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Updated: Apr 23, 2026
A High-Fidelity Porcine Model of Orthotopic Heart Transplantation Following Donation after Circulatory Death
Published on: June 6, 2025
Early United States experience with donation after circulatory death for heart retransplantation
Alexander R Berg1, Aravind Krishnan1, Elbert E Heng1
1Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA.
Insights
Donation after circulatory death (DCD) heart retransplantation is increasing, but carries a higher risk of 1-year mortality compared to donation after brain death (DBD) hearts, especially in lower-acuity recipients.
Area of Science:
- Cardiology
- Transplantation Medicine
- Public Health
Background:
- Donation after circulatory death (DCD) offers a vital strategy to expand the donor pool for heart transplantation.
- Outcomes following adult heart retransplantation (re-TX) using DCD donors are not extensively documented.
- Understanding the impact of donor type on re-TX outcomes is crucial for optimizing donor utilization.
Purpose of the Study:
- To compare 365-day survival rates after adult heart retransplantation (re-TX) using donors from circulatory death (DCD) versus brain death (DBD).
- To evaluate the impact of donor mechanism on perioperative complications and mortality in re-TX recipients.
- To assess the role of recipient acuity and allocation status in outcomes following DCD versus DBD heart re-TX.
Main Methods:
- Analysis of adult re-TX recipients from the UNOS STAR database (January 1, 2019 to October 1, 2025).
- Comparison of outcomes based on donor mechanism: DCD versus donation after brain death (DBD).
- Utilized Kaplan-Meier survival analysis, multivariable Cox regression, and propensity-score matching (PSM) for robust statistical comparison.
Main Results:
- Among 474 re-TX recipients, 11.2% received DCD hearts, with DCD use increasing over time.
- DCD recipients generally had lower transplant acuity and different allocation statuses compared to DBD recipients.
- While perioperative outcomes and early mortality were similar, adjusted and matched analyses revealed significantly lower 1-year survival for DCD re-TX compared to DBD re-TX.
Conclusions:
- Increasing use of DCD hearts in re-TX, primarily in lower-acuity patients, necessitates careful consideration.
- Risk-adjusted and matched analyses indicate a higher risk of 1-year mortality with DCD donors in re-TX.
- Cautious implementation and ongoing evaluation of DCD heart re-TX are recommended as experience and follow-up data grow.
Background:
Donation after circulatory death (DCD) expands the heart donor pool, but outcomes after adult heart retransplantation (re-TX) are not well defined.
Methods:
Using UNOS STAR data (January 1, 2019 to October 1, 2025), we studied adults undergoing orthotopic re-TX. Exposure was donor mechanism (DCD vs donation after brain death [DBD]). The primary outcome was 365-day mortality assessed with Kaplan-Meier methods and multivariable Cox regression. We also performed 2:1 propensity-score matching (PSM) using prespecified covariates.
Results:
Among 474 re-TX recipients, 53 (11.2%) received DCD hearts; DCD use rose to 32% of re-TX in 2025 (partial year). Compared with DBD, DCD recipients had lower transplant acuity (ECMO 1.9% vs 18.3%; mechanical ventilation 0.0% vs 10.0%) and differed in allocation status (p<0.001), with more Adult Status 4 listings (56.6% vs 26.6%). Perioperative complications and early mortality were similar by donor type. Unadjusted survival did not differ at 90 days (log-rank p=0.51) or 365 days (p=0.42). In adjusted Cox regression, donor mechanism was associated with 365-day mortality (DCD vs DBD hazard ratio 2.27, 95% CI 1.02-5.02; p=0.044). In the matched cohort (DCD n=51; DBD n=96), survival differed by donor mechanism at 90 days (p=0.03) and 365 days (p=0.009).
Conclusions:
DCD re-TX use is increasing and is concentrated in lower-acuity recipients. While perioperative outcomes were similar, risk-adjusted and matched analyses identified differences in 1-year survival by donor mechanism, supporting cautious, selection-sensitive implementation and continued evaluation as experience and follow-up accrue.
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