Stable Outcomes of Donation After Circulatory Death Heart Transplantation From Early Adoption to National Expansion.

BACKGROUND: Donation after circulatory death (DCD) heart transplantation has expanded rapidly in the United States, but whether outcomes have evolved during national dissemination remains uncertain. Given the increasing complexity of candidates with advanced heart failure, understanding the stability of outcomes during expansion is clinically important. We evaluated temporal changes by comparing early adoption with later expansion. METHODS: Adult DCD heart transplant recipients in the United Network for Organ Sharing registry (January 2019 to June 2024) were stratified into an early era (2019-2021) and a late era (2022-2024). The primary endpoint was 1-year graft failure. Secondary endpoints included 1-year all-cause mortality, renal-replacement therapy before discharge, and length of stay. A secondary exploratory analysis assessed overall survival up to 2 years. Inverse probability of treatment weighting was applied to adjust for baseline differences. Prespecified subgroup analyses were performed in high-risk recipients, including those with impaired functional status, pulmonary hypertension, and preoperative mechanical circulatory support. RESULTS: Among 1489 recipients (303 early, 1186 late), DCD use increased substantially over time and expanded across a greater number of transplant centers. Unadjusted and inverse probability of treatment weighting-adjusted analyses showed no significant differences between eras in length of stay, renal-replacement therapy, 1-year mortality, retransplantation, or graft failure. Exploratory analyses of overall survival up to 2 years showed no significant difference between groups. Outcomes were consistent across high-risk subgroups. CONCLUSIONS: Early outcomes after DCD heart transplantation remained stable during rapid national expansion despite broader recipient risk profiles, supporting the scalability of this strategy without evidence of outcome deterioration.