Heart transplantation is the best treatment for advanced heart failure, providing recipients with an excellent quality of life and a median post-transplant survival of 12.5 years. However, the severe shortage of donor hearts has meant that only a limited number of patients could benefit from this life-saving treatment.
Over the years, various strategies to increase the number of cadaveric donor organs have been explored. Amongst these, donation after circulatory death (DCD) has provided additional donor organs for numerous kidney, liver and lung transplant recipients. However, DCD has long been dismissed as a potential source of donor hearts due to doubts about their viability following profound hypoxia leading to asystole circulatory arrest.
After a decade-long of intense research efforts involving small and large animal models, novel techniques were finally developed to retrieve and transplant hearts from DCD donors in 2014/15. These include direct procurement and machine perfusion (DP-MP) and thoracoabdominal normothermic regional perfusion (TANRP). Mid-term survival following DCD heart transplant were found to be comparable with heart transplantation using brain dead donor hearts. Following these early successes in Australia and the United Kingdom, these innovative techniques have been cautiously adopted by heart transplant centres initially in Europe and more recently in the United Stated of America. As more centres report similar successes, adoption of DCD heart retrieval has accelerated in the last 3 years. To date, over 1,500 DCD heart have been successfully retrieved and transplanted across more than 80 centres worldwide confirming its feasibility and safety. The annual volume of DCD heart transplant is expected to continue to increase over the coming years.
Logistical and ethical considerations together with the relative merits of DP-MP and TANRP will determine the most appropriate approach for individual centre. Every heart transplant program should consider adopting these novel techniques to retrieve and transplant DCD hearts and extend the benefits of heart transplantation to all their patients who are desperately awaiting this life-saving treatment.
