Unresolved Considerations for Donor Management in Heart Transplantation After Cardiac Death: A Narrative Review.

As interest in donation after circulatory death for heart transplantation (DCD-HT) grows, the need to standardize protocols and address ongoing controversies becomes increasingly apparent. However, efforts toward standardization are complicated by the fact that numerous organ procurement organizations, transplant centers, and academic societies have each posited their own protocols. While some degree of variability is inevitable and sometimes necessary, variability regarding end-of-life care, definitions for reported metrics, and standards for allograft assessment may lead to inefficiencies in scaled execution and worsen ethical controversies for donors at the end of life. This review analyzes key areas of variation in contemporary DCD-HT protocols, including donor selection, management during withdrawal of life-sustaining therapy, allograft ischemic parameters, and more, and examines ongoing controversies across preoperative, peri-withdrawal, and intraoperative phases. By synthesizing current practices and identifying critical gaps, we aim to support the development of more standardized, ethically robust, and clinically effective protocols for DCD-HT.