Current status and challenges of DCD heart transplantation in the Asia-Pacific region

Heart transplantation remains the definitive treatment for end-stage heart failure, but donor shortages persist globally. This review aims to evaluate the current status, enabling technologies, ethical considerations, and future prospects of donation after circulatory death (DCD) heart transplantation in the Asia-Pacific region. A comprehensive narrative review was conducted using published literature and country-specific reports to assess global and regional trends in DCD heart transplantation. Particular focus was given to enabling technologies (e.g., thoracoabdominal normothermic regional perfusion [taNRP] and ex situ machine perfusion), legal and ethical frameworks, and implementation barriers across countries in the Asia-Pacific. While countries such as the UK, US, and Australia have achieved comparable survival outcomes between DCD and donation after brain death (DBD) heart transplantation, most Asia-Pacific countries remain in early stages. Australia leads the region with over 70 successful DCD heart transplants using the Organ Care System. Japan lacks legal clarity and clinical protocols for withdrawal of life-sustaining therapy, restricting DCD to kidney transplants. China employs a hybrid DBCD model but faces logistical and ethical constraints. In South Korea, India, and others, DCD heart programs are not yet established. High cost and limited availability of enabling technologies, alongside ethical controversy surrounding taNRP, are key barriers. Broader adoption of DCD heart transplantation in Asia-Pacific countries requires legal reform, ethical consensus, cost-effective perfusion strategies, and public engagement. Coordinated efforts across technological, societal, and regulatory domains are essential to expand access to this life-saving modality.