When a young patient under the care of WashU Medicine physicians Amit Pawale, MD, and Joel Schilling, MD, PhD, was admitted to the intensive care unit at Barnes-Jewish Hospital with heart failure, time was of the essence.
The patient, who previously was an elite athlete, was experiencing a rapid decline in health. Pawale, a WashU Medicine cardiac surgeon, and Schilling, a WashU Medicine cardiologist, knew that the patient’s heart was likely to fail and placed them on full cardiopulmonary support. Although a mechanical device was keeping the patient alive, the risk of complications, including death, was increasing with each day. The patient needed a heart transplant — and soon.
Today, three months post-transplant, this patient has returned to riding their bike 50 miles a day, a testament to the remarkable success of the surgery. Pawale and Schilling, who are both transplant specialists at Barnes-Jewish Hospital in St. Louis, Missouri, credit this outcome to the availability of a heart donated after circulatory death (DCD), an approach the heart transplant program implemented in 2023. DCD transplantation uses organs from donors who have no hope of recovery but do not meet the criteria for brain death — and whose healthy organs would go unused while critically ill recipients remain on the wait list.
Unlike donations after brain death (DBD), donation after circulatory death occurs when a patient has suffered catastrophic brain injury and is on ventilator support yet the patient does not meet formal criteria for brain death, defined as persistent coma, absence of brainstem reflexes and lack of ability to breathe independently.
For DCD transplants, the first step is that the patient’s care team and family decide that continuing care is futile, and the patient is a registered organ donor or their family or power of attorney expresses the patient’s desire to donate organs. Upon decision by the patient’s family or power of attorney to withdraw care, the patient is removed from the ventilator and kept comfortable. Once death is formally declared, a mandatory standoff period of two to five minutes is observed, and then the process of procuring the heart and other organs by the transplant team can begin.
The DCD program at Barnes-Jewish Hospital and WashU Medicine was initiated in response to the increasing waiting periods for heart transplants, despite the 2018 changes in organ allocation aimed at reducing wait list mortality. Although waiting periods with the new allocation system had decreased significantly, they were beginning to climb again, heightening the risk of patients experiencing complications and dying before receiving a transplant.
“With an increasing number of patients in need of urgent heart transplants nationally, we felt it was imperative to implement a DCD heart transplant program to reduce the risk of wait list mortality and complications for our patients,” Schilling says.
Since December 2023, the transplant team at Barnes-Jewish Hospital and WashU Medicine has performed 16 DCD heart transplants — viable, life-saving organs that would have been transplanted elsewhere or discarded if an appropriate candidate or center could not be found.
The DCD process not only makes available a new pool of organ donors, reducing wait times, but also offers outcomes comparable to those of DBD transplants. Further, Schilling explains that the patients who have received a DCD heart transplant at Barnes-Jewish Hospital, on average, require fewer medications to support blood pressure post-surgery than those who received a DBD heart transplant, which suggests that hearts might even perform better after DCD than DBD. Schilling points to some evidence that hormones released in the donor after brain death could negatively impact heart health, whereas in DCD, these hormones are not released, potentially resulting in a healthier organ.
“What we can say for sure is that a DCD heart, despite being stopped and restarted, is at least as good as, if not superior to, a DBD heart,” Schilling says. “All the data we have right now indicates that it is absolutely as good.”
The Washington University and Barnes-Jewish Transplant Center team is also seeing these positive outcomes in other organs. After a donor’s declaration of death and the mandated standoff period, WashU Medicine transplant specialists at Barnes-Jewish Hospital use a method called normothermic regional perfusion (NRP) to recirculate blood to help reperfuse and recondition the organs (blood vessels are clamped so that the blood does not reach the brain). In DBD transplants, organs are procured and sometimes resuscitated outside the body, in a device, through a process called ex vivo perfusion. Data on NRP shows that this in situ recirculation can improve outcomes for other abdominal organs that benefit from circulatory support, including the kidneys and liver.
“From a societal perspective in transplant,” Schilling says, “NRP is a better approach to resuscitate multiple organs to save the lives of multiple patients.”
If you would like to refer a patient for a heart transplant evaluation by WashU Medicine specialists at Barnes-Jewish Hospital, the hospital offers both DBD and DCD transplant options, which may increase your patient’s odds of receiving an organ quickly. In addition, we offer patients:
An experienced team: We have performed more than 1,000 heart transplants since 1985, with several transplants performed every month, on average. That volume means we have great expertise in providing treatment and follow-up care. Meet the heart transplant team.
Personalized care: We have developed a system of care from evaluation through follow-up that is tailored to meet individual health needs. We are here to provide comprehensive care for the rest of a patient’s life. Read more about the heart transplant process.
Research and innovation: Our affiliation with WashU Medicine means that our patients have access to the most innovative transplant procedures and care performed by leaders in the field, and the latest heart transplant research and clinical trials. This helps us offer leading-edge treatment options such as artificial heart devices.
Multi-organ transplantation: WashU Medicine transplant specialists are able to treat patients who need multi-organ transplantation such as heart-lung, heart-liver and heart-kidney. Learn more about the transplants we offer at the WashU Medicine and Barnes-Jewish Hospital Transplant Center.
Learn more about how to refer your patient to our transplant center.
