DCD Heart Research Articles

Outcomes of Donation After Circulatory Death Heart Transplantation Using Normothermic Regional Perfusion

BackgroundDonation after circulatory death (DCD) with cardiopulmonary bypass for thoracoabdominal normothermic regional perfusion (TA-NRP) has led to increased use of donor hearts. Rejection rates and long-term survival outcomes are not known. MethodsA single-center retrospective cohort review of patients who underwent DCD heart transplantation from January 2020 to December 2023 was performed. Donor and recipient characteristics, operative characteristics, and posttransplantation outcomes were analyzed. Subgroup analysis comparing co-localized vs distant donors and recipients was performed. The primary end point was 1-year survival. Secondary end points included incidences of primary graft dysfunction (PGD), cardiac allograft vasculopathy (CAV), rejection rate, and overall mortality. Our TA-NRP protocol has remained the same, consisting of sternotomy, ligation of aortic arch vessels, establishment of cardiopulmonary bypass, reintubation, resuscitation of the heart, and cold static storage during transport. ResultsIn total, 32 recipients underwent DCD heart transplantation, including 26 isolated hearts, 3 heart-lungs, and 3 heart-kidneys. The median age was 56 years for recipients and 39 years for donors; 21 donors and recipients were co-localized, whereas 11 were distant. One-year survival was 100%. Two patients required mechanical circulatory support for PGD. Four patients experienced grade 2R acute cellular rejection. Five patients had grade 1 CAV at 1 year. On subgroup analysis, distant donors and recipients had longer warm (47 vs 30 minutes; P < .005) and cold (213 vs 76 minutes; P < .005) ischemia times, without any other differences. ConclusionsOutcomes after DCD heart transplantation using TA-NRP remain encouraging with acceptable rates of rejection, PGD, CAV, and survival at 1 year.

The Rapidly Evolving Landscape of DCD Heart Transplantation.

To summarise current international clinical outcomes from donation after circulatory death heart transplantation (DCD-HT); discuss procurement strategies, their impact on outcomes and overall organ procurement; and identify novel approaches and future areas for research in DCD-HT. Globally, DCD-HT survival outcomes (regardless of procurement strategy) are comparable to heart transplantation from brain dead donors (BDD). Experience with normothermic machine perfusion sees improvement in rates of primary graft dysfunction. Techniques have evolved to reduce cold ischaemic exposure to directly procured DCD hearts, though controlled periods of cold ischaemia can likely be tolerated. There is interest in hypothermic machine perfusion (HMP) for directly procured DCD hearts, with promising early results. Survival outcomes are firmly established to be equivalent between BDD and DCD-HT. Procurement strategy (direct procurement vs. regional perfusion) remains a source of debate. Methods to improve allograft warm ischaemic tolerance are of interest and will be key to the uptake of HMP for directly procured DCD hearts.

Direct Procurement with Machine Perfusion and Normothermic Regional Perfusion in Donation after Circulatory Death Heart Transplantation

ObjectiveDonation after circulatory death (DCD) heart transplants have increased in US with DPP and TA-NRP techniques. There remains a paucity of data examining DPP and TA-NRP outcomes. The purpose of this study was to investigate the impact of DCD technique on post-transplant outcomes compared to DBD donors. MethodsAdult patients undergoing heart transplantation between December 1, 2019, and June 30, 2023 were identified in the UNOS registry. DPP and TA-NRP cohorts were detected using time of death to aortic cross-clamp of 30 minutes. Categorical variables were compared using chi-square or Fisher exact tests, while continuous variables were compared using Mann-Whitney U tests. Propensity score matching was performed using a 1:3 match. 1-year survival was analyzed using log-rank test and Cox proportional hazard regression model. ResultsDuring the study period, there were 7338 DBD and 419 DCD heart transplants. At 1-year, there was no difference in survival between unmatched (p=0.13) and matched (p=0.36) DBD and DCD recipients. There was an increase in acute rejection and rejection requiring treatment in DCD compared to DBD in the matched cohort. 134 TA-NRP and 242 DPP transplants occurred. 1-year survival and post-transplant outcomes were similar in DPP and TA-NRP. TA-NRP functional warm ischemia times increased significantly during the study period. ConclusionsIn a matched cohort, DCD heart recipients experience increased acute rejection, both treated and non-treated, compared to DBD. Despite differences in the techniques, and likely functional warm ischemic times, acute rejection, survival, and other secondary outcomes are similar between DPP and TA-NRP.

Thoraco-abdominal normothermic regional perfusion in DCD heart transplantation: a bridge from DCD to "DBD-like" donation.

Thoraco-abdominal normothermic regional perfusion in DCD heart transplantation: a bridge from DCD to "DBD-like" donation.

Optimizing Resuscitation of the Donation after Circulatory Death Heart by Mitochondrial Protection in a Female Porcine Model.

Due to the shortage of donor organs, an increasing number of transplant organs are harvested after circulatory arrest (donation after circulatory death [DCD]). Using a translational porcine model of DCD, this study developed and evaluated a protocol based on cardioprotection by multidrug postconditioning to optimize resuscitation of DCD hearts during ex situ heart perfusion (ESHP). Hearts of female pigs (45.0 ± 4.5 kg) were procured following a clinically identical DCD protocol, consisting of the termination of ventilator support and confirmation of circulatory arrest, followed by a 15-min standoff period. DCD hearts were randomly allocated to ESHP (38.4°C) in the absence (untreated, N = 5) or presence (treated, N = 5) of a postconditioning treatment added to the perfusate, consisting of Intralipid (1%), sevoflurane (2% v/v), and remifentanil (3 nM). All hearts were perfused with blood and Krebs-Henseleit solution (1:1) for 60 min in Langendorff mode and for an additional 300 min in working mode for a total perfusion time of 6 h. Oxidative capacity and detailed left ventricular mechanical function under an increasing workload (left atrial pressure, 6 to 12 mmHg) were assessed hourly. Left ventricular tissue was snap-frozen at the end of ESHP and used for molecular analyses. Left ventricular inotropy (LVdP/dtmax) did not decline over time in treated DCD hearts and was significantly higher at the end of the protocol as compared with untreated DCD hearts (ΔLVdP/dtmax = 440 mmHg/s; P = 0.009). Treated DCD hearts exhibited persistently higher left ventricular stroke work index during the 6-h period of ESHP, whereas untreated DCD hearts displayed a significant decline (change in left ventricular stroke work index = -3.10 ml · mmHg/g; P(time within untreated group) < 0.001). Treated DCD hearts displayed higher metabolic activity as measured by oxygen consumption (ΔO2 = 3.11 ml O2 · min-1 · 100 g-1; P = 0.004) and released lower amounts of cell-free mitochondrial DNA into the perfusate, a marker of potential graft dysfunction. Treated hearts also used fatty acids from Intralipid as an energy source, whereas untreated DCD hearts showed glyceroneogenesis with triglyceride accumulation and depletion of tricarboxylic acid cycle intermediates; reduced mitochondrial complex I, II, and III activities with accumulation of mitochondrial NADH, and signs of ultrastructural damage. A translationally relevant protective ESHP protocol consisting of treatment with Intralipid, sevoflurane, and remifentanil markedly accelerated functional recovery and improved viability of DCD hearts.

(294) - How Could DCD Heart Donation Affect Organ Availability for Congenital Heart Programs?

(294) - How Could DCD Heart Donation Affect Organ Availability for Congenital Heart Programs?

(7) - Impact of Institutional Volume on Outcomes Following DCD Heart Transplantation in the United States

(7) - Impact of Institutional Volume on Outcomes Following DCD Heart Transplantation in the United States

(772) - Incidence of Moderate and Severe Primary Graft Dysfunction in DBD vs. DCD Heart Transplantation in Patients with Pre-Existing Durable LVAD Support

(772) - Incidence of Moderate and Severe Primary Graft Dysfunction in DBD vs. DCD Heart Transplantation in Patients with Pre-Existing Durable LVAD Support

(424) - Outcomes with Normothermic Regional Perfusion: Comparison with Core-Cooling During DCD Heart Transplantation

(424) - Outcomes with Normothermic Regional Perfusion: Comparison with Core-Cooling During DCD Heart Transplantation

(6) - Real-World Clinical Outcomes of DCD Heart Transplantation from the OCS Heart Perfusion (OHP) Registry: Benchmarking to Other Preservation Methods

(6) - Real-World Clinical Outcomes of DCD Heart Transplantation from the OCS Heart Perfusion (OHP) Registry: Benchmarking to Other Preservation Methods

(232) - Direct Procurement Followed by Hypothermic Oxygenated Perfusion in DCD Heart Transplantation

(232) - Direct Procurement Followed by Hypothermic Oxygenated Perfusion in DCD Heart Transplantation

(524) - Predictors of Severe Graft Dysfunction After DCD Heart Transplantation with Direct Procurement and Preservation

(524) - Predictors of Severe Graft Dysfunction After DCD Heart Transplantation with Direct Procurement and Preservation

(520) - Twenty-Minute No-Touch Period Before Controlled DCD Heart Retrieval: Is There Still a Chance for Successful Recovery? The Italian Experience

(520) - Twenty-Minute No-Touch Period Before Controlled DCD Heart Retrieval: Is There Still a Chance for Successful Recovery? The Italian Experience

(46) - Outcomes of DCD Heart Transplant: NRP and OCS

(46) - Outcomes of DCD Heart Transplant: NRP and OCS

(235) - 8-Year Single-Centre Experience of DCD Heart Transplantation: Temporal Trends in Outcomes, Procedural and Recipient Characteristics

(235) - 8-Year Single-Centre Experience of DCD Heart Transplantation: Temporal Trends in Outcomes, Procedural and Recipient Characteristics

Donor heart refusal after circulatory death: An analysis of United Network for Organ Sharing refusal codes

ObjectiveDonor hearts procured after circulatory death (DCD) may significantly increase the number of hearts available for transplantation. The purpose of this study was to analyze current DCD and brain-dead donor (DBD) heart transplantation rates and characterize organ refusal using the most up-to-date United Network for Organ Sharing (UNOS) and Organ Procurement and Transplantation Network data. MethodsWe analyzed UNOS and Organ Procurement and Transplantation Network DBD and DCD candidate, transplantation, and demographic data from 2020 through 2022 and 2022 refusal code data to characterize DCD heart use and refusal. Subanalyses were performed to characterize DCD donor demographics and regional transplantation rate variance. ResultsDCD hearts were declined 3.37 times more often than DBD hearts. The most frequently used code for DCD refusal was neurologic function, related to concerns of a prolonged dying process and organ preservation. In 2022, 92% (1329/1452) of all DCD refusals were attributed to neurologic function. When compared with DBD, DCD donor hearts were more frequently declined as the result of prolonged warm ischemic time (odds ratio, 5.65; 95% confidence interval, 4.07-7.86) and other concerns over organ preservation (odds ratio, 4.06; 95% confidence interval, 3.33-4.94). Transplantation rate variation was observed between demographic groups and UNOS regions. DCD transplantation rates are currently experiencing second order polynomial growth. ConclusionsDCD donor hearts are declined more frequently than DBD. DCD heart refusals result from concerns over a prolonged dying process and organ preservation. Heart transplantation rates may be substantially improved by ex situ hemodynamic assessment, adoption of normothermic regional perfusion guidelines, and quality initiatives.

Preserved 2-y Liver Transplant Outcomes Following Simultaneous Thoracoabdominal DCD Organ Procurement Despite Effects on Liver Utilization Rate.

Current techniques for donation after circulatory determination of death (DCD) heart procurement, through either direct procurement and machine perfusion or thoracoabdominal normothermic regional perfusion (NRP), have demonstrated excellent heart transplant outcomes. However, the impact of thoracoabdominal DCD (TA-DCD) heart procurement on liver allograft outcomes and utilization is poorly understood. One hundred sixty simultaneous heart and liver DCD donors were identified using the United Network for Organ Sharing/Organ Procurement and Transplantation Network database between December 2019 and July 2021. Liver outcomes from TA-DCD donors were stratified by heart procurement technique and evaluated for organ utilization, graft survival, and patient survival. Results were compared with abdominal-only DCD (A-DCD; n = 1332) and donation after brain death (DBD; n = 12 891) liver transplants during the study interval. Kaplan-Meier methods with log-rank testing were used to evaluate patient and graft survival. One hundred thirty-three of 160 livers procured from TA-DCD donors proceeded to transplant. TA-DCD donors were younger (mean 28.26 y; P < 0.0001) with lower body mass index (mean 26.61; P < 0.0001) than A-DCD and DBD donors. TA-DCD livers had equivalent patient survival ( P = 0.893) and superior graft survival (P = 0.009) compared with A-DCD. TA-DCD livers had higher rates of organ discard for long warm ischemia time (37.0%) than A-DCD (20.5%) and DBD (0.5%; P < 0.0001), with direct procurement and machine perfusion procurements leading to a higher discard rate (18.5%) than NRP procurements (7.4%). Liver transplants after TA-DCD donation demonstrated equivalent patient outcomes and excellent graft outcomes. NRP procurements resulted in the lowest rate of organ discard after DCD donation and may represent an optimal strategy to maximize organ utilization.

(643) The New Heart Allocation System Change and DCD Heart Availability: Effects on Durable VAD Patients

(643) The New Heart Allocation System Change and DCD Heart Availability: Effects on Durable VAD Patients

(141) Normothermic Regional Perfusion Versus Direct Procurement and Preservation: Is There a Difference for DCD Heart Recipients?

(141) Normothermic Regional Perfusion Versus Direct Procurement and Preservation: Is There a Difference for DCD Heart Recipients?

The international experience of in-situ recovery of the DCD heart: a multicentre retrospective observational study

Heart transplantation is an effective treatment offering the best recovery in both quality and quantity of life in those affected by refractory, severe heart failure. However, transplantation is limited by donor organ availability. The reintroduction of heart donation after the circulatory determination of death (DCD) in 2014 offered an uplift in transplant activity by 30%. Thoraco-abdominal normothermic regional perfusion (taNRP) enables in-situ reperfusion of the DCD heart. The objective of this paper is to assess the clinical outcomes of DCD donor hearts recovered and transplanted from donors undergoing taNRP. This was a multicentre retrospective observational study. Outcomes included functional warm ischaemic time, use of mechanical support immediately following transplantation, perioperative and long-term actuarial survival and incidence of acute rejection requiring treatment. 157 taNRP DCD heart transplants, performed between February 2, 2015, and July 29, 2022, have been included from 15 major transplant centres worldwide including the UK, Spain, the USA and Belgium. 673 donations after the neurological determination of death (DBD) heart transplantations from the same centres were used as a comparison group for survival. taNRP resulted in a 23% increase in heart transplantation activity. Survival was similar in the taNRP group when compared to DBD. 30-day survival was 96.8% ([92.5%-98.6%] 95% CI, n=156), 1-year survival was 93.2% ([87.7%-96.3%] 95% CI, n=72) and 5-year survival was 84.3% ([69.6%-92.2%] 95% CI, n=13). Our study suggests that taNRP provides a significant boost to heart transplantation activity. The survival rates of taNRP are comparable to those obtained for DBD transplantation in this study. The similar survival may in part be related to a short warm ischaemic time or through a possible selection bias of younger donors, this being an uncontrolled observational study. Therefore, our study suggests that taNRP offers an effective method of organ preservation and procurement. This early success of the technique warrants further investigation and use. None of the authors have a financial relationship with a commercial entity that has an interest in the subject.