Donation After Circulatory Death Heart Transplant Without Preimplant Reanimation Using Rapid Ultraoxygenated Recovery

Importance: Rapid recovery with extended ultraoxygenated preservation (REUP) has shown promise in adult donation after circulatory death (DCD) heart transplant when used in younger donor populations (aged 16-30 years) and/or for hearts with shorter ischemic times (<4 hours). Objective: To assess the feasibility of the REUP technique in adult DCD heart transplant, without regard to donor age or anticipated ischemic time. Design, Setting, and Participants: Case series of 24 patients to undergo REUP-recovered DCD adult heart transplant at a single high-volume heart transplant center in the United States from November 2024 to July 2025. Exposure: REUP used for DCD cardiac allograft recovery without preimplant donor heart reanimation or machine perfusion. Main Outcomes and Measures: Severe primary graft dysfunction, 30-day survival, and acute rejection on first endomyocardial biopsy. Results: Twenty-four REUP-recovered DCD hearts were transplanted, with a mean donor age of 32 years and 9 donors (38%) older than 40 years. Fifty percent of recipients had prior sternotomy. The mean time from initial declaration of donor death to flush was 9 minutes. Fifteen donor hearts (60%) had a total ischemic time longer than 4 hours, including 1 that was 8 hours. Among recipients, 30-day survival was 96%. Only 1 patient (4%) had severe primary graft dysfunction, and 1 other patient (4%) had secondary graft dysfunction. On initial endomyocardial biopsy, 1 patient (4%) had acute cellular rejection grade 2R; no cases of antibody-mediated rejection were observed. Conclusions and Relevance: This study demonstrates the safety, feasibility, and efficacy of REUP for DCD heart recovery without donor heart reanimation in a broad population of donors and recipients and without regard to anticipated ischemic time. Given the high cost and complexity of current DCD heart recovery strategies, as well as ethical concerns surrounding normothermic regional perfusion, REUP may prove to be a promising procurement method. Further study is required to support continued expansion of this novel technique.