Donation after circulatory death heart transplantation: The French perspective

Heart transplantation is the gold standard treatment for patients with advanced heart failure in the absence of contraindications. In recent years, the shortage of heart donors has led to a resurgence in the use of hearts from donation after circulatory death (DCD) donors after withdrawal of life-sustaining treatment. In these donors, death is determined by the cessation of spontaneous circulation and respiration for≥5minutes and is confirmed by neurological criteria. Two heart procurement procedures are used, namely direct procurement and perfusion (DPP) and procurement after thoracoabdominal-normothermic regional perfusion (TA-NRP). Donor hearts procured using TA-NRP are reperfused and assessed inside the donor and preserved with static cold storage or ex situ machine perfusion. With DPP, hearts are reperfused and assessed ex situ with a perfusion machine. The ischaemic time before heart reperfusion is shorter with TA-NRP than with direct procurement followed by ex situ perfusion. The TA-NRP technique allows for the assessment of the function of the donor heart. Numerous studies have reported similar survival rates between recipients who have received hearts from DCD and donation after brain death (DBD) donors. The incidence of severe primary graft dysfunction varies according to the team's learning curve and the country. The heart utilization rate is greater with TA-NRP procurement than DPP. This article describes the two donor heart procurement techniques, provides a summary of the relevant literature on the outcomes of transplantation from DCD donors and reports the position of a working group, convened by the French national transplant agency, on donor and recipient selection.