Heart transplantation remains the gold-standard therapy for patients with advanced heart failure; however, its population-level impact continues to be constrained by the persistent structural shortage of donors. For decades, donation after brain death has been virtually the sole source of cardiac grafts, resulting in prolonged waiting-list times and a non-negligible risk of death before transplantation.
Within this context, the reintroduction of controlled donation after circulatory death (DCD) represents one of the most significant advances of the past decade. Initially regarded as an experimental approach, DCD heart transplantation has demonstrated post-transplant outcomes comparable to those achieved with donation after brain death, both in pioneering series from Australia and the United Kingdom and in subsequent national registries. In the United States, analyses derived from the UNOS database have confirmed that DCD heart transplantation does not adversely affect short- or mid-term survival, addressing one of the main early concerns, even with follow-up extending to five years, as reported by Benkert et al. in a study published this same month.
More recently, attention has shifted away from post-transplant outcomes toward a more uncomfortable and system-level question: does DCD truly improve patient prognosis from the moment of waiting-list registration? Previous US studies suggested shorter waiting times and a lower probability of delisting due to death or clinical deterioration, but robust evidence from allocation systems outside the United States remained limited.
The study discussed in this article directly addresses this issue by evaluating the impact of implementing a DCD programme on clinical outcomes from the time of listing in a high-volume European centre.
The authors report a single-centre observational study conducted at the Royal Papworth Hospital NHS Foundation Trust (Cambridge, United Kingdom), including 275 patients listed for heart transplantation. Outcomes were compared between the three years prior to programme implementation (n = 129) and the three years following implementation (n = 146). After the introduction of DCD, the median waiting time decreased from 77 to 45 days (p = .001), and the cumulative probability of transplantation increased significantly (p < .001). In parallel, delisting due to death or clinical deterioration declined from 18% to 6% (p = .011), and the need for mechanical circulatory support after listing decreased from 13.9% to 4.1% (p = .007). These benefits were achieved without any significant differences in short- or long-term post-transplant survival.
The authors conclude that the implementation of a heart transplantation programme incorporating controlled DCD is associated with improved clinical outcomes from the time of waiting-list inclusion, reducing time to transplantation, the risk of death or deterioration, and the need for mechanical circulatory support, without compromising post-transplant survival.
COMMENTARY:
This study delivers a clinically compelling message: DCD is not only safe from a graft-performance perspective but also favourably alters the natural history of patients while on the waiting list. This paradigm shift is consistent with accumulating evidence from recent years, yet gains additional strength by originating from a European setting with an allocation system distinct from that of the United States.
The most striking finding is the marked reduction in waiting-list time following the implementation of the DCD programme, together with a clear increase in the likelihood of transplantation. Concurrently, there is a substantial decrease in delisting due to death or clinical deterioration—an outcome that has long represented one of the greatest limitations of heart transplantation.
Equally relevant is the reduction in the need for mechanical circulatory support after listing. This frequently overlooked endpoint carries clear clinical, logistical, and economic implications. Fewer patients require VA-ECMO or ventricular assist devices as an urgent bridge, translating into fewer complications, lower resource utilisation, and potentially better clinical status at the time of transplantation.
These findings align naturally with previously published data. In the United States, UNOS-based analyses had already shown that candidates eligible for DCD hearts experience a higher probability of transplantation and a lower risk of delisting due to death or deterioration. Hess et al. further confirmed that these benefits are achieved without compromising post-transplant survival, as previously discussed in the blog.
The parallel study by Benkert et al., with five-year follow-up of DCD heart transplants in the United States, reinforced this message by demonstrating survival outcomes comparable to those observed with donation after brain death. The present work extends this knowledge by showing that the benefit of DCD begins at the time of listing rather than being confined to the post-operative period.
From a practical standpoint, the study suggests that DCD functions as a true “system decompressor”: by expanding the donor pool, competition for grafts is reduced, waiting times are shortened, and clinical progression requiring escalation to more complex mechanical support can be avoided.
As with most innovations in transplantation, this is an observational study, precluding definitive causal inference. Temporal cohort comparisons may be influenced by changes in clinical practice unrelated to DCD, including modifications in prioritisation criteria or mechanical support strategies. In this regard, the Spanish experience illustrates how allocation changes introduced in 2023 have altered recipient profiles and the proportion of urgent indications, potentially acting as additional confounders when assessing the isolated impact of new donation strategies.
Moreover, the data reflect the experience of a pioneering centre with extensive expertise and highly optimised logistics, which may overestimate the effect of DCD in less specialised environments. Finally, the sample size limits detailed subgroup analyses and precludes precise identification of patient profiles deriving the greatest benefit from this strategy.
Overall, this article reinforces a concept already suggested by national registries and accumulated experience: donation after circulatory death has evolved from a marginal alternative into a structural pillar of contemporary heart transplantation. Its value lies not only in demonstrating equivalent graft performance but also in tangibly improving patient prognosis before transplantation.
Recent data from the Spanish transplant registry confirm this trend, with sustained expansion of DCD to nearly one-third of heart transplants performed in 2024, while maintaining excellent survival outcomes. In this context, the present study provides a key missing piece: evidence that DCD enhances system efficiency and reduces the futility associated with prolonged waiting.
In summary, DCD should not be viewed merely as an additional source of organs, but rather as the logical evolution of a system seeking to gain time where previously there was only attrition. The future challenge will not be to prove its value, but to optimise its implementation, refine patient selection, and ensure consistent outcomes across different healthcare systems.
REFERENCE:
Duehmke R, Hassan M, Page A, Krishnan U, Dong P, Berman M, et al. Impact of donation after circulatory death heart transplantation on clinical outcomes after listing for heart transplantation. Eur J Cardiothorac Surg. 2025;67:ezaf315. doi:10.1093/ejcts/ezaf315.
Benkert AR, Jawitz OK, Lobo AA, Casalinova S, Goel D, Dewan KC, et al. Five-year experience of heart transplantation following donation after circulatory death. J Thorac Cardiovasc Surg. 2025;170:1687–1696. doi:10.1016/j.jtcvs.2025.08.013.
