DCD step by Step for Heart and lung donation
1. Donor Identification
•Identify a potential DCD donor (Maastricht category III or II in some systems).
•Patient has devastating neurologic or systemic injury but does not meet brain death criteria.
•Decision for withdrawal of life-sustaining therapy (WLST) is made independently of the transplant team.
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2. Consent and Donor Evaluation
•Obtain legal consent for organ donation from the family or donor registry.
•Notify the Organ Procurement Organization (OPO).
•Perform medical evaluation of the donor, including:
•Blood tests and infectious screening
•Blood type and HLA typing
•Chest imaging and bronchoscopy (for lung assessment)
•Echocardiography if possible (for heart evaluation)
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3. Operative Planning and Logistics
•Coordinate recipient centers and surgical teams.
•Prepare operating room and perfusion devices such as:
•Normothermic Regional Perfusion (NRP) system
•Ex-situ perfusion systems (e.g., heart OCS, lung perfusion devices if used)
•Ensure availability of preservation solutions and rapid procurement equipment.
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4. Transfer to Withdrawal Location
•The donor is transferred to the operating room or designated withdrawal area.
•Maintain monitoring:
•Arterial line
•ECG
•Oxygen saturation
•The procurement team remains outside until death is declared.
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5. Withdrawal of Life-Sustaining Therapy (WLST)
•ICU team withdraws:
•Mechanical ventilation
•Vasopressors/inotropes
•Other life-support measures
•Provide comfort care and palliative medications as needed.
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6. Circulatory Arrest
•Monitor for cessation of circulation defined by:
•Absence of arterial pulse
•Flat arterial line
•No cardiac activity
•No respirations
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7. No-Touch Observation Period
•After circulatory arrest, observe a mandatory stand-off period (usually 5 minutes).
•This confirms irreversibility of cardiac function and prevents autoresuscitation.
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8. Declaration of Death
•An independent physician (not involved in transplantation) formally declares death.
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9. Rapid Surgical Access
•Immediately after declaration:
•Patient is transferred to the sterile field if not already.
•Median sternotomy is performed rapidly to minimize warm ischemic time.
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10. Heart Recovery Strategy
Two main approaches:
A. Normothermic Regional Perfusion (NRP)
•Cannulate aorta and right atrium.
•Start ECMO-based perfusion.
•Clamp arch vessels to prevent cerebral reperfusion.
•Restore cardiac circulation and assess myocardial function using:
•Hemodynamics
•Echocardiography
•Lactate trends.
B. Direct Procurement with Ex-situ Perfusion
•Administer cold cardioplegia.
•Remove the heart rapidly.
•Connect the heart to ex-situ perfusion system (e.g., OCS) for assessment and preservation.
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11. Lung Procurement
•Re-intubate and resume protective ventilation.
•Perform:
•Pulmonary artery cannulation
•Left atrial venting
•Flush lungs with cold preservation solution (e.g., Perfadex).
•Topical cooling with ice slush.
•Inspect lungs and perform recruitment maneuvers.
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12. Organ Assessment
Evaluate organ viability:
Heart
•Contractility
•Lactate clearance
•Rhythm stability
Lungs
•Oxygenation (PaO₂/FiO₂)
•Bronchoscopy findings
•Compliance and edema assessment
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13. Organ Packaging and Transport
•Organs are preserved by:
•Cold static storage or
•Normothermic perfusion systems.
•Pack in sterile preservation containers with cold solution and ice.
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14. Transport to Recipient Center
•Transport rapidly to recipient hospitals.
•Implantation teams prepare recipients simultaneously to minimize ischemic time.
Dr.Sam Zeraatian Nejad Davani, Cardiovascular and Transplant surgeon. Advanced Fellow of Thoracic Organs Transplantation Chicago Illinois.