Early Outcomes of Primary Graft Dysfunction Comparing Donation After Circulatory and Brain Death Heart Transplantation: An Analysis of the UNOS Registry

Abstract

Background: Primary graft dysfunction (PGD) represents a leading cause of mortality in patients undergoing donation after brain death (DBD) orthotopic heart transplantation (OHT), requiring timely escalation to mechanical circulatory support. There is a lack of nationwide data regarding PGD after donation after circulatory death (DCD). Here, we evaluated the incidence and short-term outcomes of PGD following DCD.

Methods: Using the UNOS registry between 9/2023 and 9/2024, we identified all adult (≥18 years) recipients of OHT. The incidence and outcomes of moderate-severe PGD (24- and 72-h post-transplant) were compared between DCD and DBD. Predictors for mortality after PGD were analyzed using Cox proportional hazard models. 30-day survival was analyzed using the Kaplan-Meier method.

Results: A total of 5017 patients underwent first-time OHT, among whom 762 (15.2%) received DCD hearts. DCD had a significantly higher incidence of PGD at 24- (7.9% vs. 4.8%; p = 0.001) and 72-h (5.9% vs. 3.3%; p = 0.001) compared to DBD. 30-day (p = 0.3068) survival was not different between DCD and DBD patients with PGD. Similarly, for recipients with PGD at 72 h, 30-day (p = 0.327) survival was comparable. At 72 h, DCD recipients were more likely to be supported on ECMO (p = 0.016). Transplanting DCD organs did not impact PGD-associated mortality at 24- (HR 0.72, p = 0.442) and 72-h (HR 0.74, p = 0.457). Postoperative ECMO was associated with decreased risk of PGD-associated mortality in DCD recipients at 24- (p < 0.0001) and 72-h (p < 0.0001).

Conclusions: While PGD rates appear higher in DCD, the associated mortality remains comparable to that of DBD. Early support on ECMO may confer survival benefits in DCD recipients with PGD.

Keywords: donation after brain death; donation after circulatory death; heart transplant; primary graft dysfunction.

FIGURE 1

Flow chart for patient inclusion and exclusion using the United Network for Organ Donation registry.

FIGURE 2

Kaplan‐Meier survival analysis up to 30‐days (A) and 1‐year (B) post‐transplant between all DCD and DBD HT recipients. Shaded regions represent 95% confidence intervals.

FIGURE 3

Kaplan‐Meier survival analysis up to 30‐days post‐transplant between DCD and DBD HT recipients with primary graft dysfunction at 24 h (A) and 72 h (B). Shaded regions represent 95% confidence intervals.

FIGURE 4

Kaplan‐Meier survival analysis up to 1‐year post‐transplant between DCD and DBD HT recipients with primary graft dysfunction at 24 h (A) and 72 h (B). Shaded regions represent 95% confidence intervals.