Abstract
BACKGROUND: Donation-after-circulatory-death (DCD) heart procurement is enlarging the donor pool, yet its safety in adults with congenital heart disease (ACHD) is uncertain. We compared early (90-day) and mid-term (3-year) graft outcomes after DCD versus donation-after-brain-death (DBD) heart transplantation in ACHD recipients. METHODS: Using the United Network for Organ Sharing registry (1 January 2018 - 1 April 2025), we identified adults (≥18 y) with ACHD undergoing isolated heart transplantation. Retransplants and multiorgan procedures were excluded. The primary endpoint was graft failure (death or retransplant). Survival was analysed with Kaplan-Meier curves, multivariable Cox models, and 1:1 nearest-neighbor propensity-score matching (caliper = 0.25 SD) adjusting for donor and recipient age, sex, body-mass index, renal and hepatic function, support devices, listing status, prior sternotomy, and regional ACHD center volume. RESULTS: Among 726 ACHD transplants, 61 (8.4%) used DCD grafts and 665 (91.6%) used DBD grafts. Baseline clinical characteristics were similar, although DCD grafts had longer ischemic times (median 5.3 h vs 3.8 h, p < 0.001) and more frequent exvivo perfusion (65% vs 5.8%). Unadjusted 90-day and 3-year graft survival were lower after DCD (log-rank p = 0.009 and 0.040, respectively). On multivariable analysis, DCD procurement remained an independent risk factor for graft failure at 90 days (HR 2.56, 95% CI 1.23-5.17) and 3 years (HR 2.11, 95% CI 1.03-3.50).Propensity-matched analysis (n = 148) confirmed inferior 90-day survival for DCD recipients (log-rank p = 0.020). Post-operative morbidity and length of stay did not differ between groups. CONCLUSIONS: In the early US experience, ACHD recipients of DCD hearts experienced significantly worse short- and mid-term graft survival than those receiving DBD hearts, despite comparable peri-operative morbidity. Until preservation strategies further mitigate warm-ischemic injury, careful candidate selection is warranted when allocating DCD grafts to complex ACHD patients.