• Analysis: Carefully Selected DCD Hearts Yield Similar Early Favorable Outcomes to DBD Hearts in Transplant Recipients

    Patients who received hearts from carefully selected donor adults after circulatory death experienced favorable early outcomes similar to patients who received hearts from adults after brain death, according to a new analysis from a large national database.  

    Shivank Madan, MD, and colleagues, from Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, reported these findings in a manuscript published online Monday and in the Jan. 18 issue of the Journal of the American College of Cardiology.

    Currently, the source of heart transplantation in the U.S. is largely from donation after brain death (DBD), with well-developed and ethically accepted criteria for brain death that minimize hypoxia of the organ and provide sufficient time to access the potential donor heart before recovery. Donation after circulatory death (DCD), on the other hand, does not meet criteria for brain death, and patients become DCD donors after meeting the death criteria due to irreversible cardiopulmonary arrest after withdrawal of life support.

    The study was conducted using the United Network for Organ Sharing (UNOS) registry. All adults  18 years and older who became DCD donors between January 2020 and February 2021 were identified using a code for “non-heart beating donors,” Similarly, a separate query was performed using the traditional DBD donors from the UNOS registry during the same study period. All patients with multi-organ transplants, re-transplants, pediatric donors or recipients (younger than 18 years), and transplants with missing information post-transplant survival were excluded.

    The primary outcomes of the study was to access for all-cause mortality up to 30 days and 6 months of follow up. Secondary outcomes included post primary graft failure (defined as those with graft failure leading to death or re-transplantation) up to 30 days of follow up, rate of in-hospital stroke, hemodialysis and pacemaker insertion before discharge and post heart transplant length of stay in the hospital.

    A total of 3,611 adult patients were identified as DCD donors. Out of these, 136 adult DCD hearts were used for transplant and 3,475 were not used. There were eight patients with multi-organ or re-transplant patients, or lost to post-transplant follow-up who were excluded from the study. A total of 127 adult DCD heart transplantations met the study criteria and had information available on post-transplant. Similarly, 2,961 adult patients were identified as DBD. All patients who underwent transplant with UNOS status 1 or extracorporeal membrane oxygenation (ECMO) support were excluded from the study from both cohorts.

    Overall, compared to DBD recipients, DCD recipients were younger with median age of 54 years vs 57 years, had lower prevalence of gender mismatch (1.57% vs 11.82%), overall lower UNOS urgency status, were more likely to be blood type 0 (60.63% VS 39.72%) and have durable left ventricular assist device support (41.73% vs 27.96%). Recipients with DCD hearts were less likely to be on life support with inotropes (26.77% vs 39.31%), intra-aortic balloon pump (11.02% vs 28.84%) or ECMO (0.79% vs. 5.03%) at time of transplantation in comparison to those with DBD hearts.

    The median follow up for the overall cohort was 6.1 months for both groups. Overall Kaplan-Meier survival curve survival for the total cohort was 96.8% at 30 days and 92.5% at 6 months. The overall analysis showed that there were no significant differences in 30-day or 6-month survival, primary graft failure up to 30-days, in-hospital stroke, pacemaker insertion, hemodialysis or post-transplant length of hospital stay between patients receiving DCD vs. DBD hearts.

    Additionally, the study showed that compared with DCD donors whose hearts were not used for transplantation, DCD donors whose hearts were used were younger, more likely to be male and have blood type O, and had lower prevalence of diabetes, hypertension, coronary artery disease and smoking history. The authors examined the trends in the number of DCD donors over time and estimated that widespread adoption of DCD heart donation using DCD heart organs can potentially lead to approximately 300 additional adult heart transplants in US.

    Francis D. Pagani, MD, PhD, of the University of Michigan, wrote an accompanying editorial highlighting some of the important limitations of the study. Despite the efforts made by the authors to control for differences among recipients and donors, there was still significant confounding present from unmeasured differences that were not included in propensity-score modeling. Important information on the procedure used for DCD heart procurement (such as direct procurement with ex vivo perfusion vs. in vivo normothermic regional perfusion) was absent.

    He concluded: “A significant ethical and clinical framework now exists for DCD heart donation in the United States that has been developed from groundbreaking efforts in Australia and the United Kingdom, and now from early U.S. experiences. Because of the critical need for donor hearts, it is clinically necessary to resolve these controversies and challenges to expand the current heart donor pool in the United States.”



    Madan S, Saeed O, Forest SJ, et al. Feasibility and Potential Impact of Heart Transplantation From Adult Donors After Circulatory Death. J Am Coll Cardiol 2022;79:148–162.

    Pagani FD. Heart Transplantation Using Organs From Donors Following Circulatory Death: The Journey Continues. J Am Coll Cardiol 2022;79:163–165.

    Image Credit: Kadmy – stock.adobe.com

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