Increasing adoption of donation after circulatory death in high-risk heart transplant recipients: Insights into current practices in the United States

Objective Previous reports indicate that the majority of donation after circulatory death (DCD) heart transplants (HTs) were performed in low-priority candidates (status ≥4). We sought to characterize the contemporary practice and outcomes of DCD HTs in high- and low-risk patients. Methods Using the United Network for Organ Sharing database, 1581 adult HT recipients (2019-2024) were identified: 966 (61%) high risk (status 1-3) and 615 (39%) low risk (status 4-6). Trends in recipient selection, waitlist time, and posttransplant outcomes were examined. Results High-risk patients were more likely to be younger (56 vs 59 years; P < .001), male (83% vs 75%; P < .001), of Black race (25% vs 18%; P = .003), have hepatic dysfunction (22% vs 15%; P < .001), supported by a left ventricular assist device (42% vs 28%; P < .001), mechanically ventilated (1.4% vs 0%; P = .002), and on vasopressor support (41% vs 16%; P < .001) at time of transplant. They also experienced shorter total waitlist times (20 vs 71 days; P < .001), longer ischemic times (5.3 vs 4.7 hours; P < .001), and greater organ travel distances (359 vs 253 nautical miles; P < .001). Posttransplant survival was similar between groups ( P = .122), although the high-risk group had longer hospital stay (18 vs 16 days; P < .001). A significant increase in the use of DCD HT for high-risk patients was observed, increasing from 33% (of all DCD HTs during 2020) to 75% in 2024. Adjusted (DCD) waitlist time is doubled in high-risk patients (from 9 to 19 days) and increased 3.7-fold in low-risk patients (from 19 to 71 days). Conclusions Over the past 5 years, the practice of DCD HT has evolved, with most transplants now occurring in high-risk candidates, yielding comparable outcomes to lower-risk groups. However, DCD waitlist times have significantly increased, suggesting the need for broader and earlier adoption across all listing statuses.