Duke research published in the Journal of the American College of Cardiology (JACC): Heart Failure in January 2024 has shown that the criteria for donor hearts available for donation after brain death (DBD) can be safely expanded. The EXPAND trial used ex vivo perfusion (EVP) to transport donor hearts and resulted in greater options for accepting donor hearts based on geographic and risk profile considerations.

“Thirty-day survival out to two-year mortality rates showed the patients did really well,” says Adam D. DeVore, MD, MHS, medical director of the Duke Heart Transplant Program. “This new technology allows us to travel farther and use donors we may not previously have been able to use for heart transplant because of high-risk criteria. It grows the donor pool and increases options for patients.”

The EXPAND trial focused on donor hearts that would have to travel longer than four hours cross-clamp time, or two hours cross-clamp time with one or more risk factors that might result in graft dysfunction if the organ were subjected to cold storage. These risk factors included donor aged 55 or older, certain anatomical or patient health history features, or left ventricular ejection fraction of 40%-50%.

DeVore notes that the expanded criteria particularly benefit recipients with limitations to their potential organ matches. “If you’ve got antibodies to seventy percent of the population’s proteins, that decreases your donor pool,” DeVore explains. “Now, we can look as far as Puerto Rico or Alaska to find a suitable donor heart, where before they might have waited a long time to find one, if ever.”

Subsequent Duke research in JACC: Heart Failure in May 2025 has also shown that, although EVP has increased 25-fold for DBD heart transplant from 2015 to 2023, only 2.2% of all DBD heart transplants utilize the technology. DeVore and other study authors note that high cost and limited transplant center resources may be significant factors that reduce the practice’s use. The study also showed that outcomes for patients who receive EVP hearts are similar to those transplanted under prior criteria.

Five transplant centers performed nearly a third of the EVP procedures, the study found. “Certain centers have adopted this heavily,” DeVore notes. “Duke is passionate about heart transplant, and we’re able to access a lot of technology in procurement, preservation, and other areas. The field is changing rapidly all the time, so it can be hard to keep up with understanding who’s a good candidate, what technology is available, what’s next. We’re always happy to consult with referring physicians.”