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Researchers try new ways of preserving more hearts for transplants

Heart transplantation has long been a life-saving procedure for individuals with end-stage heart failure, but the persistent shortage of donor organs has limited the number of patients who can receive this critical intervention. A growing approach to addressing this shortage involves the use of hearts from donors who have been declared dead based on circulatory criteria, rather than the traditional brain death criteria. This method, known as donation after circulatory death (DCD), is gaining traction in the United States and other parts of the world as a way to expand the pool of available donor organs. The process, while complex and ethically nuanced, offers hope to thousands of patients on waiting lists who might otherwise die before a suitable heart becomes available.

Traditionally, heart transplants have relied on donors who are declared brain dead, meaning their brain function has irreversibly ceased, but their heart continues to beat with the assistance of life support systems. These donors are ideal because their organs remain oxygenated and viable for transplantation. However, brain-dead donors represent only a small fraction of potential organ donors, as many individuals who die in hospitals do so after their heart stops beating, often following the withdrawal of life support in cases where recovery is deemed impossible. Until recently, hearts from these donors were considered unusable for transplantation because the organ suffers damage from a lack of oxygen once circulation stops. The heart, unlike other organs such as kidneys or livers, is highly sensitive to periods of ischemia, or lack of blood flow, making it challenging to preserve for transplantation after circulatory death.

The resurgence of DCD heart transplantation is largely due to advancements in medical technology and surgical techniques that allow doctors to revive and assess the heart after it has stopped beating. One key innovation is the use of a machine called the Organ Care System, often referred to as a "heart in a box." This portable device can perfuse the heart with warm, oxygenated blood outside the body, mimicking the conditions inside a living person. By doing so, it can restart the heart, maintain its function, and allow surgeons to evaluate its viability for transplantation. This technology has been pivotal in making DCD hearts a feasible option, as it mitigates the damage caused by the period of ischemia following circulatory death.

The process of DCD heart donation typically begins when a patient, often in an intensive care unit, is determined to have no chance of recovery, and the family decides to withdraw life-sustaining treatments. After the patient’s heart stops and death is declared—usually after a waiting period of a few minutes to ensure no spontaneous restart occurs—the surgical team moves quickly to remove the heart. In some cases, the heart is placed directly into the Organ Care System for perfusion and assessment. In other protocols, particularly in countries like Australia and the United Kingdom where DCD heart transplantation has been practiced longer, surgeons may restart blood flow to the heart inside the donor’s body using a technique called normothermic regional perfusion. This involves clamping off blood vessels to the brain to prevent any chance of consciousness while restoring circulation to the heart and other organs. Once the heart is deemed viable, it is removed and prepared for transplantation.

The ethical considerations surrounding DCD heart transplantation are significant and have sparked debate among medical professionals, ethicists, and the public. One primary concern is the definition of death itself. In DCD cases, death is declared based on the permanent cessation of circulation, but the act of restarting the heart—either in the donor’s body or in a machine—raises questions about whether death was truly irreversible. Critics argue that if the heart can be revived, the donor may not have been dead in a definitive sense at the time of organ removal. Proponents, however, counter that death is determined by the permanent loss of function in the context of the donor’s overall condition, not by the potential to restart an organ in isolation. They emphasize that strict protocols are in place to ensure that death is confirmed and that no harm comes to the donor.

Another ethical issue involves the potential for conflicts of interest in the care of potential donors. Medical teams must ensure that decisions to withdraw life support are made independently of any consideration for organ donation, to avoid any perception that a patient’s death is being hastened for the sake of harvesting organs. Transparency with families is also critical, as they must fully understand the process and provide informed consent for DCD. Despite these challenges, many in the transplant community view DCD as a morally sound way to honor a patient’s or family’s wish to donate organs and save lives after death.

From a practical standpoint, DCD heart transplantation has shown promising results. Early data from programs in the United States, where the practice is relatively new compared to countries like Australia, suggest that outcomes for recipients of DCD hearts are comparable to those who receive hearts from brain-dead donors. Patients who receive DCD hearts often face long waits on transplant lists, and for many, the procedure represents their only chance at survival. The ability to use DCD hearts has the potential to significantly increase the number of heart transplants performed each year, addressing a critical public health need. In the U.S. alone, thousands of patients are on waiting lists for heart transplants, and hundreds die each year before a donor heart becomes available. Expanding the donor pool through DCD could save countless lives.

The adoption of DCD heart transplantation is not without logistical hurdles. The process requires highly specialized equipment, such as the Organ Care System, which is expensive and not available at all hospitals. Additionally, the procedure demands precise coordination among surgical teams, often under tight time constraints, as the window for successfully retrieving and reviving a heart after circulatory death is narrow. Training for medical staff and the development of standardized protocols are also essential to ensure consistency and safety across different institutions. Despite these challenges, the transplant community is increasingly embracing DCD as a vital strategy to address the organ shortage.

Beyond the immediate benefits to patients, DCD heart transplantation also reflects broader trends in medicine toward innovation and the re-evaluation of long-held assumptions. What was once considered impossible—transplanting a heart that has stopped beating—is now becoming a reality, thanks to technological advancements and a willingness to push boundaries. This progress extends beyond hearts to other organs as well, with DCD protocols being applied to lungs, livers, and kidneys, further amplifying the impact on organ donation.

For families of donors, the decision to participate in DCD can provide a sense of purpose and solace during a time of profound loss. Knowing that their loved one’s heart could give another person a second chance at life often brings comfort, even as they navigate the emotional complexities of saying goodbye. Transplant recipients, in turn, express immense gratitude for the gift of life, often forming deep, albeit anonymous, connections with the families of their donors through letters or other means facilitated by transplant organizations.

As DCD heart transplantation continues to evolve, ongoing research and dialogue will be crucial to address ethical concerns, refine techniques, and ensure equitable access to this life-saving procedure. Public awareness and education about organ donation, including the nuances of DCD, will also play a key role in increasing participation and trust in the system. While challenges remain, the growing success of DCD heart transplantation offers a beacon of hope for patients in desperate need of a new heart, demonstrating the remarkable potential of medical innovation to transform lives. The journey of a heart from a donor who has passed to a recipient in need is a testament to the resilience of the human spirit and the enduring power of generosity, even in the face of death.

Read the Full Associated Press Article at:
[ https://apnews.com/article/heart-transplants-donation-dcd-11a296d03631aef6ff6d84099463a586 ]