Expanding Use of Donation After Circulatory Death Heart Transplant in Higher Acuity Recipients

q. chen¹, A. Razavi², D. Y. Tam², A. Sallam², D. Megna², J. Chikwe³, M. E. Bowdish⁴, D. Emerson⁵, P. Catarino^2
1Cedars Sinai Medical Center, Los Angeles, California ²Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California ³Cedars-Sinai, Los Angeles, California ⁴Cedars Sinai Medical Center, La Canada, California ⁵Cedars Sinai, Los Angeles, California

Purpose: Donation after circulatory death (DCD) hearts were previously preferentially allocated to lower acuity recipients in the U.S., reflecting a reluctance to use them for higher-risk patients. We examined trends in DCD recipient characteristics and compared outcomes of DCD to donation after brain death (DBD) transplants, stratified by pre-transplant urgency status

Methods: The United Network for Organ Sharing database was used to identify 12,353 adult heart transplants (DBD 11,237, DCD 1,116) with validated records between 12/1/2019 and 12/31/2023, after excluding multiorgan or redo transplants. Temporal trends in DCD recipient characteristics were analyzed with the Cochran-Armitage Trend Test or Cochran-Mantel-Haenszel test, and data from December 2019 were combined with those from 2020. The primary endpoint was 1-year post-transplant survival, compared between DCD and DBD cohorts using the Kaplan-Meier method and stratified by pre-transplant medical urgency status. Adjusted comparison of survival was performed using a multivariate Cox regression model accounting for 19 baseline recipient and donor characteristics and clustering at a center level. The median follow-up was 13.0 (interquartile range 6.5-25.8) months.

Results: During the study period, the proportion of DCD heart recipients with status 1 & 2 increased from 17.6% (19/108) in 2020 to 52.6% (275/523) in 2023, while the proportion of DCD recipients with status 3, 4, and 6 decreased (p < 0.001, Figure-A). Before transplant, an increasing proportion of DCD heart recipients were hospitalized in the intensive care unit (18.5% [20/108] in 2020, 46.9% [245/523] in 2023, p< 0.001), with more frequent use of extracorporeal membrane oxygenation (0% in 2020, 2.3% [12/523] in 2023, p=0.03). There was also an increasing proportion of DCD heart recipients with severe functional status limitation (43.5% [47/108] in 2020 and 62.0% [324/523] in 2023) and intravenous inotrope dependency (25.9% [28/108] vs. 37.9% [198/523]) before transplant (both p< 0.001). One-year post-transplant survival was similar between the DCD and DBD cohorts when stratified by medical urgency status (Table). These findings persisted after multivariable adjustment (Figure-B). In the sensitivity analysis incorporating the interaction term between medical urgency status and donor type (DCD vs. DBD) into the multivariable Cox model, survival remained similar between the DCD and DBD cohorts irrespective of medical urgency status (all P-interaction>0.15).

Conclusion: The national use of DCD donor hearts has expanded significantly in recipients with more urgent status. One-year survival in these higher-acuity recipients remains equivalent to that of DBD heart transplants. With appropriate selection, more aggressive use of DCD donor hearts can be encouraged in higher-acuity recipients.

Identify the source of the funding for this research project: n/a