Heart transplantation remains the definitive treatment for end-stage heart failure. With increasing demand for donor hearts, donation after circulatory death (DCD) has become an alternative to the traditional donation after brain death (DBD). However, concerns about ischemia-reperfusion injury and the inability to evaluate heart viability before procurement have limited its use. Thoracoabdominal normothermic regional perfusion (TA-NRP) has emerged as a technique to overcome these challenges by restoring circulation and oxygenation to the donor heart after death declaration, allowing for assessment under near-physiologic conditions before transplantation.
This study presents a retrospective cohort analysis of 32 patients who underwent DCD heart transplantation between January 2020 and December 2023 at a single center. It evaluates patient outcomes, including survival rates, incidence of primary graft dysfunction (PGD), rejection, and cardiac allograft vasculopathy (CAV). The study also includes a subgroup analysis comparing transplants involving co-localized versus distant donors.
Methods and Patient Selection
The study reviewed electronic medical records of adult patients who received DCD heart transplants. A total of 241 heart transplants were performed at the institution during the study period, of which 32 were from DCD donors. The institution’s TA-NRP protocol, which includes sternotomy, ligation of aortic arch vessels, cardiopulmonary bypass initiation, heart resuscitation, and cold static storage for transport, was followed for all DCD transplants.
Patient and donor demographics were collected, including age, sex, body mass index, cause of heart failure, and need for preoperative mechanical circulatory support. Operative characteristics, such as ischemia times, left ventricular ejection fraction (LVEF), and duration of perfusion, were analyzed.
The primary endpoint was one-year survival. Secondary endpoints included incidence of PGD, rejection, and CAV development.
Results
The recipient median age was 56 years, and most were male. The most common cause of heart failure was nonischemic cardiomyopathy (56%), followed by ischemic cardiomyopathy (22%). Of the donors, the median age was 39 years, and 84% were male. Most donors (66%) were co-localized, while 34% were distant.
Key Findings:
- Survival & Outcomes: One-year survival was 100%. Only one patient died three years post-transplant due to sepsis during a workup for re-transplantation.
- Primary Graft Dysfunction (PGD): Two patients (6%) developed moderate-to-severe PGD, requiring mechanical circulatory support.
- Rejection Rates: Four patients (13%) experienced grade 2R acute cellular rejection; no cases of antibody-mediated rejection were reported.
- Cardiac Allograft Vasculopathy (CAV): Five patients (23%) developed grade 1 CAV at one year; none had severe cases.
- Subgroup Analysis: Distant donors were associated with longer warm (47 vs. 30 minutes) and cold (213 vs. 76 minutes) ischemia times, but no significant differences in postoperative LVEF, inotropic support duration, or hospital stay were observed.
Discussion
The study highlights excellent one-year outcomes for DCD heart transplantation using TA-NRP. The 100% survival rate and acceptable levels of PGD, rejection, and CAV suggest that TA-NRP is an effective method for procuring and transplanting DCD hearts.
Compared to previous studies, which reported similar early outcomes, this study further validates the safety of using TA-NRP. While traditional DBD transplantation remains the standard, TA-NRP allows for expansion of the donor pool, even among older donors.
Despite promising results, some challenges remain, including procedural costs, the need for highly specialized surgical teams, and logistical coordination. Future studies with larger sample sizes and longer follow-ups are necessary to establish the long-term viability of DCD heart transplantation.
Conclusion
DCD heart transplantation using TA-NRP is a viable and promising approach, with excellent one-year outcomes. The study supports its broader adoption as a means to address the growing demand for donor hearts while maintaining safety and efficacy.
Study Ranking = 4.5 (High Quality) The study is a retrospective cohort review, but it includes a well-defined patient population, robust data analysis, and clinically significant outcomes. The inclusion of one-year follow-up data and subgroup analyses strengthens its reliability, although long-term follow-up and larger sample sizes would further enhance its impact.
