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Updated: Aug 9, 2026
Pre-clinical Model of Cardiac Donation after Circulatory Death
Published on: August 2, 2019
Metabolic Considerations in Direct Procurement and Perfusion Protocols with DCD Heart Transplantation
Maria Arnold1,2, Peter Do1, Sean M Davidson3
1Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
Insights
Donation after circulatory death (DCD) heart grafts face unique metabolic challenges during withdrawal of life-sustaining therapy and ischemia. Understanding these changes is crucial for improving graft quality and patient outcomes after heart transplantation.
Area of Science:
- Cardiology
- Transplantation Medicine
- Metabolic Research
Background:
- Donation after circulatory death (DCD) heart transplantation offers improved donor heart availability and patient outcomes.
- DCD grafts experience warm, unprotected ischemia and a pre-ischemic phase after withdrawal of life-sustaining therapy (WLST), unlike brain-dead donor grafts.
- These conditions can negatively impact cardiac energy metabolism and graft quality.
Purpose of the Study:
- To review metabolic changes in DCD donor hearts during WLST, circulatory arrest, and warm ischemia.
- To elucidate the role of altered energy substrate availability in graft quality and post-ischemic recovery.
- To inform clinical protocols and pre-clinical models for DCD heart transplantation.
Main Methods:
- Literature review focusing on metabolic, hemodynamic, and biochemical changes in DCD donors.
- Analysis of cardiac energy metabolism regulation during pre-procurement phases.
- Synthesis of information on cellular damage and reperfusion effects.
Main Results:
- DCD donors exhibit acute metabolic and hemodynamic shifts, including high catecholamines, hypoxia, and warm ischemia.
- These changes induce metabolic alterations and cellular damage, further exacerbated by reperfusion.
- Altered energy substrate availability before organ procurement significantly impacts graft quality and recovery.
Conclusions:
- Understanding metabolic changes during WLST and ischemia is vital for optimizing DCD heart graft quality.
- Clinical and pre-clinical strategies should consider these metabolic alterations.
- Focusing on initial reperfusion conditions and graft evaluation is key to tailoring therapies for optimal transplantation outcomes.
Abstract:
Heart transplantation with donation after circulatory death (DCD) provides excellent patient outcomes and increases donor heart availability. However, unlike conventional grafts obtained through donation after brain death, DCD cardiac grafts are not only exposed to warm, unprotected ischemia, but also to a potentially damaging pre-ischemic phase after withdrawal of life-sustaining therapy (WLST). In this review, we aim to bring together knowledge about changes in cardiac energy metabolism and its regulation that occur in DCD donors during WLST, circulatory arrest, and following the onset of warm ischemia. Acute metabolic, hemodynamic, and biochemical changes in the DCD donor expose hearts to high circulating catecholamines, hypoxia, and warm ischemia, all of which can negatively impact the heart. Further metabolic changes and cellular damage occur with reperfusion. The altered energy substrate availability prior to organ procurement likely plays an important role in graft quality and post-ischemic cardiac recovery. These aspects should, therefore, be considered in clinical protocols, as well as in pre-clinical DCD models. Notably, interventions prior to graft procurement are limited for ethical reasons in DCD donors; thus, it is important to understand these mechanisms to optimize conditions during initial reperfusion in concert with graft evaluation and re-evaluation for the purpose of tailoring and adjusting therapies and ensuring optimal graft quality for transplantation.
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