Patients who underwent heart transplantation using donation after circulatory death (DCD) hearts showed noninferior outcomes, including 1-year survival, compared with patients who received donation after brain death (DBD) hearts, a new study shows. These data were reported by Hasan K. Siddiqi, MD, MSCR, of Vanderbilt University Medical Center, Nashville, and colleagues, in a manuscript published Monday online and in the Oct. 10 issue of the Journal of the American College of Cardiology. To expand the donor pool, especially in the past 3 years, DCD is being performed more often. The number of heart transplants could increase by roughly 30% with the use of hearts from DCD donors. The investigators in this study compared the 6-month and 1-year outcomes between recipients of DCD hearts and recipients of DBD hearts. This single-center, retrospective, observational study examined all adult heart-only transplants using data from medical records and the United Network for Organ Sharing registry from January 2020 through January 2023. The groups were compared using survival analysis and Cox regression. The primary outcome of this study was survival at the 1-year follow-up visit. A total of 385 adult heart recipients (median age=57.4 years, interquartile range [IQR]=48.0-63.7 years; 26% female; 72.5% white) were included in the study. DCD donors comprised 32% of the procedures, and 83% of the DCD donors were recovered using normothermic regional perfusion (NRP). DCD donors were younger (median=26.0 years [IQR: 21.3-33.0 years] vs. 31.0 years [IQR: 25.0-40.0 years]; p<0.001) and had fewer comorbidities than DBD donors. DCD donors were also more likely to be white (63.9% vs. 59.7%; p<0.001) and male (68% vs. 54%; p<0.001). Recipients of DCD hearts had fewer hospitalizations prior to transplantation and were not as likely to require pretransplantation temporary mechanical circulatory support, compared with recipients of DBD hearts. There was no significant difference in 1-year survival between DCD (94.3%) and DBD (92.4%) recipients (hazard ratio: 0.77; 95% confidence interval: 0.32-1.81; p=0.54). The occurrence of severe primary graft dysfunction, treated rejection during the first year or likelihood of cardiac allograft vasculopathy at 1 year after transplantation also showed similar patterns. The retrospective design of the study and the moderate sample size present some limitations, as well as the use of a single center to conduct the study. In addition, the longest follow-up duration was at 1 year, so more longitudinal studies are still needed to determine longer-term outcomes in the DCD population. Overall, this large study indicated a lack of inferiority in outcomes between DCD and DBD heart transplantation recipients. The investigators noted that the study adds to the plethora of growing evidence in support of DCD hearts as a safe way to expand the donor pool for heart transplantation. In an accompanying editorial, Sean P. Pinney, MD, of the Icahn School of Medicine at Mount Sinai, New York, and Maria Rosa Costanzo, MD, of the Midwest Cardiovascular Institute, Naperville, Illinois, discussed the history of heart transplantation and DCD, and what the future holds as the donor pool expands. “Were it not for the development of temporary and durable mechanical circulatory support devices, eligible candidates too sick for transplant would have died before a suitable donor heart became available. Now the field of heart transplantation finds itself once again at the beginning of a paradigm shift,” Pinney and Costanzo wrote. The editorialists noted their excitement about the contributions the present study makes towards the shift in approach to heart transplantation, although unknowns still exist in the DCD versus DBD debate. They highlighted the need for long-term studies. “Given the ethical, legal, and financial sensitivities surrounding DCD, it is imperative that the dissemination of these practices into additional centers proceeds thoughtfully and with appropriate guardrails so that outcomes are not jeopardized and public trust in the transplant system is preserved. It is exciting to be in the midst of a paradigm shift, particularly one that benefits patients desperately in need of life-saving therapies,” concluded the editorialists. Sources: Siddiqi HK, Trahanas J, Xu M, et al. Outcomes of Heart Transplant Donation After Circulatory Death. J Am Coll Cardiol. 2023;82:1512-1520. Pinney SP, Costanzo MR. Donation After Circulatory Death: Shifting the Paradigm in Heart Transplantation. J Am Coll Cardiol. 2023;82:1521-1523. Image Credit: Microgen – stock.adobe.com