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Published on: August 2, 2024
Myocardial Stress During Donor Withdrawal Is Associated With Graft Dysfunction After Circulatory Death Heart
Awab Ahmad1, Chen Chia Wang2, Mark Petrovic2
1From the Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
Insights
We developed the Delta Myocardial Stress Index (ΔMSI) to measure heart stress in organ donors. Elevated ΔMSI, not just time, predicts severe graft dysfunction after heart transplants.
Area of Science:
- Cardiology
- Transplant Surgery
- Physiology
Background:
- Donation after circulatory death (DCD) heart transplantation outcomes are influenced by donor physiology.
- Assessing myocardial stress during the agonal phase is crucial for predicting graft function.
Purpose of the Study:
- To develop and validate the Delta Myocardial Stress Index (ΔMSI) as a metric for myocardial oxygen supply-demand imbalance.
- To evaluate the association between ΔMSI and posttransplant primary graft dysfunction (PGD) in DCD heart recipients.
Main Methods:
- Retrospective analysis of high-resolution hemodynamic data from 191 adult DCD heart transplants.
- Calculation of ΔMSI, a novel metric integrating myocardial oxygen supply and demand.
- Statistical assessment of the association between ΔMSI trajectories and severe PGD.
Main Results:
- ΔMSI trajectories were significantly elevated in donors who developed severe PGD (p < 0.001).
- Two ΔMSI phenotypes were identified; high ΔMSI was independently associated with severe PGD (OR: 2.49, p = 0.02) and 90-day mortality (OR: 4.58, p = 0.03).
- Cumulative ΔMSI burden, not withdrawal-to-declaration-of-death (WTD) time alone, mediated the association between WTD and PGD.
Conclusions:
- ΔMSI provides a noninvasive quantification of myocardial stress during DCD donor withdrawal.
- Physiologic myocardial stress, rather than solely agonal duration, is linked to severe PGD.
- These findings advocate for a shift towards physiologic assessment of donor myocardial resilience over time-based thresholds.
Abstract:
We developed a physiologically grounded metric-the Delta Myocardial Stress Index (ΔMSI)-to estimate myocardial oxygen supply-demand imbalance during the donor agonal phase and evaluated its association with posttransplant graft dysfunction. We performed a retrospective single-center study of adult donation after circulatory death (DCD) heart transplants (February 2020-June 2025). High-resolution hemodynamic data from withdrawal to declaration of death (WTD) were analyzed. Delta Myocardial Stress Index, integrating myocardial oxygen supply-demand balance, was derived from available hemodynamic data. Associations between ΔMSI and severe primary graft dysfunction (PGD) were assessed. Among 191 cases (16 severe PGD events), ΔMSI trajectories were significantly elevated in donors who developed severe PGD ( p < 0.001). Two distinct ΔMSI trajectory phenotypes were identified; high ΔMSI was independently associated with severe PGD (odds ratio [OR]: 2.49, p = 0.02) and 90 day mortality (OR: 4.58, p = 0.03). The association between WTD and PGD operated primarily through cumulative ΔMSI burden ( p = 0.02), whereas WTD alone was not associated with PGD after accounting for ΔMSI ( p = 0.25). Delta Myocardial Stress Index provides a noninvasive quantification of myocardial stress during DCD withdrawal. Myocardial stress, rather than agonal duration alone, was associated with severe PGD. These findings support a shift from time-based thresholds toward physiologic assessment of donor myocardial resilience.
