Primary graft dysfunction in donor after brain death vs normothermic regional perfusion heart transplants

Primary graft dysfunction (PGD) is a leading cause of death within 30 days of heart transplant (HT). Advancements in procurement in donors after circulatory death (DCD), including normothermic regional perfusion (NRP), have led to increased utilization. The purpose of this study was to assess incidence and risk factors for PGD in a modern cohort of HTs who received donors after brain death (DBD) vs DCD allografts procured using NRP.

Retrospective cohort analysis of adult, heart-only transplants at a single center from 1/1/21 to 6/30/23. Modified ISHLT 2014 Consensus Criteria for PGD were used. Risk factors were assessed in univariable analyses and multivariable logistic regression.

172 patients met inclusion criteria; 100 DBD, 72 NRP. The DBD arm had higher rates of inotrope dependence and mechanical circulatory support (MCS) pre-transplant; the NRP arm had longer total ischemic time and MCS duration pre-transplant. Incidence of PGD was non-significantly higher in the NRP arm (22% vs 13%, p = 0.11). In the multivariable model, NRP was associated with significantly higher risk of PGD (OR 2.88, 95% CI 1.15-7.20, p = 0.02). PGD patients had longer intensive care unit (ICU) stays, post-transplant inotrope duration, and higher rates of renal replacement therapy. Post-transplant mortality and cardiac function were not significantly different.

After adjustment for demographics and clinical characteristics, NRP was associated with higher risk of PGD vs DBD. While index hospitalization resource utilization was increased for PGD patients, midterm outcomes were not different. Further studies are warranted to understand characteristics of NRP that may be associated with increased PGD risk and the clinical significance of PGD post-NRP.