Donor Type and Organ Preservation in Heart Transplantation: Association with Recovery Following Severe Primary Graft...

Primary graft dysfunction (PGD) remains a major cause of post-heart transplant morbidity and mortality. Prior studies have focused on predictors of developing PGD. Less is known about factors associated with post-PGD recovery.

We queried the Scientific Registry of Transplant Recipients for adult heart transplants between September 2023 and December 2025. Severe PGD was defined as dependence on new extracorporeal membrane oxygenation or ventricular assist device support at 24 hours post-transplant. Outcomes were compared across donor type (donation after circulatory death [DCD] vs donation after brain death [DBD]) and procurement/preservation strategies (normothermic regional perfusion (NRP), ex-vivo heart perfusion (EVP), static cold storage). The primary outcome was overall survival. Secondary outcomes included graft failure and 30-day survival. Inverse probability of treatment weighting (IPTW) was used to adjust for confounding.

Among 7059 heart transplant recipients, 462 (6.5%) developed severe PGD, which was associated with significantly worse survival. Among patients with severe PGD, DCD recipients had higher unadjusted survival compared with DBD (1-year survival 84.1% vs. 65.1% [log-rank P=0.001]). In IPTW-adjusted analyses DCD transplants were associated with improved survival (adjusted hazard ratio, 0.44; 95% CI, 0.23-0.85; P=0.014). Preservation strategy was not associated with survival after adjustment. DCD was associated with higher odds of 30-day survival in unadjusted analyses.

Compared with DBD, DCD recipients with severe PGD demonstrated improved survival. Preservation strategy was not independently associated with survival, though subgroup analyses were limited by small numbers. Among predictors of early recovery, ventricular support devices at 24 hours were independently associated with lower odds of 30-day survival compared with ECMO.