Primary Graft Dysfunction Requiring Mechanical Circulatory Support After Heart Transplantation From Circulatory Death Donors

Primary graft dysfunction (PGD) is a significant cause of early mortality after heart transplantation (HT). Early experience with HT from donation after circulatory death (DCD) donors suggest an increased risk of PGD requiring mechanical circulatory support (MCS). We evaluated PGD requiring MCS among 3,284 adult HTs (2,683 donation after brain death [DBD] and 601 DCD-HTs) registered in the United Network for Organ Sharing (UNOS) database between September 2023 and September 2024. Compared with DBD-HT recipients, DCD-HT recipients demonstrated a higher incidence of severe PGD requiring extracorporeal membrane oxygenation (ECMO) ± left ventricular unloading (10.15% vs. 5.67%; adjusted odds ratio [OR] = 1.92 (1.39-2.66); p < 0.01), ECMO or "continuous-flow percutaneous ventricular-assist device (CF-PVAD) alone" (10.65% vs. 6.00%; adjusted OR = 1.93 [1.41-2.65]; p < 0.01), and PGD requiring any form of temporary MCS (19.30% vs. 13.72%; adjusted OR = 1.73 [1.35-2.22]; p < 0.01). Increased risk persisted in sensitivity analyses across most donor-recipient subgroups. Within DCD-HTs, risk of severe PGD was unaffected by procurement method. Although severe persistent PGD rates declined by 72 hours post-transplantation, they remained slightly elevated in DCD-HTs (6.49% vs. 4.55%; p < 0.05). Importantly, despite the increased occurrence of severe PGD in DCD-HTs, overall, 90 day survival rates were similar between DBD and DCD-HT groups. These results highlight the need to investigate potential differences in PGD mechanisms between DCD and DBD-HTs.