Prolonged pulseless electrical activity warm ischemia predicts mortality and graft dysfunction in donation after circulatory death heart transplant.

Abstract

Prolonged asystolic warm ischemic time during donation after circulatory death (DCD) heart transplantation worsens outcomes. Despite recommendations from the American Society of Transplant Surgeons, declaration of death upon pulseless electrical activity (PEA) instead of asystole remains inconsistent. This study evaluated the association between prolonged PEA warm ischemic time (PWIT) and outcomes in adult recipients of cardiac allografts recovered using thoracoabdominal normothermic regional perfusion (TA-NRP). Adult heart transplants from DCD allografts recovered with TA-NRP from January 2020 to February 2025 were reviewed, excluding multiorgan transplants and congenital heart disease. PWIT was defined as the time from systolic blood pressure <30 mm Hg to TA-NRP perfusion. Receiver operating characteristic curve analysis was used to dichotomize PWIT, and inverse probability of treatment weighting was used to adjust for confounders when associating prolonged PWIT with outcomes. In total, 133 patients met inclusion criteria with a median PWIT of 11 minutes (interquartile range, 9-13 minutes), of whom 57 (42.9%) were not declared at PEA. Receiver operating characteristic curve analysis identified a PWIT inflection point of 12 minutes when predicting 90-day mortality, with 99 (74.4%) patients having PWIT ≤12 minutes and 34 (25.6%) with >12 minutes. Adjusted outcomes after inverse probability of treatment weighting found that PWIT >12 minutes was associated with increased rates of severe primary graft dysfunction (odds ratio [OR], 4.62; P = .013) and 90-day (OR, 7.67; P = .010) and 1-year mortality (OR 5.93, P = .014). PWIT >12 minutes is significantly associated with increased mortality and severe primary graft dysfunction in NRP-recovered DCD hearts. Standardization of declaration upon PEA instead of asystole, in addition to other strategies to minimize PWIT, could improve postoperative adult heart transplant recipient outcomes.