Hearts Not Dead after Circulatory Death

In recent weeks, two pioneering cardiac surgery teams, Dhital and colleagues in Australia (1) and Large and colleagues in the UK (2), reported on what could rapidly become the best and sole affordable solution to the relentlessly growing number of patients awaiting heart transplantation, i.e., transplantation of grafts obtained from donors after death following circulatory arrest, previously termed “non-heart beating donors.” Both groups presented their slightly differing approaches to organ procurement and evaluation at the 2015 Annual Meeting of The International Society for Heart & Lung Transplantation, confirming several successful short-term outcomes for adult, orthotopic heart transplantation with donation after circulatory death (DCD). As would be expected, a handful of specialists from around the world enthusiastically recognize a realistic complement to “traditional” cardiac donation after brain death (DBD), whereas others may condemn this approach, considering the ethical, practical, and liability aspects as indomitable.Many remain uncertain, possibly because of the apparent paradox, or at least the uncertainty, surrounding transplantation of hearts obtained from donors after “cardiac death.” The Times recently titled “«dead» hearts successfully transplanted into living patients” (2, 3). When it comes to DCD hearts, it appears inappropriate to speak of donation after cardiac death, and potentially even misleading, given that hearts are able to withstand limited periods of warm ischemia without cardioprotection. Although in some countries determination of death based on cardiocirculatory criteria alone is permitted, in many, a prolonged waiting period (e.g., 10–20min) between circulatory arrest and organ procurement is required to ensure that permanent neurologic damage has occurred (4, 5). A better terminology (6) would therefore be “DCD.” One important aspect of these reports lies in the fact that this approach goes against the established dogma that irreversible lesions immediately follow the onset of myocardial ischemia. Indeed, the very first heart transplantations, including those performed by Barnard in 1967, were performed with DCD organs (7). However, with the establishment of brain death criteria in the 1970s, DCD hearts were considered “substandard” and therefore rapidly abandoned. More recently, with revival of interest in DCD donation for improving graft availability notably for kidney, liver, and lung, five categories of DCD patients have been established in the modified Maastricht classification system (8). Distinctions between the different categories are based on the specific circumstances surrounding donor death; for example, dead on arrival at the hospital versus anticipated circulatory arrest following withdrawal of treatment. Furthermore, types of DCD patients have also been classified as controlled or uncontrolled according to whether or not the precise course of circulatory death is known. In theory, all DCD patients are potential heart donors, provided that the inclusion criteria are met and ischemic time is limited; however, it is currently unclear whether certain DCD categories would produce better outcomes. It could be argued, for example, that Maastricht category III donors (anticipated circulatory arrest) would be best suited for cardiac graft donation as conditions are controlled and pre-circulatory arrest