Hot-Button DCD Heart Transplants Bolstered by Survival Data

In heart transplantation, donation after circulatory death (DCD) appeared to be a viable way to expand the donor pool without a long-term survival penalty, based on the first 6 years of experience in the U.S.

Across heart transplants recorded in a national registry, there was no difference in mortality between hearts donated after irreversible loss of circulatory function and those donated after brain death. DCD and donation after brain death (DBD) resulted in similar 30-day mortality (2.8% vs 2.7%, P=0.80) and 5-year survival (77.3% vs 78.3%, P=0.90) among organ recipients.

The caveat was that patients given DCD hearts were more likely to experience severe primary graft dysfunction (PGD; 10.3% vs 5.3%, P<0.001), and they required more hemodialysis (20.4% vs 16.3%, P<0.001), reported Masaki Tsukashita, MD, PhD, of Allegheny General Hospital in Pittsburgh, and colleagues.

“DCD HTx [heart transplantation] offers comparable long-term survival to DBD HTx, despite higher severe PGD. These findings provide reassurance and support continued expansion of DCD heart utilization in the United States,” the authors wrote in the Annals of Thoracic Surgery.

“In addition, similar 1-year survival across early and later eras suggests that national dissemination of DCD HTx may have occurred without a pronounced learning-curve effect,” they added.

DCD heart transplants have been on the rise since the first recorded case in the U.S. in December 2019.

They are considered necessary due to the severe shortage of organs otherwise available, as the prior reliance on brain-dead donors meant that many people who signed up to be organ donors died not meeting criteria for brain death, and were thus unable to donate hearts. Brain death was the proxy that ensured circulatory death.

Ethical concerns have nevertheless pumped the brakes on DCD procurement in its early years.

DCD organ transplants usually rely on restarting the heart while blocking any further blood flow to the brain with the assumption that brain death will promptly follow — apparently violating the dead-donor rule that donors cannot be made dead in order to obtain their organs, and that organ retrieval cannot cause death.

Novel heart recovery techniques are poised to clear the way for wider DCD organ procurement. For example, researchers have developed the “rapid recovery with extended ultraoxygenated preservation” (REUP) technique for rapid recovery of DCD hearts without the need for cardiac reanimation.

“As procurement technique continues to evolve, including [REUP], additional shifts in DCD utilization patterns and outcomes may emerge,” Tsukashita’s team noted.

Study authors used the United Network for Organ Sharing (UNOS) database to identify adult heart transplant recipients from December 2019 to December 2025. They counted 19,432 adult heart transplants, of which 13.3% were from DCD donors.

Recipients of DCD hearts generally had a more favorable risk profile, being less likely to have pulmonary hypertension (57.3% vs 61.7%, P<0.001) and having lower use of extracorporeal membrane oxygenation at transplant (3.9% vs 8.1%, P<0.001) than DBD recipients.

Average cross-clamp-to-cross-clamp time was longer in the DCD group compared with the DBD group (5.19 vs 3.64 hours, P<0.001).

Following propensity score matching, 2,155 matched DCD-DBD pairs were available for analysis.

In their study, Tsukashita and colleagues were also interested in differences between the two standard DCD procurement techniques.

They found that one in three DCD hearts came via the normothermic regional perfusion (NRP) technique, and this method was independently associated with lower in-hospital mortality (adjusted OR 0.51, 95% CI 0.30-0.88) compared with direct procurement and perfusion (DPP). Five-year survival was similar between NRP and DPP groups (83.9% vs 75.4%).

“These findings should be interpreted cautiously, given the surrogate classification of procurement strategy,” they noted. They explained that the UNOS database did not provide this detail, leaving them to infer from the recorded time interval from declaration of circulatory death to aortic cross-clamp whether DPP or NRP was involved (DPP <30 minutes; NRP ≥30 minutes).

“In addition, contemporary DCD preservation strategies are heterogeneous and may include combinations of NRP with machine perfusion or hypothermic preservation approaches, which cannot be distinguished in the registry and thus may confound outcome comparisons,” study authors added.

Other major limitations include the possibility of residual selection bias despite propensity score matching.

Of note, the UNOS registry also only began routinely collecting PGD and post-operative ECMO data in September 2023.

The investigators attributed the finding of excess PGD in the DCD setting to warm ischemic injury incurred during the agonal phase in procurement; this may be partially reversible with current ex situ and in situ perfusion technologies, hence the lack of impact on long-term survival.