Adults with congenital heart disease experience worse short- and mid-term graft survival following heart transplantation from DCD donors: The early US experience

JHLT Open Pub Date : 2025-09-05 DOI:10.1016/j.jhlto.2025.100383

Alexander R. Berg BS , Danielle M. Mullis BS , Aravind Krishnan MD , Elbert E. Heng MD , Nataly Montano Vargas BS , Daniel I. Alnasir BS , Alyssa C. Garrison MS , Y. Joseph Woo MD , John W. MacArthur MD

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Abstract

Background

Donation-after-circulatory-death (DCD) heart procurement is enlarging the donor pool, yet its safety in adults with congenital heart disease (ACHD) is uncertain. We compared early (90-day) and mid-term (3-year) graft outcomes after DCD versus donation-after-brain-death (DBD) heart transplantation in ACHD recipients.

Methods

Using the United Network for Organ Sharing registry (1 January 2018 – 1 April 2025), we identified adults (≥18 y) with ACHD undergoing isolated heart transplantation. Retransplants and multiorgan procedures were excluded. The primary endpoint was graft failure (death or retransplant). Survival was analysed with Kaplan-Meier curves, multivariable Cox models, and 1:1 nearest-neighbor propensity-score matching (caliper = 0.25 SD) adjusting for donor and recipient age, sex, body-mass index, renal and hepatic function, support devices, listing status, prior sternotomy, and regional ACHD center volume.

Results

Among 726 ACHD transplants, 61 (8.4%) used DCD grafts and 665 (91.6%) used DBD grafts. Baseline clinical characteristics were similar, although DCD grafts had longer ischemic times (median 5.3 h vs 3.8 h, p < 0.001) and more frequent exvivo perfusion (65% vs 5.8%). Unadjusted 90-day and 3-year graft survival were lower after DCD (log-rank p = 0.009 and 0.040, respectively). On multivariable analysis, DCD procurement remained an independent risk factor for graft failure at 90 days (HR 2.56, 95% CI 1.23–5.17) and 3 years (HR 2.11, 95% CI 1.03–3.50).

Propensity-matched analysis (n = 148) confirmed inferior 90-day survival for DCD recipients (log-rank p = 0.020). Post-operative morbidity and length of stay did not differ between groups.

Conclusions

In the early US experience, ACHD recipients of DCD hearts experienced significantly worse short- and mid-term graft survival than those receiving DBD hearts, despite comparable peri-operative morbidity. Until preservation strategies further mitigate warm-ischemic injury, careful candidate selection is warranted when allocating DCD grafts to complex ACHD patients.

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成年先天性心脏病患者在DCD供体心脏移植后的短期和中期移植存活率较差：早期美国经验

背景：循环死亡后捐赠（DCD）心脏获取扩大了供体池，但其在成人先天性心脏病（ACHD）患者中的安全性尚不确定。我们比较了ACHD受者DCD与脑死亡后捐赠（DBD）心脏移植后早期（90天）和中期（3年）的移植结果。方法使用联合器官共享注册网络（2018年1月1日- 2025年4月1日），我们确定了患有ACHD的成年人（≥18岁）接受孤立心脏移植。排除再移植和多器官手术。主要终点是移植物衰竭（死亡或再移植）。生存率分析采用Kaplan-Meier曲线、多变量Cox模型和1:1最近邻倾向评分匹配（卡尺= 0.25 SD），调整供体和受体年龄、性别、体重指数、肾功能和肝功能、支持装置、清单状态、既往胸骨切开术和区域ACHD中心容积。结果726例ACHD移植中，DCD移植61例（8.4%），DBD移植665例（91.6%）。基线临床特征相似，尽管DCD移植物缺血时间更长（中位5.3 h vs 3.8 h, p < 0.001），体外灌注更频繁（65% vs 5.8%）。DCD后未调整的90天和3年移植物存活率较低（log-rank p分别= 0.009和0.040）。在多变量分析中，获得DCD仍然是90天（HR 2.56, 95% CI 1.23-5.17）和3年（HR 2.11, 95% CI 1.03-3.50）移植失败的独立危险因素。倾向匹配分析（n = 148）证实DCD患者的90天生存率较低（log-rank p = 0.020）。术后发病率和住院时间组间无差异。结论在早期的美国经验中，尽管围手术期发病率相当，但DCD心脏移植的ACHD受者的短期和中期移植生存率明显低于DBD心脏受者。在保存策略进一步减轻热缺血损伤之前，在为复杂的ACHD患者分配DCD移植物时，需要仔细选择候选者。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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JHLT Open

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