Contemporary Trends in Approval for Donation After Circulatory Death Heart Transplantation in the United States

Objective To characterize contemporary U.S. patterns of donation after circulatory death (DCD) candidate approval and center adoption, and to quantify the association between DCD approval and waitlist outcomes. Methods From the UNOS registry, 20,613 adult candidates listed for isolated heart transplantation in 2019-2024 were identified; 2023-2024 was defined as the contemporary era. Listing centers with ≥20 candidates in 2023-2024 (n=103) were classified as high (≥75%) or low (<25%) DCD approval. One-year cumulative incidence of transplantation and waitlist death or delisting was modeled by Fine-Gray sub distribution hazards regression. Results DCD approval at listing is associated with higher 1-year transplantation [adjusted sHR 1.29, 95% CI 1.13-1.47] and lower waitlist death/delisting [sHR 0.56, 0.42-0.76] at the candidate level. Contemporary center-level DCD approval (60.4% overall) is sharply bimodal: 21 centers (20%) approved none and 9 (9%) approved all. Center adoption gradually expanded: by 2024, mean center-level approval reached 79% among early adopters (first DCD approval 2019-2020, n=49), 60% among intermediate adopters (2021-2022, n=24), and 50% among late adopters (2023-2024, n=19). High-approval centers have higher 1-year transplantation [89% vs. 81%, adjusted sHR 1.43, 95% CI 1.17-1.74] and lower death/delisting [3% vs. 7%, sHR 0.54, 0.37-0.78] compared to low-approval centers; the gap persisted after accounting for pre-DCD-era program quality. Conclusions DCD approval was associated with improved contemporary era waitlist outcomes at both the candidate- and center-levels. Expanding access depends on program adoption more than candidate selection and translates into benefit that warrants institutional investment.