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Unresolved Considerations for Donor Management in Heart Transplantation After Cardiac Death: A Narrative Review
Jeffrey KiHyun Park1, Jennie Yee Ngai1
1NYU Grossman School of Medicine, New York, NY.
Insights
Standardizing donation after circulatory death for heart transplantation (DCD-HT) protocols is crucial. This review analyzes variations and controversies to promote more effective and ethical DCD-HT practices.
Area of Science:
- Cardiology
- Transplantation Surgery
- Bioethics
Background:
- Donation after circulatory death for heart transplantation (DCD-HT) is gaining traction.
- Current DCD-HT protocols lack standardization across different organizations.
- Variability in end-of-life care and allograft assessment complicates DCD-HT execution and ethics.
Purpose of the Study:
- To analyze variations in current DCD-HT protocols.
- To examine controversies in DCD-HT across different phases of donation.
- To support the development of standardized DCD-HT protocols.
Main Methods:
- Review of contemporary DCD-HT protocols.
- Analysis of variations in donor selection and management.
- Examination of peri-withdrawal and intraoperative phases.
Main Results:
- Significant variability exists in DCD-HT protocols regarding donor management and allograft assessment.
- Ethical controversies are exacerbated by inconsistent definitions and practices.
- Critical gaps in current protocols were identified.
Conclusions:
- Standardization of DCD-HT protocols is essential for clinical effectiveness and ethical integrity.
- Addressing protocol variations can improve efficiency and reduce ethical concerns.
- Further development is needed for robust and standardized DCD-HT practices.
Abstract:
As interest in donation after circulatory death for heart transplantation (DCD-HT) grows, the need to standardize protocols and address ongoing controversies becomes increasingly apparent. However, efforts toward standardization are complicated by the fact that numerous organ procurement organizations, transplant centers, and academic societies have each posited their own protocols. While some degree of variability is inevitable and sometimes necessary, variability regarding end-of-life care, definitions for reported metrics, and standards for allograft assessment may lead to inefficiencies in scaled execution and worsen ethical controversies for donors at the end of life. This review analyzes key areas of variation in contemporary DCD-HT protocols, including donor selection, management during withdrawal of life-sustaining therapy, allograft ischemic parameters, and more, and examines ongoing controversies across preoperative, peri-withdrawal, and intraoperative phases. By synthesizing current practices and identifying critical gaps, we aim to support the development of more standardized, ethically robust, and clinically effective protocols for DCD-HT.
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