The expansion of donation after circulatory death (DCD) has transformed the landscape of heart transplantation in the United States. In this comprehensive national registry study published in JHLT Open, Park and colleagues evaluated whether thoracoabdominal normothermic regional perfusion (TA-NRP) impacts graft survival following heart transplantation compared to traditional donation after brain death (DBD) and DCD with direct procurement and perfusion (DPP).
Using data from the Scientific Registry of Transplant Recipients (SRTR), the investigators examined all adult primary heart transplants performed between January 1, 2020, and May 31, 2024. The study included 13,558 heart transplants: 12,185 DBD (89.9%), 899 DCD DPP (6.6%), and 474 DCD TA-NRP (3.5%). This analysis represents one of the first large-scale national evaluations specifically examining graft survival associated with TA-NRP recovery.
DCD heart transplantation has emerged as a crucial strategy to address the persistent shortage of donor hearts. TA-NRP, introduced in the United States in 2020, involves restoring in situ circulation after circulatory death to evaluate and preserve organ function prior to procurement. This differs from DPP, which typically relies on rapid procurement followed by ex-situ machine perfusion. While early clinical reports suggested promising outcomes, long-term graft survival data remained limited prior to this study.
The primary outcome of the study was graft loss, defined as death or re-transplantation within two years. Secondary outcomes included patient survival, acute rejection, in-hospital mortality, coronary artery disease (CAD), hospital readmissions, and maintenance immunosuppression use during the first year.
Importantly, the results demonstrated no statistically significant differences in two-year graft survival among DCD TA-NRP, DCD DPP, and DBD recipients. Adjusted hazard ratios showed equivalent outcomes: TA-NRP versus DBD (aHR 0.98), TA-NRP versus DPP (aHR 1.04), and DPP versus DBD (aHR 0.94). Patient survival similarly showed no significant differences after adjustment for donor and recipient characteristics.
Baseline characteristics varied between groups. Recipients of TA-NRP hearts were more frequently male and non-Hispanic White and tended to have lower listing urgency status. They were less likely to require preoperative mechanical support, inotropes, or blood transfusions. Donor characteristics also differed, with TA-NRP donors more often male and younger. Despite these demographic and clinical differences, multivariable modeling demonstrated that recovery method itself was not independently associated with graft loss or mortality.
Secondary outcomes further reinforced the safety profile of TA-NRP. Rates of treated acute rejection, in-hospital mortality, coronary artery disease, and one-year readmissions did not differ significantly between groups after adjustment. While steroid maintenance therapy was slightly more common in DCD recipients, tacrolimus and mycophenolate use were comparable.
The study also performed sensitivity analyses restricted to centers performing TA-NRP, demonstrating consistent findings and mitigating concerns that center experience or regional practice patterns might confound results.
From a clinical standpoint, these findings are significant. Concerns surrounding DCD heart transplantation have historically focused on warm ischemia time, potential inflammatory activation, and risk of primary graft dysfunction. However, this study suggests that when appropriately selected and managed, TA-NRP recovery does not compromise intermediate-term graft survival.
Beyond survival outcomes, TA-NRP offers potential systemic advantages. Prior research has demonstrated improved multi-organ yield and potential cost reductions compared to ex-situ machine perfusion approaches. Additionally, TA-NRP may shorten transport distances and optimize donor heart assessment prior to procurement.
Nevertheless, disparities were observed in recipient demographics, with fewer Black recipients receiving TA-NRP hearts. While outcomes were equivalent after adjustment, the authors note that selection bias and inequitable allocation patterns warrant further investigation. Addressing disparities in heart transplantation remains an ongoing priority in transplant medicine.
Limitations include reliance on registry data, absence of granular rejection data beyond required reporting intervals, and relatively short follow-up due to the recent adoption of TA-NRP. Furthermore, recovery method classification was inferred from time intervals rather than directly coded procedural data. Despite these limitations, the large national sample strengthens the study’s conclusions.
In summary, this landmark registry analysis demonstrates that heart transplantation using DCD with thoracoabdominal normothermic regional perfusion yields graft and patient survival comparable to both DCD direct procurement and traditional DBD recovery. These findings support broader utilization of TA-NRP as a viable, safe, and effective strategy to expand the donor pool and address the ongoing shortage of transplantable hearts.
As heart transplantation continues to evolve, TA-NRP appears positioned to play a central role in the next generation of donor heart recovery strategies.
