Barriers and opportunities in donation after circulatory death heart transplantation

Abstract

Background: Heart utilization from donation after circulatory death (DCD) donors remains highly variable across the United States, potentially resulting in missed transplantation opportunities. This study aimed to quantify the frequency of clinically viable, non-utilized DCD hearts and identify usage barriers.

Methods: We conducted a retrospective, national registry analysis of donors ≤55 years old who donated ≥1 organ, focusing primarily on DCDs. Donor characteristics, particularly age, warm ischemic time (WIT), and ejection fraction (EF), as well as reasons for non-recovery and offer refusal, were analyzed. Scientific Registry of Transplant Recipients (SRTRs) heart yield model was employed to identify non-utilized DCD hearts clinically comparable to transplanted DCD hearts.

Results: In 2023, 613 DCD hearts were transplanted, accounting for 13.5% of all heart transplants. Only 15.5% of DCD hearts from donors ≤55 years old were utilized. Marked variation in risk-adjusted DCD heart yield was observed between states, Organ Procurement Organizations (OPOs), and Regions. Donors of transplanted DCD hearts had a median age of 32, WIT 24 mins, and EF 63%. The yield model identified between 701 and 1,243 non-utilized DCD hearts with characteristics comparable to transplanted cases. Concerns about delayed progression to circulatory arrest after life support withdrawal was a key reason for non-utilization.

Conclusions: Despite wider acceptance of DCD heart transplantation, an increasing proportion of DCD hearts remain unused despite favorable characteristics. Concerns related to delayed progression to circulatory arrest are a significant barrier to heart utilization. Addressing geographic variability and improving predictive models for donor viability could double DCD heart utilization and expand heart transplantation volume by approximately 700-1,200 (15%-27%) annually.

Keywords: Brain death; Circulatory death; DCD; Donation after circulatory death donors; Heart transplantation; Normothermic regional perfusion.