The Spanish Heart Transplant Registry, coordinated by the Heart Failure and Transplantation Section of the Spanish Society of Cardiology, annually reports the most relevant data on heart transplantation activity in Spain. This report, corresponding to 2024, provides detailed information on the epidemiology, clinical characteristics, and outcomes of all procedures performed in accredited centers across the country.

For more than three decades, this registry has served as an international benchmark for data completeness and consistency, reflecting the maturity of a system that has maintained technical excellence, interhospital coordination, and sustained survival outcomes over time.

This year’s report not only allows assessment of recent trends in heart transplantation but also highlights emerging areas of development, including donation after circulatory death (DCD), optimization of organ allocation criteria, and the growing role of ventricular assist devices as a bridge to transplantation.

In 2024, a total of 347 heart transplants were performed in Spain, representing a 6.8% increase compared with 2023 and confirming the stability of transplant activity over the past decade, which has remained in the range of 300–350 procedures per year. Since 1984, more than 10300 transplants have been performed nationwide, underscoring the maturity and organizational capacity of the national program.

Recipients aged >60 years accounted for 32% of the procedures, while 8.6% were pediatric recipients. The overall recipient profile remains stable, with 73% male and a mean age of 49.6 years, showing a gradual trend toward older and more clinically complex candidates.

Reoperations accounted for nearly 30% of all cases, and the use of pretransplant mechanical circulatory support continues to increase. In 2024, 43.2% of recipients were transplanted while on some form of circulatory assistance, predominantly ventricular assist devices (26.8%), followed by ECMO (15%) and intra-aortic balloon pump (1.5%). Among assisted patients, the proportion supported by ECMO has progressively increased in recent years, now representing one-third of all supports. Urgent listing accounted for 47% of procedures, compared with 41% in 2023, reflecting the impact of the new prioritization system implemented in 2023 and the growing proportion of patients supported with ECMO.

Donor characteristics showed a mean age of 42.9 ± 15.4 years, with a predominance of male donors (69%). Of particular note was the progressive expansion of controlled donation after circulatory death, which accounted for 101 transplants in 2024 (29.1%), compared with only 2% in 2020. Over the period 2020–2024, DCD already represents 13.9% of all grafts implanted in Spain. This trend consolidates Spain’s position as an international leader in the use of this type of donation.

Ischemic times have progressively decreased over the last decade, with a slight increase in 2024. The widespread adoption of the bicaval technique (86.7%) and improved logistics in DCD have contributed to maintaining excellent graft preservation.

One-year survival reached 85.2% (mean value for 2021–2023), and 5-year survival stood at 74.3%, representing a sustained improvement compared with previous periods and results comparable to or better than those reported in major international registries. The main causes of death during the first year remain primary graft failure, infection, and acute rejection, although the latter two have shown a downward trend.

The authors conclude that heart transplantation activity in Spain remains stable in both volume and outcomes, with short- and midterm survival comparable to that reported in international registries. They highlight the maturity of the national program, built upon excellent coordination between donation and transplant teams, and emphasize the sustained growth of controlled DCD as one of the most promising areas for future development. They also note the increasing clinical complexity of current recipients, with a higher incidence of reoperations and pretransplant mechanical support use, factors that reflect the natural evolution of clinical practice and the upcoming challenges for heart transplantation in Spain.

COMMENTARY:

The 2025 Spanish Heart Transplant Registry confirms the maturity and stability of the national program, reflecting consistent activity sustained over the past decade in volume, outcomes, and organizational structure. In an international context marked by donor variability and scarcity, Spain continues to rank among the countries with the highest transplant rate per million population and with excellent long-term survival outcomes.

Compared with registries from a decade ago, the current landscape is strikingly different. The typical recipient is now older and more complex, with a higher incidence of previous cardiac surgery and an increasing use of ventricular assist devices (VADs) as a bridge to transplantation. What used to be an exception has become almost the rule: nearly 30% of procedures are reoperations, and more than 40% of patients undergo transplantation while on mechanical circulatory support. This shift reflects both technological advances and the ability to maintain patients with end-stage heart failure alive until a suitable organ becomes available.

Mechanical support prior to transplantation is reported globally in the registry but without specifying the type or duration of each device (eg, ECMO, LVAD, Impella, or CentriMag). This represents an area with clear potential for improvement. A more detailed analysis distinguishing short-term support—particularly the Impella 5.5, increasingly used in cardiogenic shock either as a bridge or as a step-down strategy after ECMO—would allow a more precise interpretation of transplant outcomes. This device, capable of providing up to 5.5 L/min of effective cardiac output, offers prolonged support with low hemolysis and fewer complications, enabling extubation, improved pretransplant recovery, and prioritization under urgency status 0B, which could potentially enhance overall outcomes. In fact, a multicenter national study is currently underway compiling data from more than one hundred Impella 5.5 cases implanted in Spain since its introduction. Preliminary results are promising and may provide key insights to contextualize the survival figures observed in the registry.

Donation after circulatory death has evolved from an experimental initiative to a consolidated and expanding source of organs, with overall results comparable to those obtained with donation after brain death. This achievement, made possible through outstanding coordination between the National Transplant Organization (ONT) and transplant teams, represents one of the greatest recent successes of the Spanish system and opens a promising path to mitigate donor shortage. However, international literature reminds us that DCD is not free of clinical challenges. Several studies describe a higher incidence of primary graft dysfunction—often biventricular—attributed to warm ischemia and reperfusion injury inherent to the procedure. Nonetheless, contemporary series show that short- and midterm survival is comparable to that of brain-dead donors, with no increase in conduction abnormalities or major complications.

In Spain, the thoracoabdominal normothermic regional perfusion (TA-NRP) technique is employed, allowing in situ restoration of coronary circulation and oxygenation before procurement, combined with static cold storage. This approach has proven to improve myocardial recovery and reduce the incidence of primary graft dysfunction, consolidating Spain’s position as one of Europe’s leading countries in controlled DCD heart transplantation.

Current survival, approximately 85% at 1 year and 74% at 5 years, suggests that we may have reached a physiological plateau that will be difficult to surpass without disruptive advances in immunosuppression, organ preservation, or candidate selection. While transplant volume has stabilized, the field continues to advance in technical precision and organizational efficiency.

Spanish heart transplantation today rests on three solid pillars: impeccable logistics, highly experienced surgical teams, and an exemplary coordination network that sustains a unique culture of collective effort. However, the challenges of the coming years will be more structural than technical: optimizing organ allocation, reducing futility in high-risk recipients, and preserving equity in an increasingly complex environment with limited resources.

When reviewing the evolution of the registry, it becomes evident that transplantation in Spain has transitioned from a medical milestone to a sustained clinical reality—no less admirable for its consistency. Each case still represents a delicate balance between science, coordination, and generosity. We may have reached maturity in outcomes, but not in ambition. Controlled DCD, next-generation ventricular assist devices, refined allocation criteria, and expanded circulatory support programs outline the path toward a future in which every available organ provides the best possible chance of success.

Ultimately, the 2025 report not only reaffirms the excellence of the Spanish model but also underscores the need for ongoing adaptation. Every transplant continues to represent, beyond the statistics, an act of precision, trust, and shared hope.

REFERENCE:

González-Vílchez F, Almenar-Bonet L, Gómez-Bueno M, Crespo-Leiro MG, Cobo-Belaustegui M, Crespín-Crespín M, et al. Spanish heart transplant registry. 36th official report of the Heart Failure Association of the Spanish Society of Cardiology. Rev Esp Cardiol (Engl Ed). 2025 Oct;78(10):906–915. English, Spanish. doi: 10.1016/j.rec.2025.04.011.