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Early Heart Transplant Experience With Normothermic Regional Perfusion
Quick Takes
- In the early U.S. experience with donation after circulatory death (DCD) heart transplant, organ reperfusion with normothermic regional perfusion (NRP) was associated with better short-term survival outcomes compared to organ reperfusion with direct procurement and perfusion (DPP).
- Donor organ discard rates were higher for DPP (9.6%) compared to NRP (1.4%).
Study Questions:
For heart transplantation following donation after circulatory death (DCD HT), what are the short-term outcomes associated with organ procurement using a normothermic regional perfusion (NRP) strategy compared to a direct procurement and perfusion (DPP) strategy?
Methods:
Data from the United Network for Organ Sharing (UNOS) registry, from January 2019 to December 2023, were used in this study. The analysis included all adult transplant recipients undergoing DCD HT. Excluded from the study were heart recipients with missing survival data, death to cross-clamp time >180 minutes, prior transplants, or multiorgan transplants. The type of organ reperfusion strategy (NRP or DPP) was not directly collected by UNOS but was inferred based on ancillary data (time to cross-clamp). The primary outcome studied was overall survival.
Results:
A total of 918 DCD HT recipients were included in the study, with 622 (68%) transplants using a DPP strategy and 296 (32%) using NRP. Donor organ discard rate (hearts not ultimately transplanted divided by total hearts recovered) was 9.6% for DPP and 1.4% for NRP.
In the unadjusted Kaplan-Meier survival analysis, the NRP strategy compared to DPP was associated with better overall survival (log-rank, p = 0.005). Thirty-day survival was 98.6% (95% confidence interval [CI], 97.2%-100.0%) for NRP and 96.0% (95% CI, 94.1%-97.5%) for DPP. One-year survival was 95.2% (95% CI, 92.3%-98.2%) for NRP and 90.1% (95% CI, 87.4%-92.8%) for DPP. Similar results were noted with a propensity-matched cohort. After adjustment, the NRP strategy was independently associated with improved survival compared to the DPP strategy (hazard ratio, 0.39; 95% CI, 0.22-0.70; p = 0.002). No significant differences were noted in many of the secondary outcomes assessed, including hospital length of stay, acute rejection prior to discharge, rejection within 1 year, new-onset dialysis, and left ventricular ejection fraction.
Conclusions:
In this study of the early U.S. experience with DCD HT, the use of a NRP reperfusion strategy was associated with better short-term survival outcomes compared to a DPP strategy.
Perspective:
The growing adoption of DCD HT is significantly expanding the donor organ pool while maintaining favorable post-transplant outcomes comparable to those seen with traditional donation after brain death. In the U.S., centers primarily use one of two strategies: direct procurement and perfusion (DPP), which is more common, or NRP. Both strategies allow for the heart to be reperfused after death to assess function and suitability for transplantation.
This study’s findings are promising, showing low organ discard rates and suggesting a potential signal for improved short-term outcomes with the NRP approach, though outcomes for the DPP approach are also encouraging. Long-term outcomes will still need to be evaluated. With both reperfusion strategies generally effective, the choice of approach is influenced by many factors such as cost, resource availability, state and local regulations, and ethical considerations. Each strategy offers unique advantages and disadvantages, underscoring the need for additional research to determine their optimal use in specific scenarios. The field of DCD HT is evolving and future research like this study will be critical in shaping best practices.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Heart Transplant
Keywords: Heart Transplantation, Perfusion, Tissue and Organ Procurement
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