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Conventional Cardiac Surgery in Donation After Circulatory Death Heart Transplantation: A United Network for Organ
Samantha N Machinski1, Yeahwa Hong1,2, Umar Nasim1
1Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
Insights
Prior conventional cardiac surgery in donation after circulatory death (DCD) heart transplant recipients is linked to lower early survival. However, outcomes are similar regardless of donor type, suggesting DCD heart transplantation is a viable option for this high-risk group.
Area of Science:
- Cardiology
- Transplantation Medicine
- Surgical Outcomes
Background:
- Growing demand for heart transplants necessitates exploring allograft allocation strategies.
- Nearly one-third of adult donation after circulatory death (DCD) heart transplant recipients have a history of conventional cardiac surgery.
Purpose of the Study:
- To evaluate the outcomes of DCD heart transplantation in recipients with prior conventional cardiac surgery.
- To compare the survival rates between DCD and donation after brain death (DBD) heart transplants in this specific patient population.
Main Methods:
- Analysis of the UNOS registry for adult DCD heart transplant recipients from January 2019 to March 2024.
- Exclusion of patients with durable left ventricular assist devices or congenital heart surgery.
- Stratification of recipients based on prior conventional cardiac surgical history and analysis of 1-year posttransplant survival.
Main Results:
- Conventional cardiac surgery was associated with reduced 1-year survival in DCD heart transplant recipients (89.6% vs. 96.8%, p < 0.001).
- This survival difference persisted in propensity score-matched analyses (89.0% vs. 95.3%, p = 0.02).
- Combined coronary revascularization and valvular interventions showed the lowest 1-year survival rates (77.9%).
- Among recipients with prior conventional cardiac surgery, DCD and DBD donors had comparable 1-year survival (aHR 0.897, p = 0.635).
Conclusions:
- Prior conventional cardiac surgery is a significant factor associated with reduced early posttransplant survival in DCD heart transplant recipients.
- No significant difference in early outcomes was observed between DCD and DBD donors within the subgroup of patients with prior conventional cardiac surgery.
- DCD heart transplantation represents a viable strategy for expanding the donor pool, even in high-risk populations with prior cardiac surgical history.
Objective:
This study evaluates outcomes following donation after circulatory death (DCD) heart transplantation among recipients with prior conventional cardiac surgery.
Methods:
The UNOS registry was queried to analyze adult recipients who underwent DCD heart transplantation between 1/1/2019 and 3/31/2024. Patients with durable left ventricular assist devices or congenital heart surgery were excluded. Recipients were stratified by conventional cardiac surgical history prior to transplantation. The primary outcome was 1-year posttransplant survival. Subgroup analyses investigated the impact of surgical subtype and donor type on 1-year survival.
Results:
Among 785 DCD recipients included, 233 (29.7%) underwent prior conventional cardiac surgery. Conventional cardiac surgery was associated with reduced 1-year survival (89.6% vs. 96.8%, p < 0.001). Inferior survival persisted in a propensity score-matched comparison (89.0% vs. 95.3%, p = 0.02). Combined coronary revascularization and valvular interventions conferred the lowest 1-year survival rates among surgical subtypes (77.9% vs. 96.8%, p < 0.001). Among adults with conventional cardiac surgery, DCD and DBD recipients demonstrated comparable 1-year survival (aHR 0.897, 95% CI 0.57-1.40, p = 0.635).
Conclusion:
Conventional cardiac surgical history is associated with reduced early posttransplant survival. Within this subgroup, adjusted analyses demonstrated no observed difference in early outcomes between DCD and DBD donors. These findings suggest DCD heart transplantation may be a viable strategy for organ donor pool expansion in this high-risk population.
Practitioner Points:
Growing transplant volume and waitlist demand underscore the importance of efficient, safe allograft allocation. Nearly one-third of adults undergoing DCD heart transplant have undergone prior conventional cardiac surgery. Despite lower early survival among these recipients, outcomes are independent of donor type, suggesting that use of DCD donors in this population does not confer additional mortality risk and supporting the continued utilization of DCD donors in this high-risk population.
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