Potential intermediate-term survival differences among heart transplant recipients from circulatory death vs brain death donors

Background

This study builds upon previous analyses by examining heart transplant survival from donation after circulatory death (DCD) vs donation after brain death (DBD) using the United Network for Organ Sharing (UNOS) database, with follow-up extended to 3 years post-transplant.

Methods

We conducted a retrospective cohort study of 1,453 DCD and 16,561 DBD adult heart transplants from January 2019 to June 2024 using the UNOS database. Propensity scores were generated based on clinically relevant covariates, and 1-to-1 propensity-score matching was performed. Survival analysis was conducted using Cox proportional hazards regression and Kaplan-Meier curves, with the log-rank test comparing overall survival and the Wald test examining yearly survival rates between DCD and DBD groups.

Results

Mortality was not significantly different between DCD and DBD total cohorts (hazard ratio [HR] = 1.1, 95% confidence interval [CI] 0.9-1.3, p = 0.493). After propensity-score matching, balanced cohorts of 1,423 DCD and 1,423 DBD transplants were created with standardized mean difference among covariates well below 6%. In the matched cohort, DCD transplant mortality was 1.2 times higher than that of DBD transplants (HR 1.2, 95% CI 0.9-1.5). Kaplan-Meier curves revealed nonsignificantly lower overall survival for DCD recipients (log-rank p = 0.096). Survival rates were comparable in year 1: 91.6% vs 91.5%, p = 0.96, but significant differences emerged in subsequent years: 84.7% vs 89.4%, p = 0.007 in year 2; 80.3% vs 85.6%, p = 0.025 in year 3.

Conclusions

Intermediate-term survival following DCD heart transplantation may be lower compared to DBD transplantation. Further investigation is warranted to identify the underlying factors contributing to this potential disparity.