Cardiac Allograft Vasculopathy After Donation After Circulatory Death Heart Transplantation.

Abstract

Use of donation after circulatory death (DCD) heart transplantation (HT) has dramatically expanded, with survival comparable to donation after brain death/standard recovery (DBD/SR). As cardiac allograft vasculopathy (CAV) remains a leading cause of post-HT morbidity, we sought to analyze CAV incidence among DCD recipients. We used the Organ Procurement and Transplantation Network to tabulate adult (≥18 years) HT recipients between December 2019 and January 2024. DCD recipients were further stratified into the direct procurement with normothermic machine perfusion (DCD/DP-NMP) and thoracoabdominal normothermic regional perfusion (DCD/TA-NRP). The primary outcome of interest was the incidence of CAV over the first posttransplant year. Of 12,060 transplants, 11,262 (93.4%) used DBD/SR allografts, 566 (4.7%) used DCD/DP-NMP allografts, and 232 (1.9%) used DCD/TA-NRP allografts. The overall incidence of CAV at 1 year was 4.0% for the DBD/SR group, 3.8% for DCD/DP-NMP, and 7.1% for DCD/TA-NRP. After comprehensive risk adjustment, transplantation with DCD/TA-NRP allografts remained associated with greater hazard of CAV over the first posttransplant year, relative to DBD/SR (hazard ratio [HR] 1.83; 95% CI, 1.08-3.10). However, DCD/DP-NMP procurement was linked with comparable CAV hazard as DBD/SR (HR, 1.51; 95% CI, 0.92-2.50). Considering recipients at high-volume centers, DCD/TA-NRP remained significantly associated with increased hazard of CAV (HR, 2.22; 95% CI, 1.27-3.89; reference: DBD/SR). In this national analysis of CAV incidence among DCD HT recipients, DCD/TA-NRP, but not DCD/DP-NMP, was associated with greater risk of CAV.