Comparing Procurement Methods in Donation after Circulatory Death Heart Transplantation: An Analysis of the UNOS Registry

Background: In donation after circulatory death (DCD) heart transplants, choosing an optimal procurement method between normothermic regional perfusion (NRP) and direct procurement and preservation on the TransMedics Organ Care System (OCS) remains an important consideration. Thus, we aimed to evaluate long-term outcomes between NRP and OCS in DCD heart transplants. Methods: Using the UNOS registry, we queried all adults (≥18 years old) undergoing DCD and donation after brain death (DBD) heart transplantation between December 2019 and September 2023. TransMedics OCS donors were defined by time from death to clamp ≤30 minutes. Comparatively, NRP donors were defined by time from death to clamp >30 minutes. Kaplan–Meier recipient and graft survival analyses were conducted. Multivariate Cox proportional hazard models were used to identify independent predictors of mortality. Results: We identified 11,767 DBD transplants, 507 OCS, and 265 NRP recipients. Acute rejection rates were not significantly different between groups (p = 0.42). However, significant differences in overall survival were identified between DBD, OCS, and NRP (p = 0.019). Nonetheless, this difference may be attributed to a significant decline in survival for OCS recipients at 3 years (60.7% vs. 78.8% for DBD vs. 83.3% for NRP). Moreover, there were significant differences in graft survival (p = 0.02), with NRP demonstrating superior outcomes at 3 years (83.3%) compared to 60.7% for OCS and 80.0% for DBD. Conclusion: Both procurement methods demonstrate comparable short-term survival and graft function. However, long-term outcomes are more favorable among NRP recipients than OCS and conventional DBD methods. Nevertheless, continued investigation is needed to understand why this mortality difference exists.