Early Single Center Experience of Heart Transplantation from Donation After Circulatory Death Donors in the United States

Purpose Heart transplantation (HT) from donation after circulatory death (DCD) donors has been proposed as a means of addressing the scarcity of available donor grafts. International experience has suggested that DCD HT is safe, with outcomes comparable to donation after brain death (DBD) HT. Herein we describe our center's early experience using 2 DCD heart procurement strategies: 1) A direct procurement and perfusion (DPP) protocol, and 2) A thoracoabdominal normothermic regional perfusion (TA-NRP) protocol. Methods In September 2020, we launched a DCD HT program as part of a randomized trial using DPP and the OCS Transmedics platform. We subsequently launched a TA-NRP program. The TA-NRP protocol uses mobile cardiopulmonary bypass (CPB) to assess hearts in situ following declaration of death. Functional warm ischemic time (FWIT) was defined as the time from onset of mean pressure <50mm Hg or oxygen saturation <70%, to cold flush (DPP) or initiation of CPB (TA-NRP). FWIT was ≤30 minutes for DPP, while there was no pre-defined limit for TA-NRP. Data was prospectively collected. Donor and recipient characteristics were analyzed. We report 30-day survival as the primary endpoint. Secondary endpoints include incidence of primary graft dysfunction requiring mechanical support, immediate cardiac performance, ventilator days, need for renal replacement therapy, and intensive care and hospital length of stay. Results From September 2020 to October 2021, our center attended 50 candidate DCD donors, and performed 33 DCD HTs (66.0%), comprised of 13 DPP and 20 TA-NRP protocol donors. Among candidate DPP donors, 13 of 23 (56.5%) hearts were transplanted, whereas among candidate TA-NRP donors, 20 of 27 (74.1%) were transplanted. Year-to-date, DCD as a proportion of all HTs at our center has been 43.1%. Comparing similar time periods before and after implementing our DCD heart transplant program revealed a 20.3% increase in transplant activity. Donor and recipient characteristics are described in tabular format. 30-day survival is 100% among all DCD heart recipients. The incidence of primary graft dysfunction and other secondary endpoints are comparable with standard DBD HT. Conclusion DCD HT using both the DPP and TA-NRP procurement protocols is feasible and safe. Outcomes in our early single center experience are comparable with standard DBD HT. Heart transplantation (HT) from donation after circulatory death (DCD) donors has been proposed as a means of addressing the scarcity of available donor grafts. International experience has suggested that DCD HT is safe, with outcomes comparable to donation after brain death (DBD) HT. Herein we describe our center's early experience using 2 DCD heart procurement strategies: 1) A direct procurement and perfusion (DPP) protocol, and 2) A thoracoabdominal normothermic regional perfusion (TA-NRP) protocol. In September 2020, we launched a DCD HT program as part of a randomized trial using DPP and the OCS Transmedics platform. We subsequently launched a TA-NRP program. The TA-NRP protocol uses mobile cardiopulmonary bypass (CPB) to assess hearts in situ following declaration of death. Functional warm ischemic time (FWIT) was defined as the time from onset of mean pressure <50mm Hg or oxygen saturation <70%, to cold flush (DPP) or initiation of CPB (TA-NRP). FWIT was ≤30 minutes for DPP, while there was no pre-defined limit for TA-NRP. Data was prospectively collected. Donor and recipient characteristics were analyzed. We report 30-day survival as the primary endpoint. Secondary endpoints include incidence of primary graft dysfunction requiring mechanical support, immediate cardiac performance, ventilator days, need for renal replacement therapy, and intensive care and hospital length of stay. From September 2020 to October 2021, our center attended 50 candidate DCD donors, and performed 33 DCD HTs (66.0%), comprised of 13 DPP and 20 TA-NRP protocol donors. Among candidate DPP donors, 13 of 23 (56.5%) hearts were transplanted, whereas among candidate TA-NRP donors, 20 of 27 (74.1%) were transplanted. Year-to-date, DCD as a proportion of all HTs at our center has been 43.1%. Comparing similar time periods before and after implementing our DCD heart transplant program revealed a 20.3% increase in transplant activity. Donor and recipient characteristics are described in tabular format. 30-day survival is 100% among all DCD heart recipients. The incidence of primary graft dysfunction and other secondary endpoints are comparable with standard DBD HT. DCD HT using both the DPP and TA-NRP procurement protocols is feasible and safe. Outcomes in our early single center experience are comparable with standard DBD HT.