Clinical outcomes and one-year survival in heart transplant recipients from donors after circulatory death versus brain death: a meta-analysis of current evidence

Background Heart transplantation remains the definitive treatment for end-stage heart failure; however, donor scarcity limits global availability. In this context, the use of donors after circulatory death (DCD) has emerged as a strategy to expand the organ pool through recovery techniques such as normothermic regional perfusion and ex-vivo preservation. Nevertheless, doubts persist regarding the clinical outcomes of this modality, particularly in terms of early survival and primary graft dysfunction, compared to standard donors after brain death (DBD). Current evidence remains limited and heterogeneous. Purpose To evaluate and compare early clinical outcomes and one-year survival rates in adult heart transplant recipients from DCD versus DBD donors, aiming to validate DCD as a non-inferior and safe strategy to mitigate the global donor organ shortage. Methods A meta-analysis was conducted including randomized clinical trials and cohort studies. The search was performed across three electronic databases (PubMed, Scopus, and Web of Science), including studies published between 2015 and February 2026. Adult recipients (≥18 years) of primary heart transplants from donors after circulatory death (DCD) were included and compared with donors after brain death (DBD). Eligible studies were required to report at least one of the following outcomes: 30-day survival, one-year survival, and/or incidence of primary graft dysfunction (PGD). Results Seven selected studies were included in the statistical analysis. For primary graft dysfunction (PGD), 4,110 recipients were analyzed (DBD n=1,817; DCD n=2,293). The model shows a significantly higher risk in the DBD group (RR=1.37; 95% CI: 1.09-1.72; p=0.006) with low heterogeneity (I²=28%). Regarding survival, no statistically significant differences were observed between groups; 11,975 recipients were included (DBD n=4,002; DCD n=7,973) (RR=0.99; 95% CI: 0.98-1.01; p=0.46) with low heterogeneity (I²=12%). Quality and bias assessment was performed using the ROBINS-I tool, which showed that 57% of the studies have a low overall risk of bias, while the remaining 43% present a moderate risk in domains D1 and D5. Conclusion Heart transplantation with donors after circulatory death is an effective and safe alternative that proves to be a comparable option to brain death transplantation regarding 1-year survival. It is associated with a lower incidence of primary graft dysfunction, although further prospective studies are required for confirmation.1-year survivalSevere Primary Graft Dysfunction