Expanding Use of Donation After Circulatory Death Heart Transplantation to Higher Acuity Recipients

Donation after circulatory death (DCD) hearts were initially used more often in medically stable recipients, reflecting both caution for use in higher risk patients and greater availability to lower acuity candidates. We examined temporal trends in DCD recipient characteristics and compared outcomes of DCD with donation after brain death (DBD) transplants, stratified by pretransplant recipient waitlist status.

From the United Network for Organ Sharing database (December 1, 2019-December 31, 2023), we identified 12,352 first-time, isolated adult heart transplants (DCD, 1114; DBD, 11,238). Temporal trends in DCD recipient characteristics were analyzed. The primary end point was 1-year posttransplant survival compared between DCD and DBD cohorts after stratifying by pretransplant waitlist status. December 2019 data were combined with 2020.

DCD heart transplantation accounted for 3.6% of all heart transplants in December 2019/2020 and 15.2% in 2023 (P < .001). The proportion of DCD recipients with status 1 and 2 listing increased from 17.6% in December 2019/2020 to 52.6% in 2023, with more frequent use of pretransplant mechanical circulatory support (13.9% to 20.2%; both P < .05). After adjustment, DCD and DBD cohorts had similar 1-year survival irrespective of pretransplant waitlist status (status 1and 2: hazard ratio [HR], 1.12 [95% CI, 0.84-1.51]; status 3: HR, 1.01 [95% CI, 0.63-1.61]; status 4: HR, 0.82 [95% CI, 0.51-1.31]; status 6: HR ,0.88 [95% CI, 0.43-1.80]).

The use of DCD hearts has expanded significantly in higher acuity recipients. One-year survival in these recipients remains equivalent to DBD transplants. With appropriate selection, more aggressive use of DCD donor hearts may be encouraged in higher acuity recipients.