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Despite advances in mechanical support, heart transplantation still remains the gold standard treatment for end-stage drugresistant heart failure. It provides both excellent long-term survival and a near-normal quality of life. Unfortunately, as the number of patients eligible for heart transplantation continues to rise, the number of suitable donors after brain death (DBD) continues to fall. In the UK, this increasing disparity between demand and supply results in less than half of patients being transplanted while 43% of the waiting list are either permanently removed or die waiting for a heart transplant [1]. With the heart transplant waiting list increasing at a rapid rate (Fig. 1), attention has fallen on extended criteria donors. In Europe, it is now routine to consider those hearts from donors up to 65 years old, those with ventricular hypertrophy or those with a history of prolonged cardiac arrest. However, even after incorporating these marginal donors, there remains an increasing shortfall in meeting demand. In an attempt to push the boundaries still further, some enthusiasts, including Tolboom et al. in this edition, are looking towards the donation after circulatory determined death (DCD) donor to bridge the gap. DCD donors are patients who have sustained catastrophic brain injury but who will not proceed to brain stem death or where brain stem testing would be inappropriate. After consultation between the intensive care doctors and the family, a decision to withdraw therapy is made after it has been established that it would be futile to continue and not in the best interests of the patient.

Resuscitating heart transplantation: the donation after circulatory determined death donor