Donor heart refusal following circulatory death: an analysis of United Network for Organ Sharing refusal codes

Objective Donor hearts procured following circulatory death (DCD) may significantly increase the number of hearts available for transplantation. The purpose of this study was to analyze current DCD and brain-dead donor (DBD) heart transplantation rates and characterize organ refusal using the most up to date United Network for Organ Sharing (UNOS) and Organ Procurement and Transplantation Network (OPTN) data. Methods We analyzed UNOS and OPTN DBD and DCD candidate, transplantation, and demographic data from 2020 through 2022 and 2022 refusal code data to characterize DCD heart utilization and refusal. Subanalyses were performed to characterize DCD donor demographics and regional transplantation rate variance. Results DCD hearts were declined 3.37 times more often than DBD hearts. The most frequently used code for DCD refusal was neurological function, related to concerns of a prolonged dying process and organ preservation. In 2022, 92% (1,329/1,452) of all DCD refusals were attributed to neurological function. When compared to DBD, DCD donor hearts were more frequently declined due to prolonged warm ischemic time (OR 5.65; 95% CI, 4.07-7.86) and other concerns over organ preservation (OR 4.06; 95% CI, 3.33-4.94). Transplantation rate variation was observed between demographic groups and UNOS regions. DCD transplantation rates are currently experiencing second order polynomial growth. Conclusion DCD donor hearts are declined more frequently than DBD. DCD heart refusals result from concerns over a prolonged dying process and organ preservation. Heart transplantation rates may be substantially improved by ex situ hemodynamic assessment, adoption of normothermic regional perfusion guidelines, and quality initiatives.