Donation after Circulatory Death in Heart Transplantation.

Heart transplantation has traditionally relied on donation after brain death (DBD), but persistent shortages in available donor hearts have elevated interest in donation after circulatory death (DCD). Despite DCD now comprising a significant share of organ donations globally, clinical implementation remains challenged by limited evidence, procedural inconsistencies, and higher risks of ischemic injury and primary graft dysfunction. Recent technological advancements in organ prefusion, particularly normothermic regional perfusion (NRP) and ex situ machine perfusion techniques, have demonstrated improved outcomes for DCD transplants, with comparable short- and mid-term survival to DBD. Clinical evidence suggests that effective management of warm ischemia and optimized donor selection criteria can mitigate risks, achieving high utilization rates and excellent recipient outcomes. Nonetheless, significant global variations in DCD practices indicate the need for standardized guidelines to improve adoption rates and consistency in results. Future directions include refining perfusion technologies, clarifying thresholds for ischemic times, identifying real-time biomarkers for graft viability, and expanding large-scale comparative studies to conclusively evaluate long-term outcomes. By addressing these challenges through structured protocols and ongoing technological innovations, DCD heart transplantation holds substantial potential to significantly broaden the donor pool and improve survival outcomes, representing a pivotal advancement in addressing global shortages of transplantable hearts.