Donation After Circulatory Death in Heart Transplantation

Abstract

Heart transplantation has traditionally relied on donation after brain death (DBD), but persistent shortages in available donor hearts have elevated interest in donation after circulatory death (DCD). Despite DCD now composing a significant share of organ donations globally, clinical implementation remains challenged by limited evidence, procedural inconsistencies, and higher risks of ischemia injury and primary graft dysfunction. Recent technologic advancements in organ prefusion, particularly normothermic regional perfusion (NRP) and ex situ machine perfusion techniques, have demonstrated improved outcomes for DCD transplants, with short- and mid-term survival rates comparable to DBD. Clinical evidence suggests that effective management of warm ischemia and optimised donor selection criteria can mitigate risks, achieving high utilisation rates and excellent recipient outcomes. Nonetheless, significant global variations in DCD practices indicate the need for standardised guidelines to improve adoption rates and consistency in results. Future directions include refining perfusion technologies, clarifying thresholds for ischemia times, identifying real-time biomarkers for graft viability, and expanding large-scale comparative studies to conclusively evaluate long-term outcomes. With these challenges addressed through structured protocols and ongoing technologic innovations, DCD heart transplantation holds substantial potential to significantly broaden the donor pool and improve survival outcomes, representing a pivotal advance in addressing global shortages of transplantable hearts.

Keywords: direct procurement and perfusion; donation after brain death; donation after circulatory death; heart transplantation; normothermic regional perfusion.