cDCDD and Heart Procurement: Challenges from a French Critical Care Perspective.

Controlled donation after the circulatory determination of death (cDCDD) is currently one of the most promising ways to increase organ availability. In France, a national cDCDD protocol requiring abdominal normothermic regional perfusion (A-NRP) has been in place since 2015. The recent consideration of heart procurement from cDCDD donors has reignited clinical and ethical debates within the critical care community. This position paper, endorsed by the two French intensive care societies, provides a critical care perspective on this evolving practice. Two key challenges are identified. First, heart procurement may require the withdrawal of life-sustaining measures (WLSM) to occur in or near the operating room, in contrast with French current practice where WLSM mostly takes place in the ICU. Intensivists strongly advocate maintaining ICU-based WLSM whenever possible, and ensuring continuity of care and end-of-life support when relocation is unavoidable. Second, the use of NRP raises concerns about the permanence of death and compliance with the dead donor rule. These concerns can be addressed through targeted biomedical research and a robust ethical framework affirming that death is declared prior to NRP and that no return to life is possible thereafter. Transparent engagement with these challenges is essential to sustain trust in the cDCDD pathway.