Utilization of Hearts Donated After Circulatory Death Improves All-Cause Survival in Candidates With Durable Left Ventricular Assist Devices

Heart transplantation practices have evolved significantly following the 2018 heart allocation policy changes and the introduction of donation after circulatory death (DCD) heart transplantation in 2019. Under the new system, candidates supported with durable left ventricular assist devices (DLVADs) experience longer waitlist times with worse outcomes. This study evaluates the impact of DCD heart utilization on waitlist outcomes among DLVAD candidates using the United Network for Organ Sharing (UNOS) registry. Adult candidates with DLVADs listed for isolated heart transplantation from December 1, 2019, to March 31, 2023, with a 2 year follow-up period extending to March 31, 2025. Candidates were stratified by approval status to accept DCD donor offers. The outcomes were 2 year cumulative incidences of transplantation, delisting due to death or clinical deterioration, and all-cause survival from the time of initial waitlisting. Among 2,993 candidates, 487 (16.3%) were approved to accept DCD donor offers. Approval for DCD donor offers was associated with a significantly lower risk of delisting, a higher likelihood of transplantation, and improved all-cause survival. Moreover, this survival improvement persisted in the multivariable Cox regression. These findings highlight the growing use and clinical value of DCD heart utilization in expanding access to transplantation and improving outcomes in DLVAD candidates awaiting transplantation.