Center Expertise Does Not Affect Outcomes After Donation After Circulatory Death (DCD) Heart Transplantation

N. Menko¹, S. Li², R. Singh³, S. Rabi⁴, E. Michel⁵, D. A.. D'Alessandro⁶, A. Osho^3
1Massachusetts General Hospital, Brookline, Massachusetts ²Massachusetts General Hospital, Revere, Massachusetts ³Massachusetts General Hospital - Division of Cardiac Surgery, Boston, Massachusetts ⁴Massachusetts General Hospital, Division of Cardiac Surgery, Boston, Massachusetts ⁵Massachusetts General Hospital, Somerville, Massachusetts ⁶Massachusetts General Hospital, Boston, Massachusetts

Purpose: The Donation after Circulatory Death heart transplant trial in the United States included the first 10 centers to perform DCD heart transplants. Given the unique DCD procurement, implantation, and post-operative management, this study investigates whether expertise gained from trial participation is associated with improved DCD heart transplantation outcomes.

Methods: The United Network for Organ Sharing (UNOS) registry as of March 2024 was used to identify all adult DCD heart transplants from December 2019 to March 2023. Expert centers were defined as trial centers that performed ≥5 heart transplants during the trial period and Non-expert centers as any other centers performing DCD transplants. Previous transplants, multi-organ transplants, and loss to follow-up were excluded. Normothermic regional perfusion was excluded to focus on direct procurement and perfusion. Minimum follow-up was 6 months. The primary outcome was risk-adjusted 1-year survival. The survival was adjusted for male gender, transplant year, and out-of-body time. Secondary outcomes were hospital length of stay (LOS), acute rejection prior to discharge, treated acute rejection within 1 year, 30-day survival, and 6-month survival.

Results: Of 407 eligible patients, 196 patients were transplanted at Expert centers and 211 patients at Non-expert centers. Recipients at Expert centers were more likely to require a durable left ventricular assist device at the time of transplant (41.3% vs 25.1%, p=0.002) and had shorter warm ischemia times (median: 24.0 vs. 27.0, p= < 0.001).
One-year survival was 89.3% in the Expert cohort and 92.4% in the Non-expert cohort (p=0.355). Risk-adjusted 1-year survival showed no difference between groups (p=0.136). Transplantation in 2020 (HR 0.22 95% CI 0.07-0.70, p= 0.010) was associated with a lower 1-year mortality risk. Hospital LOS was similar between groups (23.52 days vs. 25.60 days, p=0.500), as were 30-day survival (96.4% vs. 96.2%, p=0.877) and 6-month survival (90.8% vs. 92.9%, p= 0.559). Recipients at Expert centers were more likely to experience acute rejection prior to discharge (25.5% vs. 90.0%, p= < 0.001), and treated acute rejection within 1 year (21.4% vs. 7.1%, p= < 0.001), although this was noted in DBD transplants as well. All centers demonstrated higher acute rejection rates during early DCD transplantation (with Expert centers making up the majority of early transplanters), and have since demonstrated a reduction in acute rejection rates.

Conclusion: Survival outcomes are similar between DCD heart recipients at Expert and Non-expert centers, although warm ischemic times were significantly shorter in Expert procurements. As DCD procurements become more standardized through specialized procurement teams, we anticipate even fewer differences between Expert and Non-expert outcomes, promoting more widespread use of this technique nationwide.

Identify the source of the funding for this research project: This research was conducted as part of an internship, and I did not receive any funding for this project.