United Network of Organ Sharing Analysis: Heart Transplant Practice Changes with Recent Evolutions in Donation After Circulatory Death and Donor Heart Management: Comparison of 2 Study Periods Before and After Donation After Circulatory Death.

BACKGROUND: Recently, several major evolutions emerged in heart transplantation (HTx), such as donation after circulatory death (DCD) HTx and advances in donor heart management, which are rapidly reshaping our clinical practice. The aim of the study is to analyze practice changes across the 2-quarter decade period under the current allocation system. METHODS: The United Network of Organ Sharing database was analyzed to see practice changes between 2 periods: period 1 (October 2018 to June 2021) versus period 2 (July 2021 to December 2023). DCD HTx, listing status, blood types, cumulative incidence of HTx, and 1-y survival were analyzed. All single-organ adult HTx were included. Multiorgan transplants/re-HTx were excluded. RESULTS: A total of 12 402 candidates were analyzed (6269 period 1 and 6133 period 2). DCD HTx has increased from 2.4% to 9.5%. Period 2 had a shorter median waitlist days than period 1 (24 versus 40 d, P < 0.001). The proportion of status 1 and 2 increased, whereas for status 3 and 4 decreased. Status 2 with intra-aortic balloon pump decreased, whereas endovascular mechanical circulatory support increased. Both blood type O and non-O had a higher cumulative incidence of HTx in period 2 than period 1. Candidates in period 2 were 12.1% more likely to get HTx over time compared with the period 1 (subdistribution hazard ratio, 1.121; 95% confidence interval, 1.068-1.176; P < 0.001) and 14% less likely to be delisted than period 1 (subdistribution hazard ratio, 0.860; 95% confidence interval, 0.768-0.963; P = 0.009). CONCLUSIONS: Newer practice after the allocation system change is successfully transitioned, marked by increased DCD HTx. This increase in HTx incidence extends critical access gains even to blood type O candidates. Future allocation of equity requires continuous monitoring and reevaluation of evolving policies. CLINICAL PERSPECTIVE: This research highlights the recent successful transition (2018-2021 versus 2021-2023) in HTx practice, with recent evolutions such as donation after circulatory death or improved donor heart management. This has created a positive impact, with increased heart transplant cases and shorter waitlist times among candidates and also among blood type O candidates.