Heart transplantation from donation after circulatory death: a meta-analysis of national registries

Background: Although it has been widely recognized that heart transplantation (HT) following donation after circulatory death (DCD) can be a successful strategy to expand the donor pool, its clinical outcomes compared to donation after brain death (DBD) are still the subject of intense investigation. We reviewed the clinical characteristics of HT after DCD from the three largest multicenter nationwide registries, highlighting technical aspects, donor and recipient selection, and early outcomes. Moreover, we performed a meta-analysis of survival outcomes of DCD vs. DBD using reconstructed individual patient time-to-event data. Methods: The PubMed, Web of Science, and Scopus databases were searched in January 2024 to identify the most recent reports from three large multicenter nationwide registries (United States, United Kingdom, and Australia) of HT after DCD. Clinical characteristics were summarized using descriptive statistics, and survival curves were reconstructed for DBD using individual patient time-to-event data. The pooled hazard ratio (HR) with confidence interval (CI) was calculated via Cox regression. Results: A total of 646 DCD HT patients and 7,253 DBD controls were included in this review. In the majority of cases, donors were young males. The mean age of recipients ranged from 48 to 57 years, and the majority were males with idiopathic dilated cardiomyopathy. Up to 40% of patients required postoperative mechanical circulatory support with extracorporeal membrane oxygenation (ECMO). The meta-analysis estimated a pooled 1-year survival of 91.1% (95% CI: 88.6-93.7%) and 90.1% (95% CI: 89.4-90.8%) for DCD and DBD patients, respectively (P=0.91), with a pooled HR of 0.88 (95% CI: 0.65-1.20). Conclusions: Although the generally more favorable clinical profile of DCD donors and recipients may constitute a potential selection bias, our meta-analysis documented similar early and medium-term survival outcomes for DCD and DBD HT.