This registry study examined adult heart transplant recipients (September 2023–December 2025) from the SRTR to determine whether donor type (DCD vs. DBD) and preservation strategy (NRP, ex-vivo perfusion, static cold storage) are associated with survival after severe primary graft dysfunction (PGD), defined as new ECMO or VAD dependence at 24 hours post-transplant.
6.5% of 7,059 recipients (n=462) developed severe PGD. DCD recipients with severe PGD had markedly better 1-year survival than DBD recipients (84.1% vs. 65.1%; log-rank P=0.001), and this held after IPTW adjustment (aHR 0.44; 95% CI 0.23–0.85; P=0.014). Preservation strategy was not independently associated with survival. VAD support at 24 hours (vs. ECMO) was linked to lower odds of 30-day survival.
Subgroup analyses by preservation strategy were limited by small numbers, reducing statistical power. Observational design with IPTW adjustment cannot fully eliminate unmeasured confounding. The study window (Sept 2023–Dec 2025) is relatively short, limiting longer-term follow-up data.
When severe PGD occurs after heart transplant, DCD-sourced grafts appear to recover better than DBD grafts — clinicians should not assume DCD hearts carry worse post-PGD prognosis. Among patients on mechanical support at 24 hours, ECMO may be preferable to VADs as a bridge strategy for early survival.
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