Special Session 2 - Organ Transplant in Mainland and Overseas

The National Organ Allocation System of China, known as China Organ Transplant Response System (COTRS), stands as a testament to the country's commitment to an ethical and transparent approach in organ donation and transplantation. 
As one of the five subsystems of the National Organ Donation and Transplantation System, COTRS plays a crucial role in upholding the legal mandates set forth by the 2007 China State Council Regulation and its comprehensive update in 2023. COTRS's role extends beyond mere legal compliance, anchoring the national system in the bedrock principles of justice, fairness and transparency, thereby nurturing and safeguarding the foundational cornerstone of organ donation worldwide: public trust.
Originating from a decade-long research project at the University of Hong Kong's Department of Surgery (2004-2014), COTRS has been operational since April 6, 2011, marking over 13 years of continuous service. The core of COTRS algorithm is derived from the complex scientific policies for organ allocation, which are publicly accessible on the COTRS and National Health Commission (NHC) websites. These policies largely mirror its international counterparts in term of medical and scientific criteria, as well as the ethical considerations outlined in the WHO's guiding principles. The significant role of COTRS was further highlighted by the 2023 revision of the State Council Regulation.
As the official operational system in organ allocation, the data produced by COTRS form the basis for official organ traceability records, and have been published annually on the WHO website since 2015, in compliance with WHO requirements for its member states. In 2022, COTRS also played a central coordination role in facilitating the historic first organ sharing between Hong Kong SAR and Mainland China.

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.