D067 - When Non-Beating Hearts Beat Again: Equivalent Three-Year Survival After DCD and DBD Heart Transplantation

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Author Block: A. Asassfeh, Medical College of Wisconsin, Milwaukee, WI
*Purpose: To evaluate medium-term recipient survival after heart transplantation from donation after circulatory death (DCD) versus donation after brain death (DBD) donors in the United States since the implementation of DCD heart donation.
*Methods: Adult heart transplant recipients in the UNOS/OPTN registry (January 2020-June 2022) were analyzed to allow complete three-year follow-up. Kaplan-Meier survival was extended to five years for visualization. Multivariable Cox modeling estimated adjusted hazard ratios for three-year mortality, accounting for donor, recipient, and transplant factors. Retransplants were treated as deaths.
*Results: Among 8,171 recipients, 7,767 (95.1%) received hearts from DBD donors and 404 (4.9%) from DCD donors. At 3 years, recipient survival was 85.2% (95% CI 84.4-86.0) for DBD and 85.5% (95% CI 82.1-89.1) for DCD transplants (log-rank p = 0.822). At 5 years, survival was 75.5% (95% CI 73.9-77.3) for DBD and 65.7% (95% CI 51.9-83.4) for DCD recipients (log-rank p = 0.683). After adjustment for recipient, donor, and transplant characteristics, DCD donation was not independently associated with 3-year mortality (adjusted HR 0.89, 95% CI 0.67-1.19, p = 0.44).
Figure 1. Post-transplant survival by donor type (DCD vs DBD) at 3 and 5 years
Table 1. Baseline characteristics

	Characteristic		DBD n = 7,767 (95.1%)		DCD n = 404 (4.9%)		p
	Recipient age		54 [36, 63]		57 [44, 64]		<0.001
	Recipient sex						0.002
	- Male		5,514 (71%)		316 (78%)		—
	- Female		2,253 (29%)		88 (22%)		—
	Recipient ethnicity						<0.001
	- White		4,563 (59%)		278 (69%)		—
	- Black		1,884 (24%)		85 (21%)		—
	- Hispanic		916 (12%)		30 (7.4%)		—
	- Asian		293 (3.8%)		7 (1.7%)		—
	- Other/Unknown		111 (1.4%)		4 (1.0%)		—
	Recipient BMI (kg/m²)		26.6 [22.6, 30.8]		29.4 [25.7, 32.8]		<0.001
	Primary diagnosis						<0.001
	- Dilated cardiomyopathy		4,160 (54%)		218 (54%)		—
	- Ischemic cardiomyopathy		1,869 (24%)		118 (29%)		—
	- Restrictive/Hypertrophic		651 (8.4%)		36 (8.9%)		—
	- Congenital		789 (10%)		12 (3.0%)		—
	- Other/Unknown diagnosis		298 (3.8%)		20 (5.0%)		—
	Donor age (years)		30 [21, 38]		28 [23, 35]		0.049
	Donor sex						<0.001
	- Male		5,453 (70%)		351 (87%)		—
	- Female		2,314 (30%)		53 (13%)		—
	Donor ethnicity						<0.001
	- White		4,645 (60%)		311 (77%)		—
	- Black		1,418 (18%)		37 (9.2%)		—
	- Hispanic		1,458 (19%)		50 (12%)		—
	- Asian		129 (1.7%)		3 (0.7%)		—
	- Other/Unknown		117 (1.5%)		3 (0.7%)		—
	Cold ischemia time (hours)		3.40 [2.90, 4.00]		4.90 [3.40, 6.40]		<0.001
	Donor creatinine (mg/dL)		1.00 [0.70, 1.60]		0.79 [0.60, 1.00]		<0.001
	Recipient on ECMO at transplant		429 (5.5%)		3 (0.7%)		<0.001
	Waitlist time (days)		35 [10, 154]		44 [13, 175]		0.023

Values are presented as median (interquartile range) or number (percentage). P-values compare DCD vs DBD groups using Wilcoxon rank-sum or chi-square tests.
Table 2. Multivariable Cox model for 3-year survival

	Variable		HR (95% CI)		p
	DCD vs DBD		0.89 (0.67 - 1.19)		0.44
	Recipient Age (per 5 years)		1.04 (1.01 - 1.06)		0.001
	Donor Age (per year)		1.00 (1.00 - 1.01)		0.33
	Recipient Sex (Male vs Female)		0.95 (0.83 - 1.10)		0.52
	Recipient Ethnicity vs White
	Black/African American		1.45 (1.27 - 1.66)		<0.001
	Hispanic/Latino		0.98 (0.80 - 1.20)		0.86
	Asian		0.95 (0.68 - 1.33)		0.79
	Other/Unknown		1.32 (0.82 - 2.11)		0.25
	Primary Diagnosis vs Dilated CM
	Ischemic CM		1.35 (1.17 - 1.55)		<0.001
	Restrictive/Hypertrophic CM		0.83 (0.65 - 1.07)		0.15
	Congenital		1.85 (1.46 - 2.33)		<0.001
	Other/Unknown		0.98 (0.70 - 1.36)		0.89
	Donor Ethnicity vs White
	Black/African American		1.13 (0.97 - 1.31)		0.10
	Hispanic/Latino		1.01 (0.87 - 1.18)		0.88
	Asian		1.10 (0.71 - 1.73)		0.66
	Other/Unknown		0.66 (0.36 - 1.20)		0.17
	BMI vs Normal (18.5-25)
	Underweight (< 18.5)		1.10 (0.84 - 1.44)		0.48
	Overweight (25-30)		1.07 (0.92 - 1.25)		0.37
	Obese (≥ 30)		1.23 (1.06 - 1.44)		0.008
	Cold Ischemia Time (per 6 h)		1.52 (1.11 - 2.07)		0.009
	Recipient on ECMO at Transplant		1.41 (1.12 - 1.78)		0.004
	Donor Creatinine (mg/dL)		1.00 (0.97 - 1.04)		0.85
	Waitlist Time (per day)		1.00 (1.00 - 1.00)		0.037

*Conclusions: Recipient survival after DCD heart transplantation was comparable to that of DBD transplants through three years of follow-up, including after multivariable adjustment, with no difference at five years. These findings support the continued use and expansion of DCD hearts in appropriate recipients.