Early outcomes after DCD heart transplantation remained stable during rapid national expansion despite broader recipient risk profiles, supporting the scalability of this strategy without evidence of outcome deterioration.
Key Findings
Results
DCD heart transplantation expanded substantially in the United States between 2019 and 2024, with increased use across a greater number of transplant centers.
Study included 1,489 adult DCD heart transplant recipients from the UNOS registry (January 2019 to June 2024)
Recipients were stratified into an early era (2019–2021, n=303) and a late era (2022–2024, n=1,186)
The late era group was approximately four times larger than the early era group, reflecting rapid national expansion
Expansion occurred both in volume and geographic reach across transplant centers
Results
There was no significant difference in 1-year graft failure (the primary endpoint) between the early and late eras of DCD heart transplantation.
Primary endpoint was 1-year graft failure
Both unadjusted and inverse probability of treatment weighting (IPTW)-adjusted analyses showed no significant differences between eras
IPTW was applied to adjust for baseline differences between the two cohorts
Results were consistent despite broader recipient risk profiles in the later era
Results
Secondary outcomes including 1-year all-cause mortality, renal-replacement therapy before discharge, and length of stay did not differ significantly between eras.
No significant differences were found between early and late eras in 1-year all-cause mortality
Renal-replacement therapy rates before discharge were not significantly different between eras
Length of stay did not differ significantly between groups
Retransplantation rates also showed no significant difference between eras
Results
Overall survival up to 2 years did not differ significantly between the early and late eras in exploratory analyses.
The 2-year survival analysis was described as a 'secondary exploratory analysis'
No significant difference was found between early and late era groups
This extended the primary findings beyond the 1-year primary endpoint window
The exploratory nature of this analysis was prespecified
Results
Outcomes remained consistent across prespecified high-risk subgroups during the national expansion of DCD heart transplantation.
Prespecified subgroup analyses were performed in high-risk recipients
High-risk subgroups included recipients with impaired functional status, pulmonary hypertension, and preoperative mechanical circulatory support
Outcomes were described as 'consistent across high-risk subgroups' between eras
This suggests the stability of outcomes was not limited to lower-risk recipients
Results
The late era DCD recipients had broader recipient risk profiles compared to the early era, yet outcomes remained stable.
Baseline differences existed between early and late era cohorts, necessitating IPTW adjustment
The paper notes 'increasing complexity of candidates with advanced heart failure' as a clinical context
Despite broader risk profiles in the later era, no outcome deterioration was observed
This finding supports the scalability of DCD heart transplantation as a strategy
What This Means
This research looked at whether the outcomes of a relatively new type of heart transplantation — called donation after circulatory death (DCD) — have remained safe and effective as it has spread rapidly across the United States. In traditional heart transplantation, organs come from donors who are brain-dead but whose hearts are still beating. DCD transplantation uses hearts from donors whose hearts have stopped, which requires special techniques to preserve and restart the organ. The study used national registry data from 1,489 adult heart transplant recipients between 2019 and 2024, comparing those who received DCD hearts in the early years of adoption (2019–2021) to those in the later expansion period (2022–2024).
The study found that key outcomes — including 1-year graft failure (the organ stopping working), patient survival at 1 and 2 years, need for dialysis before leaving the hospital, length of hospital stay, and need for a second transplant — were all statistically similar between the two time periods. This held true even after accounting for the fact that patients in the later era tended to be sicker and higher-risk. Importantly, the stability of outcomes also extended to vulnerable subgroups, such as patients who needed mechanical heart support before transplant, those with high blood pressure in the lungs, or those with poor physical functioning.
This research suggests that DCD heart transplantation has scaled up nationally without a decline in patient outcomes, even as it has been applied to more complex patients at more transplant centers. This is significant because it indicates the techniques and protocols for DCD heart transplantation appear to be transferable and reproducible across the broader transplant community, potentially expanding the pool of available donor hearts and reducing waiting times for patients with life-threatening heart failure.
Ueno K, Kelley D, Shuto T, Miyamoto S, Dominic J, Atluri P. (2026). Stable Outcomes of Donation After Circulatory Death Heart Transplantation From Early Adoption to National Expansion.. Journal of cardiac failure. https://doi.org/10.1016/j.cardfail.2026.05.019