Donation After Circulatory Determination of Death in Congenital Heart Disease: Should We Embrace?

The lack of donors that are age and size appropriate has compromised pediatric heart transplantation. There may be poor outcomes following mechanical circulatory support as a bridge to heart transplant in certain younger patient cohorts, which combined with the scarcity of donors, increases the morbidity and mortality in children waiting for a heart transplant. Transplantation of hearts donated after circulatory determination of death (DCDD) has been utilized to increase the pool of pediatric donor allografts. The original approach included direct procurement and perfusion in the recipient (DPP), and recently ex-situ normothermic machine perfusion (NMP). However, NMP is expensive, and this methodology does not allow for a functional assessment in a loaded state of the donor organ prior to transplantation. NMP is also not available to the smallest pediatric patients. An alternative method, normothermic regional perfusion (NRP), can overcome the limitations of NMP. NRP is a thoraco-abdominal dynamic in-situ organ assessment method and is instituted following declaration after determination of circulatory death. In-situ tissue perfusion is established to the transplantable organs using a bypass circuit based on strict, prespecified guidelines that do not violate the "dead donor rule." The first pediatric DCDD heart transplant using NRP was performed in 2019, and since then, several centers have reported immense success. Ethical concerns for cerebral reperfusion have not been substantiated by clinical data. Utilization of DCDD donors can vastly expand the donor pool in congenital heart disease (CHD).