Heart transplantation outcomes with donation after circulatory death in patients with left ventricular assist device

Abstract

Aims: Donation after circulatory death (DCD) has emerged as a strategy to increase the donor pool for heart transplantation (HT). Left ventricular assist device (LVAD) patients represent a discrete and unique population. We sought to explore the early outcomes of DCD-HT compared with donation after brain death (DBD) HT in LVAD patients.

Methods and results: We obtained data from the United Network of Organ Sharing database. The main cohort consisted of adults listed for HT between 17 October 2018 and 3 July 2024, with LVAD implanted before or after listing. The primary outcome was survival within the first year post-HT. There were 3336 patients with LVAD underwent HT during the study period (median age 55 years (interquartile range 45-62), 24% women, 29% Black, 89% DBD). The short-term post-HT mortality in LVAD patients who underwent DCD HT was not significantly different from DBD (adjusted hazard ratio [aHR] 1.00, 95% CI 0.70-1.42, P value > 0.9). The likelihood of transplantation within 1 year was higher at centres performing DCD (aHR 1.44, 95% CI 1.39-1.49, P < 0.001). Despite the longer donor-recipient distance in DCD-HT, in-hospital outcomes (stroke and acute kidney injury requiring dialysis) were not different from DBD-HT. A higher incidence of primary graft dysfunction (adjusted risk ratio [aRR] 3.8, 95% CI 2.5-5.7, P < 0.001), and treated rejection was observed with DCD-HT (aRR 1.48, 95% CI 1.14-1.93, P = 0.003).

Conclusions: In LVAD patients who received DCD HT, early post-transplant survival, stroke, acute kidney injury and length of stay were not significantly different from those who underwent DBD HT. There were increased rates of primary graft dysfunction and treated rejection among LVAD patients who underwent DCD HT. Patients in a DCD centre were significantly more likely to be transplanted earlier.

Keywords: Donation after brain death; Donation after circulatory death; Heart transplantation; Left ventricular assist device.

Figure 1

STROBE diagram illustrating the number of patients screened, those included in the time‐to‐transplant analysis, and those included in the post‐transplant analysis. It also details the number of individuals excluded and the reasons for their exclusion.

Figure 2

Heart transplants (HT) performed in patients with (dark blue and red) or without (light blue and red) an LVAD, using either the DCD (red shades) or DBD (blue shades) approach, throughout the study period.

Figure 3

(A) Likelihood of heart transplant within 1 year from listing at a DCD versus non‐DCD centre, accounting for time‐varying exposure of becoming a DCD centre. (B) Likelihood of heart transplant within 1 year from listing by DCD versus non‐DCD centre status and left ventricular assist device (LVAD) versus non‐LVAD patient status. The Cox regression models with time‐varying exposure are adjusted for recipient age at listing, sex at birth, self‐reported race/ethnicity, and to account for potential non‐proportional baseline hazards in specific subgroups, the model was stratified by blood type (O vs. non‐O) and medical urgency (high priority UNOS status 1–2 vs. lower priority statuses). aHR: adjusted hazard ratio, CI: confidence interval.

Figure 4

Kaplan–Meier shows 1‐year post‐HT survival in LVAD patients according to (A) donation after DBD (red) versus DCD (blue); and (B) to mode of donor heart procurement (DPP, direct procurement and perfusion, red versus NRP, normothermic regional perfusion, blue). The Cox regression models were adjusted for recipient age, gender, race/ethnicity, diabetes mellitus, cigarette use, ischaemic cardiomyopathy, estimated glomerular filtration rate, support with veno‐arterial extra‐corporeal membrane oxygenation, predicted heart mass, female donor‐male recipient mismatch and donor age.