The transformation of adult heart transplantation in the United States and Western Europe

In nearly 60 years, heart transplantation has transformed from a daring vision to an established surgical procedure. Since the first adult heart transplant in the United States was performed at Stanford Hospital in 1968, the field has made significant strides. However, challenges remain, including a shortage of donor organs and socioeconomic disparities.

A recent review, led by researchers from the Stanford Department of Cardiothoracic Surgery in collaboration with Germany's Helios Hospital, examines the current state, challenges, and future directions of adult heart transplantation in its two highest-volume regions – the United States and Western Europe. While both areas have achieved remarkable success, they have embraced varying approaches in their transplantation systems, shaped by the cultural and political attitudes of the region.

"As a leader in the field, Stanford has a decades-long history of pioneering and advancing heart transplantation," said Carol Chen, MD, first author on the paper and Surgical Director of Adult Heart Transplantation at Stanford Health Care. "Our aim with the review was to provide clinicians around the world with insights into how other transplant systems operate and to encourage opportunities to learn from one another."

Structures and Policies in Transplant Organizations

Drawing on extensive literature review and studies over the past decades, Dr. Chen described how transplant management systems have evolved differently in the United States compared to many European nations. In particular, opt-in versus opt-out (presumed consent) donation frameworks stood out.

"Despite being an opt-in organ donation system, the United States has one of the highest donation rates around the world," said Dr. Chen. In the United States, both organ donation and transplant rates have steadily increased since 2015. Over the last decade, the overall heart transplant rate has increased more than 80%, driven by national allocation policy changes and more aggressive organ recovery practices. She noted that, in contrast, European nations have demonstrated minimal growth in transplant volumes during this same time frame.

In Europe, organ donation policies and practices vary significantly, and many countries have adopted an organ donation opt-out system. International organizations like Eurotransplant and Scandiatransplant play crucial roles in optimizing organ sharing across borders and increasing donor organ availability. Despite these frameworks, many European countries continue to struggle with low donation rates due to limited resources, public awareness, and ethical concerns surrounding opt-out systems.

"Compared to the single centralized organ allocation system employed in the United States, the burden of navigating the multiple layers of regional, national, and international donation and allocation policies may play a role in the lower number of transplants performed in Europe versus the United States," said Dr. Chen.

Addressing the Donor Pool Shortage Through Innovation

With thousands of patients waiting for a heart transplant around the world, the demand for organs far exceeds the available supply. The authors highlight how each region has taken varied approaches to this issue, including the use of mechanical circulatory support systems, marginal donors, and hearts from donation after circulatory death (DCD) patients.

Recently, researchers have also explored using bioengineered hearts, mechanical devices, and xenotransplantation to address the donor organ shortage. All have had varying levels of success, but none have yet been able to replace a donated heart.

Technology is also transforming organ transport, helping to overcome the logistical challenges of time and distance. “By utilizing new technology, we can safely bridge greater distances between donor and recipient. This capability expands the donor pool and gives more of our patients at Stanford a chance at a new life," said William Hiesinger, MD, Associate Professor of Cardiothoracic Surgery and Section Chief of Heart & Lung Transplantation and Mechanical Circulatory Support at Stanford.

In 2022, Stanford cardiothoracic surgeons developed and applied a method to transplant a beating heart, supported by an organ perfusion system machine, into the recipient. Many transplant programs around the country have now adopted this technique. The use of these organ preservation systems has the potential to allow worldwide sharing of organs, increasing the possibility of finding a match for recipients.

"Overcoming challenges such as donor shortages, geographic barriers, and regulatory inconsistencies will require a collective effort to ensure equitable access to life-saving therapies for all patients now and in the future," said Dr. Chen.

The paper, “Adult Heart Transplantation in the USA and Western Europe: State of the Art Review,” was published in the European Heart Journal in November 2025. 

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