Heart transplantation in controlled donation after circulatory determination of death: the Italian experience

Abstract

Background: Donation after circulatory death (DCD) donation is becoming more and more popular worldwide. However, in this setting of donation, heart graft suffers from the ischemic injury related with the cardiac arrest. In Italy, the declaration of death with cardiac parameters requires the registration of electrocardiograph for twenty minutes resulting in a very prolonged grafts' warm ischemia time. The aim of this study is to present the Italian preliminary experience on heart transplantation (HTx) from controlled DCD (cDCD) donors.

Methods: Despite a very long period of warm ischemic time (WIT) expected, in April 2023, a DCD heart program was started in Italy and in May 2023 the first DCD heart transplant was performed. In the present paper, preliminary results of the national program are analyzed.

Results: Since May 2023 until December 2024, 40 DCD heart transplants were performed in Italy. Donors' characteristics were the followings: 31 male, nine female, mean age of 46.6±14.7 years. Causes of death were: 19 trauma, eight cerebral bleeding, four post-anoxia coma, nine others. Three donors showed mild coronary artery disease at angiography. Mean WIT was 43.2±10.8 minutes. Thoraco-abdominal normothermic regional perfusion (T-A NRP) was used in all cases. Recipients' characteristics were the followings: 33 males, seven females, mean age 59.1±12.3 years, 16 re-operations (REDO), 18 on an urgent list. Eight (21%) patients required post-transplant extracorporeal membrane oxygenation (ECMO), four (50%) of whom were successfully weaned. Thirty-day mortality was 10%. Median duration of post-transplant mechanical ventilation, intensive care unit stay and hospital stay was 45 hours, six days and 28 days respectively. At discharge, mean ejection fraction (EF) was 57.8%±10% and tricuspid annular plane systolic excursion (TAPSE) 18.2±3.1 mm, without any significant valvular disfunction.

Conclusions: Italian preliminary results suggest that DCD heart transplantation can be successful despite a very long WIT and marginal donors' characteristics. A larger experience and data about medium and long-term results are mandatory to better confirm the short-term findings.

Keywords: DCD donation; Donation after circulatory death heart transplantation (DCD HTx); normothermic regional perfusion (NRP).