards for Thoracoabdominal Normothermic Regional Perfusion

BACKGROUND

Thoracoabdominal normothermic regional perfusion (TA-NRP) has emerged as a powerful technique for optimizing organ procurement from donation after circulatory death donors. Despite its rapid adoption, standardized guidelines for TA-NRP implementation are lacking, prompting the need for consensus recommendations to ensure safe and effective utilization of this technique.

METHODS

A working group composed of members from The American Society of Transplant Surgeons, The International Society of Heart and Lung Transplantation, The Society of Thoracic Surgeons, and The American Association for Thoracic Surgery was convened to develop technical guidelines for TA-NRP. The group systematically reviewed existing literature, consensus statements, and expert opinions to identify key areas requiring standardization, including predonation evaluation, intraoperative management, postdonation procedures, and future research directions.

RESULTS

The working group formulated recommendations encompassing donor evaluation and selection criteria, premortem testing and therapeutic interventions, communication protocols, and procedural guidelines for TA-NRP implementation. These recommendations aim to facilitate coordination among transplant teams, minimize variability in practice, and promote transparency and accountability throughout the TA-NRP process.

CONCLUSIONS

The consensus guidelines presented herein serve as a comprehensive framework for the successful and ethical implementation of TA-NRP programs in organ procurement from donation after circulatory death donors. By providing standardized recommendations and addressing areas of uncertainty, these guidelines aim to enhance the quality, safety, and efficiency of TA-NRP procedures, ultimately contributing to improved outcomes for transplant recipients.

Donation After Circulatory Death Heart Transplant: Current State and Future Directions

Orthotopic heart transplant is the gold standard therapeutic intervention for patients with end-stage heart failure. Conventionally, heart transplant has relied on donation after brain death for organ recovery. Donation after circulatory death (DCD) is the donation of the heart after confirming that circulatory function has irreversibly ceased. DCD-orthotopic heart transplant differs from donation after brain death-orthotopic heart transplant in ways that carry implications for widespread adoption, including differences in organ recovery, storage and ethical considerations surrounding normothermic regional perfusion with DCD. Despite these differences, DCD has shown promising early outcomes, augmenting the donor pool and allowing more individuals to benefit from orthotopic heart transplant. This review aims to present the current state and future trajectory of DCD-heart transplant, examine key differences between DCD and donation after brain death, including clinical experiences and innovations in methodologies, and address the ongoing ethical challenges surrounding the new frontier in heart transplant with DCD donors.