National Midterm Outcomes of Ex-Vivo Heart Perfusion in Heart Transplantation

Ex-vivo heart perfusion (EVHP) has emerged as a transformative preservation strategy in heart transplantation with increasing adoption over the past decade. We sought to characterize the midterm outcomes of heart transplantation using EVHP.

We queried the United Network for Organ Sharing database to identify adult heart transplants performed between October 2018 and December 2025. Patients were stratified by use of EVHP or static cold storage (SCS). The primary outcome was 3-year post-transplant survival, assessed using the Kaplan-Meier method. Secondary outcomes were severe primary graft dysfunction, acute rejection, and freedom from cardiac allograft vasculopathy.

Among 22,463 heart transplant recipients, 2,703 (12%) received allografts preserved with EVHP. EVHP hearts were more frequently donated after circulatory death (1,679 [62.1%] vs 944 [4.8%], p<0.001) and had longer procurement distances (480.70 vs 282.80 miles, p<0.001). Recipients in the EVHP group had higher rates of severe primary graft dysfunction (152 [9.4%] vs 330 [5.2%], p<0.001) and acute rejection episodes (280 [13.0%] vs 1,630 [10.2%], p<0.001). Three-year survival following transplantation was similar between EVHP and SCS groups (88.3% vs 88.8%, p=0.95). However, freedom from cardiac allograft vasculopathy at 3-year was lower in the EVHP than the SCS group (79.0% vs 82.4%, p=0.003).

In a cohort of isolated heart transplant recipients, EVHP-preserved donor hearts were predominantly donated after circulatory death with longer procurement distances, yet yielded similar 3-year outcomes as SCS. However, increased perioperative complications and incidence of cardiac allograft vasculopathy at 3 years with EVHP warrant further investigation.