DCD heart donation in the Netherlands: a national success

More than 2 years ago, the first heart transplant from a DCD donor took place in the Netherlands. Transplant surgeons praise the close cooperation between the various centers and the efficient implementation of the new technique.

Olivier Manintveld is a cardiologist at Erasmus MC. Together with colleagues from UMC Utrecht and UMC Groningen, he formed the project group that introduced the DCD method in the Netherlands.

Manintveld: 'We had been monitoring developments regarding DCD donation for years. There has been a shortage of donor hearts for years. As a result, 1 in 7 people on the heart waiting list dies. Because the numbers of classic brain-dead heart donors kept declining, we had to take action.'

Differences between DBD and DCD

Manintveld: 'In a DCD procedure (Donation after Circulatory Death), circulatory arrest occurs. After a 'no touch' period of five minutes, death is determined. The heart is removed and placed in a machine. In the machine, the heart starts beating again after the supply of oxygen and blood. In this way, the heart can be preserved for a maximum of eight hours before it is transplanted.

With classic DBD donors (Donation after Brain Death), the person has been declared brain dead. The heart is stopped in a controlled manner, after which it is packed in ice and can be preserved for a maximum of four hours. Because the heart in DBD donation on ice no longer receives oxygen or nutrients, damage to the heart cells occurs more quickly. With DCD donation, the surgeon has more peace of mind and time to perform the operation because the heart is protected on the perfusion machine.'

Perfusion machine training

Initially, the transplant surgeons who were going to use the new method were supposed to follow training in Boston from the manufacturer of the perfusion machine. However, the coronavirus pandemic threw a spanner in the works. 'Fortunately, we were still able to follow the training at Erasmus MC,' says Dr. Niels van der Kaaij, cardiothoracic surgeon at UMC Utrecht and one of the three transplant surgeons who started the project.

National protocol

Niels van der Kaaij: 'Together with the NTS and Eurotransplant, we drew up a national protocol. Everyone on the waiting list for a donor heart was asked if they would also be willing to receive a heart according to the new method. We then worked across centers. We put the general interest of the patient first: the procedures were performed in the order of the national waiting list.'

Rapid introduction through good cooperation

Efficient cooperation ensured that the introduction of the new method went as smoothly as possible. Van der Kaaij: 'You want to prevent every center from having to go through the same learning curve. In order not to make the same mistakes multiple times, we gained experience together as much as possible. When a team from one center performed a retrieval according to the DCD heart donation procedure, a team from another center went along to observe and learn. In addition, the centers discussed data and case studies with each other in an open and constructive manner. That was a special collaboration, in which the coordinating role of the NTS was also very important.'

Great potential for DCD donors

After attending a symposium in the United Kingdom, where they had already started with DCD heart donation procedures, the project group decided to take stock of whether the method could be introduced in the Netherlands. 'There turned out to be great potential for DCD donors in the Netherlands,' says Manintveld.

VWS subsidy

'In 2018, a national symposium took place in which, in addition to transplant surgeons, intensivists, the Dutch Transplant Foundation (NTS), and the Ministry of Health, Welfare and Sport (VWS) also participated. Intensive consultation followed regarding, among other things, the precise surgical method, financing, and protocols. VWS pledged a subsidy in 2020, and with that, DCD heart donation could start.'

Good results

Soon after the introduction of the new DCD heart donation procedure, the Dutch results proved to be encouraging. 'In the Netherlands, fifty percent of heart donors are currently DCD donors,' says Dr. Michiel Erasmus, cardiothoracic surgeon at UMC Groningen and the third transplant physician from the project group. 'The outcomes after DCD donation are at least as good as with the DBD method. Moreover, it results in more transplants.' In the past two years, a total of 57 additional heart transplants have been performed thanks to the new method (figures as of July 2023 - view current figures).

Effect on the waiting list

Erasmus: 'Up to and including June, for example, we have already performed 30 heart transplants in the Netherlands this year, while the norm for years was 40 per year. If we can perform close to 60 heart transplants this year, we will have well exceeded that number in 2023. Hopefully, we will then also see a decrease in the number of people on the waiting list and in the number of people who die before a suitable donor heart becomes available. We are already seeing a stabilization in the number of people on the waiting list, whereas it had only been growing in recent years.'

Looking to the future

Although the results of the DCD heart donation procedure are already very good, the transplant physicians state that there is still room for improvement. 'I am thinking, among other things, of the logistical procedure,' says Erasmus. 'Placing a heart from a DCD donor on the perfusion machine currently costs quite a lot of money and involves a lot of staff. Perhaps other perfusion machines will come onto the market in the future, which could make it even more efficient.'

In this context, Manintveld points to donor identification: 'We are already quite proactive with donation in the Netherlands, but it can always be better. The DCD heart donation procedure could be explained even better within the organ donation chain, allowing us to identify even more potential donors. We could also adjust the criteria that donor hearts must meet, for example by raising the age limit for potential DCD donors. This could make even more hearts available for a DCD transplant.'

More choices for patients

Finally, Van der Kaaij states that thanks to the new method, more choices can be made in the future. 'Some patients might be better off receiving a heart pump first, while other patients should receive a donor heart immediately. Because the number of donor hearts was so low in the past, we hardly had these options before. Thanks to DCD heart donors, we hope to be able to provide more and more customized care in the future.'