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Ischemic Time and Severe Primary Graft Dysfunction in Heart Transplantation Using Normothermic Regional Perfusion
Abstract   Peer reviewed

Ischemic Time and Severe Primary Graft Dysfunction in Heart Transplantation Using Normothermic Regional Perfusion

H. Zappacosta, M. Daniel, A. Girish, S. McKay, P. Cho, J. White, J. Song, D. Telesca and A. Ardehali
The Journal of heart and lung transplantation, v 45(5), pp 294-294
Apr 2026
DOI: https://doi.org/10.1016/j.healun.2026.02.632

Abstract

Organ Transplantation Thoracic Surgery
Purpose: Normothermic regional perfusion (NRP) is an expanding method for procurement in donation after circulatory death (DCD). The relationship between cold, functional warm, combined ischemic time, and severe primary graft dysfunction (PGD) in DCD-NRP heart transplant remains unclear. Methods: The United Network for Organ Sharing database was queried for adult DCD-NRP isolated heart transplants from September 2023 to June 2025. NRP was defined as > 30 minutes between time of circulatory death and cross-clamp. Functional warm ischemic time (FWIT) was defined as time between agonal phase start and brain death plus 10 minutes. To control for variability in agonal phase definitions, FWITs > 45 minutes were excluded. Combined ischemic time was defined as the sum of FWIT and cold ischemia. A logistic regression analysis was used to assess predictors of severe PGD. Recipients were categorized according to traditional cold ischemic time limitations: < 4 hours and ≥ 4 hours. Perioperative outcomes were compared. Results: A total of 222 DCD-NRP heart transplants met study criteria. FWIT did not affect odds of severe PGD (Figure) and was not a predictor of severe PGD (Adjusted Odds Ratio (AOR) 0.98; p=0.762). 104 (46.8%) recipients received hearts with a cold ischemic time ≥ 4 hours, and perioperative outcomes were similar to the < 4 hours cold ischemic time group, including severe PGD (8.7% vs 5.1%; p=0.29), 30-day mortality (3.8% vs 3.4%; p=0.45), and in-hospital mortality (4.8% vs 3.4%; p=0.31). Odds of severe PGD across cold and combined ischemic times demonstrated similar curves (Figure). Cold ischemic time and combined ischemic time (per hour) were predictors of severe PGD (AOR 1.98; AOR 1.97), but with statistical significance not exceeding 5.3% and 5.6%, respectively. Conclusion: In DCD-NRP heart transplantation, FWIT does not impact severe PGD outcomes. Though cold ischemia is not a statistically significant predictor of severe PGD in the current dataset, trends point towards this conclusion.

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