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Updated: Sep 17, 2025
A High-Fidelity Porcine Model of Orthotopic Heart Transplantation Following Donation after Circulatory Death
Published on: June 6, 2025
Early Outcomes of Primary Graft Dysfunction Comparing Donation After Circulatory and Brain Death Heart
Ye In Christopher Kwon1, Michael Keller1, Kareem Elhigzi1
1Division of Cardiothoracic Surgery, Department of Surgery, Pauley Heart Center, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA.
Insights
Primary graft dysfunction (PGD) is more common after donation after circulatory death (DCD) heart transplants than donation after brain death (DBD) transplants. However, PGD in DCD recipients does not increase mortality, and ECMO may improve survival.
Area of Science:
- Cardiology
- Transplantation Surgery
- Critical Care Medicine
Background:
- Primary graft dysfunction (PGD) is a major cause of mortality in donation after brain death (DBD) orthotopic heart transplantation (OHT).
- Nationwide data on PGD following donation after circulatory death (DCD) is limited.
- This study evaluates PGD incidence and short-term outcomes in DCD recipients.
Purpose of the Study:
- To determine the incidence of PGD in DCD heart transplant recipients.
- To compare short-term outcomes of PGD between DCD and DBD heart transplant recipients.
- To identify predictors of mortality in patients experiencing PGD post-OHT.
Main Methods:
- Utilized the UNOS registry (9/2023-9/2024) for adult OHT recipients.
- Compared incidence and outcomes of moderate-severe PGD (24h and 72h) between DCD and DBD groups.
- Analyzed mortality predictors using Cox models and 30-day survival via Kaplan-Meier analysis.
Main Results:
- DCD hearts (15.2%) showed significantly higher PGD incidence at 24h (7.9% vs. 4.8%) and 72h (5.9% vs. 3.3%) compared to DBD.
- 30-day survival was comparable between DCD and DBD patients with PGD at both 24h and 72h.
- DCD recipients with PGD were more likely to require ECMO at 72h; postoperative ECMO use decreased PGD-associated mortality risk in DCD recipients.
Conclusions:
- PGD rates are higher in DCD heart transplantation, but associated mortality is comparable to DBD.
- Early extracorporeal membrane oxygenation (ECMO) support may offer survival benefits for DCD recipients experiencing PGD.
- Findings highlight the need for vigilant PGD management in DCD OHT.
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.
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