Donation after circulatory death (DCD) is a technique utilising the heart from donors after withdrawal of life support and requires the donor to sustain circulatory cessation prior to organ retrieval. Our unit was the first to perform heart transplants utilising distantly procured hearts from DCD donors in 2014. We report the experience at our institution and lessons learnt throughout this period.
The TransMedics™ organ care system (OCS) facilitated transportation of DCD hearts back to our hospital. The OCS allows for normothermic reperfusion, assessment and optimisation of the donor hearts. Donors were under 55 years of age, with no known history of cardiac disease. Originally, the time from withdrawal of life support to delivery of preservation fluid was mandated to be less than 30 minutes. In 2018 this was revised to commence once systolic arterial pressure is <90 mmHg. Evaluation of organ suitability for transplantation is determined by metabolic assessment of lactate extraction and reduction in the overall value over time, as well as visual assessment of the heart en route.
To date our unit has retrieved 101 hearts and performed 73 DCD heart transplants. The average donor age was 32.5 ± 10.4 years (61 males and 12 females) with LVEF at referral 62 ± 5%. The average recipient age was 53.5 ± 12.8 years (61 males and 12 females) with LVEF 23 ± 10%. Median ICU stay was 5 (2-10) days and hospital stay 17.5 (11-27.6) days.  The average time on the OCS was 279.4 ± 57.2 minutes. The 30 day survival was 97.2% and 6 month survival was 95.5%, with one early death secondary to complications from severe primary graft dysfunction.
The application of ex-vivo perfusion to donor heart procurement has transformed cardiac transplantation by facilitating the use of a previously non-utilised source of donors and has contributed to an annual increase of 25% in heart transplant activity at our institution. To date our DCD heart procurement is safe and reproducible with early and mid-term outcomes comparable to those of traditional brain dead donors with 91% (86%) and 87% (81%) 1 and 5 year survival respectively.