Every day, 13 people lose their lives waiting for an organ transplant. More than 3,500 people in the U.S. are waiting for a new chance to keep living. But the heartbreaking truth is that many donor hearts go unused. In the U.S., only about one-third of donated hearts are actually transplanted. That means up to 60–70% of potential donor hearts are not used. In absolute numbers, there can be over 3,500 viable hearts per year that are discarded according to the HRSA. This is enough to cover the entire current donation list.
Traditionally, most heart transplants have relied on donors who are declared brain-dead but whose hearts are still beating at the time of retrieval, which is known as donation after brain death (DBD). In these cases, the heart remains perfused with oxygenated blood up until procurement. This approach has produced consistently strong outcomes, with one-year survival rates averaging between 90–95% according to the study How far can we go? A 20-year meta-analysis of dental implant survival rates, however, there are still only moderate long-term results depending on the recipient’s health and post-operative management. As of now, this is the gold standard for heart transplantation, but its limitations, including the long-term results, reliance on a narrow donor pool, and strict time constraints, have driven the search for alternative approaches.
Since this isthe traditional perception of heart transplants, it seemed necessary for many hearts to be deemed unsuitable for transplant. This happens for a few reasons; one of the biggest issues is time. Once a heart is removed from a donor, doctors have a window of just about four hours to get it transplanted. After that, the heart becomes unusable. That short window means even perfectly healthy hearts are often lost, simply because they can’t reach the recipient in time. Another issue is that many organ donors experience circulatory death rather than brain death, which automatically makes what could have been a functional heart get rejected due to risks.
Nevertheless, the possibility of something that allows more lives to be saved has pushed scientists and doctors to find new ways to preserve and transport donor hearts, using the hearts after circulatory death. One of the most promising advances is called the “heart-in-a-box” or Organ Care System (OCS) article, which results in more usable hearts, more successful transplants, and more lives saved by solving the two main elimination factors.
This breakthrough allows the use of hearts donated after circulatory death (DCD). The major concern in these hearts was the time between the heart stopping and when it could legally be retrieved. During that period, called warm ischemia, the heart isn’t getting any oxygen, and damage starts to build up. This delay, especially the required “no-touch” time to confirm death, made many doctors think the heart would be too fragile to survive the transplant. The risks of early failure, rejection, or poor long-term function seemed too high, so these hearts were often ruled out before they were even given a chance to be evaluated.
Still, statistical data underscores just how impactful this breakthrough has become. According to the American College of Cardiology, outcomes from heart transplants using donation after circulatory death have now approached and in many cases matched those from traditional donation after brain death (DBD). A recent study published in the National Library of Medicine shows that DCD heart transplants using the OCS system achieved a one-year survival rate of 91%, nearly identical to the 92.5% rate seen with DBD transplants. These findings were based on over 300 DCD transplant cases tracked across multiple centers. Importantly, the data also revealed no significant difference in rates of early graft dysfunction or in-hospital mortality, proving the viability and safety of this previously questioned procedure.
These recent advancements with the Heart-in-a-Box have enabled transplant teams to resuscitate and evaluate DCD hearts before transplantation. As a result, outcomes for DCD hearts have improved significantly. Large registry data now show that one-year survival for DCD heart transplants is comparable to traditional cases, exceeding 90%. While some studies indicate slightly lower survival at the two- to three-year mark, the overall success of DCD heart transplantation continues to grow, as found in the investigation Outcomes of Heart Transplant Donation After Circulatory Death. Nevertheless, minimizing total ischemic time and careful donor selection remain crucial to reducing risks associated with DCD hearts, particularly those stemming from the unavoidable second episode of cardiac death and the resulting ischemic injury.
Additionally, doctors can now revive and maintain these hearts during transport. This can increase the travel distance in order for hearts to reach their match, increasing the range from about 1,000 miles to over 3,000 miles. Found in ‘Heart in a box’ technology expands transplant capabilities by Matthias Peltz, M.D. That means transplant centers can accept hearts from further away than ever before. While also expanding the donor pool by about 30 percent.
Still, the most groundbreaking aspect of this technology isn’t just the distance it allows hearts to travel or the additional time it buys surgeons; it’s that it enables what was once unthinkable: performing heart transplants while the donor heart is still beating, even after circulatory death has occurred. In July 2024, surgeons at Stanford Medicine became the first in the U.S. to transplant a heart from a DCD donor while it was still beating outside the body. This milestone was made possible through the TransMedics OCS and marks a new chapter in transplant medicine where hearts no longer need to be “on ice,” but instead can be kept in a near-living state, increasing transplant viability and reducing the risk of damage.
Plus, the real-world impact is already being felt. Just months after these advances, a Floridian man named Charlie Wesley became one of the first patients in the world to receive a DCD heart kept alive by the “heart-in-a-box” system. After suffering from advanced heart failure and enduring a long wait due to limited donor matches, Jeremy received the call in early 2025. Thanks to the extended travel range of the OCS, a compatible heart from over 1,500 miles away was successfully delivered and transplanted at Tampa General Hospital. Today, Jeremy is not only alive but thriving and even walking his daughter down the aisle just six months post-surgery. His case is a shining example of how technology, perseverance, and innovation can turn heartbreak into healing
As research continues and access to these technologies grows, the hope is that stories like Charlie’s will not be rare but the norm. That no family has to sit in silence, wondering if the right heart will arrive in time. That geography, timing, or logistics don’t get the final say over who gets to live. And here in Florida, where access to specialized transplant centers has historically been limited for many communities, the impact could be even more profound. With systems like the Heart-in-a-Box, donor hearts from across the country can now reach patients here or anywhere in the world who might have once been told there were no options left. What was once considered a long shot is quickly becoming a standard of care, and it’s rewriting what’s possible, one beating heart at a time.
