[Heart transplantation from donation after circulatory death: current overview and future challenges]

In the treatment of end-stage heart disease, heart transplantation often represents the only viable option, particularly in terms of survival and quality of life. The evolution and refinement of medical therapy have substantially decreased mortality rates in cardiac patients, enabling them to progress to advanced stages of heart disease and consequently expanding the pool of eligible transplant candidates. A partial response to this growing demand has come from technological advancements in the development of devices designed to replace cardiac function. Meanwhile, the donor pool remains insufficient to cover the transplant demand, though expanded through multiple strategies, including increasing donor age, public awareness campaigns, research into xenotransplantation, and the use of hearts from donors who meet circulatory death criteria. Conventionally, since 1968, donors' death has been ascertained with brain death criteria; the use of cardiocirculatory death criteria, a recent rediscovery, has long been limited to organs other than the heart, considering also the significant differences among various countries' regulations. In Italy, the law requires 20 min of electrical asystole to ascertain death, a longer time than in other countries, raising doubts about the resumption of cardiac activity, thus limiting the use of such donors for heart donation in our country. However, as a result of the collaboration of experts, since May 2023 protocols have been developed to successfully include donors with circulatory death criteria in the heart donor pool. This review aims to provide the medical community with a detailed analysis of the ethical, legislative, technical, clinical, and scientific aspects that have enabled the opening of a new era in transplantation, with specific reference to heart transplantation. This innovation assumes a historical significance comparable to the first heart transplant performed in 1967, marking a fundamental turning point in the treatment of end-stage heart disease.