Rapid Adoption of DCD Heart Transplantation Expands Donor Pool

The transplant team at Cleveland Clinic Weston Hospital became the first in South Florida to perform a modern adult heart transplant using a heart donated after circulatory death (DCD). In doing so, the center joined a growing number of U.S. transplant programs adopting this innovative approach.

“Advances in organ recovery and preservation now allow us to safely evaluate and transplant hearts donated after circulatory death. The available evidence shows that carefully selected DCD hearts can provide outcomes comparable to hearts donated after brain death,” says Antonio Polanco, MD, a cardiothoracic and heart transplant surgeon at Cleveland Clinic Weston Hospital.

The use of DCD hearts has increased rapidly since the practice was reintroduced in the United States in 2019. According to Organ Procurement and Transplantation Network (OPTN) data, approximately 8% of heart transplants in 2022 involved DCD organs. That proportion increased to 13% in 2023 and reached nearly 18% in 2024.

“DCD transplantation gives us another opportunity to identify suitable donor hearts for patients who urgently need a transplant,” Dr. Polanco says. “Since adopting this approach, we have been able to consider a broader range of donor offers that previously may not have been available to our patients.”

DCD Versus DBD

Although the earliest heart transplants used hearts from donors after circulatory death, the field shifted to organs donated after brain death (DBD) in the early 1980s. The change followed the development of uniform brain-death criteria and reflected concerns about the increased risk of ischemic injury during the recovery of DCD hearts.

“A donor heart can be damaged when its blood and oxygen supply are interrupted for too long, affecting its ability to pump normally,” Dr. Polanco explains. “Machine perfusion has helped transform DCD heart transplantation by restoring circulation to the organ and allowing the transplant team to assess its function before implantation.”

Cleveland Clinic Weston Hospital has used machine perfusion for donor kidneys since the Transplant Center opened in 2013. More recently, the center established a machine-perfusion program that has supported more than 65 adult liver transplants using a variety of advanced preservation techniques.

“Cleveland Clinic Weston Hospital has developed significant experience using advanced organ-preservation technologies across multiple transplant programs,” Dr. Polanco says. “Applying that expertise to heart transplantation strengthens our ability to evaluate donor organs and select the best option for each patient.”

Heart Recovery Methods

When a potential organ donor has sustained a severe, irreversible brain injury or devastating illness and is near death, the donor's family may choose to allow a natural death. After life support is withdrawn and circulatory death is declared, a five-minute observation period is required to monitor for signs that the heart has restarted before organ recovery begins.

A DCD heart can then be recovered using one of two approaches: ex situ normothermic machine perfusion (NMP), or normothermic regional perfusion (NRP) followed by static cold storage (SCS). Both methods allow the heart to be reanimated and evaluated at the donor site to determine whether it is suitable for transplantation.

Weston Hospital has transplanted donor organs preserved and transported with the TransMedics Organ Care System (OCS), currently the only FDA-approved system for ex situ perfusion of DCD hearts.

“Ex situ machine perfusion keeps the donor heart beating and supplied with oxygen and nutrients during transport,” Dr. Polanco says. “It also gives us valuable information about the heart's function and metabolism so we can make a more informed decision about whether it is suitable for transplantation.”

Alternatively, NRP uses extracorporeal membrane oxygenation (ECMO) technology to restore circulation within the chest and abdomen of a donor after circulatory death. Once the heart's viability is confirmed, the organ is recovered, preserved using traditional static cold storage and transported to the recipient's transplant center.

The Transplant Center at Weston Hospital has performed adult liver transplants using DCD organs recovered through NRP and plans to adopt this recovery method for DCD hearts.

Patient Outcomes

Studies have found that machine-perfused DCD hearts can achieve patient- and graft-survival outcomes comparable to those associated with DBD hearts preserved using static cold storage.

Results from the Donors after Circulatory Death Heart Trial, published in 2023, showed a 94% survival rate among recipients of DCD hearts, compared with 90% among recipients of DBD hearts. Although the U.S.-based, multicenter, unblinded, randomized controlled trial found a higher incidence of primary graft dysfunction among DCD heart recipients, the difference did not affect patient or graft survival at 30 days or one year.

In another study, researchers used the OPTN/United Network for Organ Sharing registry to identify adult heart transplant recipients from 2019 through 2021. They found comparable mortality outcomes between recipients of DCD and DBD hearts. The registry review also found that DCD donors tended to be younger and male, while recipients of DCD hearts were more likely to have a lower UNOS status of 3 through 6, indicating less medical urgency.

“As experience with DCD transplantation has grown, transplant centers have become increasingly comfortable evaluating these hearts for patients with varying levels of medical urgency,” Dr. Polanco says. “We are also assessing a broader range of potential donors, including women and individuals who fall outside traditional donor-age criteria.”

Looking Ahead

Research continues to focus on improving organ-recovery and preservation strategies, reducing ischemic time and enhancing the viability of DCD hearts. In addition to monitoring the mid- and long-term performance of NMP and NRP recovery methods, investigators are studying hypothermic machine perfusion as another potential preservation option for DCD hearts.

“DCD heart transplantation has advanced rapidly, but there is still more to learn,” Dr. Polanco says. “Continued research will help us refine recovery and preservation techniques, reduce ischemic injury and better understand the long-term performance of these donor hearts.”

The continued evolution of DCD heart transplantation could significantly expand the donor pool. Improved preservation methods also may make it possible to match donors and recipients across greater distances.

“The goal is to make more donor hearts safely available to the patients who need them,” Dr. Polanco says. “As preservation technology continues to improve, we may also be able to transport hearts across greater distances, creating more opportunities to match the right donor organ with the right recipient.”