Hearts Donated After Circulatory vs Brain Death Tied to More Graft Dysfunction but Similar Survival

NEW ORLEANS, LA—Hearts derived from donors following circulatory death (DCD) have a higher rate of primary graft dysfunction (PGD) following transplantation than those donated after brain death (DBD), according to new data. That said, the patients who receive the organs see similar survival through 5 years.

The findings, though retrospective, support the expansion of DCD heart transplantation with “thoughtful donor selection,” said Tal Kibel (Drexel University College of Medicine, Philadelphia, PA), a medical student who presented the findings at the recent 2025 Society of Thoracic Surgeons  Annual Meeting.

In the US, the United Network for Organ Sharing (UNOS) says, DCD accounted for 43% of all deceased organ donors in 2024, but only a minority of cardiac transplantations are done using hearts obtained after circulatory death. Cardiac DCD transplant is growing, however, and several studies have now shown the feasibility of using these hearts as well as satisfactory longer-term outcomes.

Cardiac DCD transplant is growing, however, and several studies have now shown the feasibility of using these hearts as well as satisfactory longer-term outcomes.

For the current study, researchers reviewed data from UNOS on 2,706 and 18,872 patients who received DCD and DBD heart transplant in the US, respectively, between December 2019 and September 2025. Those in the DCD group were more likely to be male but less likely to have pulmonary hypertension or be on an intra-aortic balloon pump or extracorporeal membrane oxygenation (ECMO) compared to those in the DBD arm. Procurement distance was on average longer for DCD versus DBD hearts (380.9 vs 299.3 miles).

Following transplantation, more than twice as many of those who received DCD hearts experienced PGD compared to their DBD counterparts (10.2% vs 5.0%; P < 0.001). Additionally, there was more need for dialysis (21.9% vs 17.3%; P < 0.001) with DCD but no difference in the rate of mortality at 30 days (2.9% vs 2.8%; P = 0.83) or hospital length of stay (24 vs 25 days; P = 0.06).

At 5 years, there was no difference in the adjusted rate of all-cause mortality between the groups (76.5% vs 76.9%; HR 1.07; 95% CI 0.93-1.24).

With DCD, the hearts are preserved in two ways: the normothermic regional perfusion (NRP) technique, which involves restoring partial circulation in the donor’s body after circulatory death is declared, and direct procurement and perfusion (DPP), where the heart is reanimated on an extracorporeal perfusion machine and assessed. 

When the DCD patients were stratified by use of NRP (n = 839) or DPP (n = 1,867), there was no difference in the rates of PGD (10.1% vs 10.3%; P = 0.9) or need for dialysis (21.2% vs 22.2%; P = 0.55). However, the recipients of DCD hearts taken with NRP had half the mortality of the DPP arm, both in the hospital (2.4% vs 5.4%; P < 0.001) and at 30 days (1.7% vs 3.4%; P = 0.018). Survival was similar at 5 years (81.8% vs 75.2%; P = 0.1).

Kibel acknowledged that the dataset was sometimes inconsistent and incomplete, without information on preservation strategy or intraoperative variables. Lastly, NRP and DPP classifications were based on time and not necessarily accurate.

In an email, senior author Masaki Tsukashita, MD (Allegheny Health Network, Pittsburgh, PA), told TCTMD that ECMO use has been previously linked to PGD, though the etiology of this outcome is “multifactorial.”

“Our speculation is that PGD in DCD is mostly driven by donor factors (warm ischemic time, long transport, myocardial edema, etc), which can be reversible if the donor heart was [a] relatively healthy, good functioning one without major structural valve [or] coronary artery disease,” he explained. “Whereas PGD in DBD is mostly driven by recipient factors, [including] sick recipients on VA ECMO [or] mechanical ventilator, bleeding/massive transfusions during transplant, [and] high pulmonary vascular resistance.”

As far as procurement goes, several nonrandomized studies have already shown a lower PGD rate with NRP compared with DPP, but the former has been plagued by ethical concerns, with many states imposing a moratorium on the practice. A new technique called rapid recovery with extended ultraoxygenated preservation (REUP) is showing promise, but it’s not yet used widely.

“It is well known that longer the cold ischemic time, the higher the PGD rate,” Tsukashita said. REUP “may be a breakthrough. . . . However, the data is still limited to a single institution experience. I would like to see wider adoption of the method and data based on multicenter experience.”