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  • Review Article
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Heart transplantation: advances in expanding the donor pool and xenotransplantation

Nature Reviews Cardiology volume 21, pages 25–36 (2024)Cite this article

Subjects

Abstract

Approximately 65 million adults globally have heart failure, and the prevalence is expected to increase substantially with ageing populations. Despite advances in pharmacological and device therapy of heart failure, long-term morbidity and mortality remain high. Many patients progress to advanced heart failure and develop persistently severe symptoms. Heart transplantation remains the gold-standard therapy to improve the quality of life, functional status and survival of these patients. However, there is a large imbalance between the supply of organs and the demand for heart transplants. Therefore, expanding the donor pool is essential to reduce mortality while on the waiting list and improve clinical outcomes in this patient population. A shift has occurred to consider the use of organs from donors with hepatitis C virus, HIV or SARS-CoV-2 infection. Other advances in this field have also expanded the donor pool, including opt-out donation policies, organ donation after circulatory death and xenotransplantation. We provide a comprehensive overview of these various novel strategies, provide objective data on their safety and efficacy, and discuss some of the unresolved issues and controversies of each approach.

Key points

  • Heart transplantation is a crucial therapy for patients with advanced heart failure, but the availability of organs is limited, necessitating strategies to expand the pool of organ donors.

  • Interest is growing in heart transplantation from donors with hepatitis C virus (HCV) viraemia to recipients negative for HCV, with the initial experience of these transplantations producing excellent outcomes, and from donors positive for HIV to recipients positive for HIV.

  • Multiple case series of heart transplantation from donors with positive nucleic acid testing for SARS-CoV-2 infection have reported no significant difference in outcomes compared with heart transplantation from donors without SARS-CoV-2, although a trend towards increased early mortality in recipients from donors with active SARS-CoV-2 infection was reported in one study.

  • An opt-out organ donation policy, in which individuals are presumed to be willing deceased organ donors unless they opt out, is a governmental strategy adopted by various countries to increase the donor pool.

  • Donation after circulatory (rather than brain) death, with either direct procurement and perfusion or normothermic regional perfusion, could initiate the largest expansion in heart transplantation in recent years.

  • Heart xenotransplantation is still largely in the investigational phase but the experience of heart transplantation from gene-edited pigs into humans is promising.

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Fig. 1: SARS-CoV-2-positive organ donation protocol.
Fig. 2: National consent policies for organ donation.
Fig. 3: Protocol for heart donation after circulatory death.
Fig. 4: The 10-GE pig.

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Authors and Affiliations

  1. The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, New York, NY, USA

    Stephanie Jou, Sean R. Mendez, Jason Feinman, Lindsey R. Mitrani, Valentin Fuster & Claudia Gidea

  2. Transplant Institute, New York University Langone Health, New York, NY, USA

    Massimo Mangiola

  3. Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA

    Nader Moazami

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S.J., S.M., J.F. and L.M. researched data for the article. All the authors contributed to the discussion of content. S.J., S.M., J.F., L.M. and M.M. wrote the manuscript. All the authors reviewed/edited the manuscript before submission.

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Jou, S., Mendez, S.R., Feinman, J. et al. Heart transplantation: advances in expanding the donor pool and xenotransplantation. Nat Rev Cardiol 21, 25–36 (2024). https://doi.org/10.1038/s41569-023-00902-1

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