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Published on: January 12, 2019
Trends in Use and Early Outcomes of Ex Vivo Machine Perfusion in Heart Transplantation From Donation After Brain
Shivank Madan1, Lorenzo D'Angelo1, Jill Teitelbaum2
1Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
Insights
Ex vivo machine-perfusion (EVMP) for donor hearts shows similar survival to static cold storage (SCS), even with older donors and longer transport. EVMP use is increasing, offering comparable outcomes despite extended ischemic times.
Area of Science:
- Cardiology
- Transplantation Medicine
- Organ Preservation
Background:
- Donor hearts from donation after brain death (DBD) are increasingly older and transported longer distances.
- This leads to prolonged ischemic times and increased risks of ischemic injury with conventional static cold storage (SCS).
- Ex vivo machine-perfusion (EVMP) may mitigate these risks, particularly for older donors, but its use and outcomes are uncertain.
Purpose of the Study:
- To analyze the adoption and outcomes of EVMP for donor hearts compared to SCS.
- To evaluate survival rates stratified by ischemic time and donor age.
Main Methods:
- Analysis of 12,363 adult DBD donor hearts (SCS vs. EVMP) from January 2020 to June 2024 using United Network for Organ Sharing data.
- EVMP use and recipient survival at 6 months and 1 year were assessed.
- Cox hazards regression and Kaplan-Meier survival analyses were performed, stratified by ischemic time and donor age (>40 years).
Main Results:
- EVMP use increased from 1.39% to 10.65% during the study period, driven by a few high-volume centers.
- EVMP hearts had similar 6-month and 1-year mortality risk compared to SCS hearts (Cox-HR=1.12).
- EVMP attenuated the increased mortality risk associated with longer ischemic times (≥6 hours) and older donors.
Conclusions:
- EVMP adoption for DBD donor hearts is increasing in the US, demonstrating comparable survival outcomes to SCS.
- EVMP effectively manages risks associated with older donors and longer ischemic times.
- Further research comparing EVMP with other heart transport technologies is warranted.
Introduction:
Hearts from donation after brain death (DBD) donors are increasingly older and transported over greater distances, prolonging ischemic times and increasing ischemic injury risks with conventional static cold storage (SCS). Ex vivo machine-perfusion (EVMP) of DBD donor hearts could mitigate these risks, potentially improving outcomes, especially in older donors. However, broader use rates and outcomes of EVMP remain uncertain.
Methods:
In total, 12,363 adult DBD-HTs (11,802 SCS, 561 EVMP) that met study criteria (January 2020-June 2024) were identified in United Network for Organ Sharing. EVMP use and recipient survival at 6 months and 1 year were analyzed, stratified by ischemic time (<4, 4-6, ≥6 hours), including subgroup analysis for older donors (>40 years). Cox hazards regression (Cox-HR), Kaplan-Meier survival, and marginal-effects probabilities were used.
Results:
EVMP use in DBD-HTs increased from 1.39% (January-June 2020) to 10.65% (January-June 2024), with substantial regional variability and few high-volume centers driving most of this use. Compared with DBD-HTs with SCS, DBD-HTs with EVMP had similar mortality risk at 6 months and 1 year (Cox-HR, 1.12; 0.86-1.45; P = .414), despite EVMP hearts being from older donors, transported longer distances, and having longer ischemic times. On stratifying by ischemic time and older donors, although DBD-HTs with SCS had higher 1-year mortality risk (Cox-HR=3.69; 1.81-7.51; P <.001, ischemic-time ≥6 hours) compared with the reference cohort, the increase in mortality was substantially attenuated in DBD-HTs where EVMP was used (Cox-HR, 1.77; 0.87-3.61; P = .115, ischemic time ≥6 hours).
Conclusions:
Adoption of EVMP for donor heart transport in DBD-HTs has steadily increased in the United States, showing comparable survival outcomes to SCS despite older donors and longer ischemic times. Additional studies comparing EVMP with other emerging heart transport technologies are needed.
