Improved Long-Term Outcomes after Heart Transplantation Utilizing Donors with Traumatic Mode of Brain Death

Background:

Donor’s brain death (BD) is associated with impairment of myocardial function and hemodynamic performance and therefore impacts the recipient’s prognosis. The impact of mode of BD on heart transplantation (HTx) outcomes has been poorly studied, with early results suggesting that it might impact survival and vasculopathy. We aimed to explore the impact of mode of donor’s BD on HTx outcomes.

Methods:

All patients who underwent HTx between 1991-2017 and are followed-up at our center were categorized according to donor’s BD mechanism: “traumatic BD” (blunt and penetrating head trauma; TBD) versus “non-traumatic BD” (NTBD). Primary end-points were all-cause mortality and rejections. Rejections were assessed by total rejection score (TRS; 0R=0,1R=1,2R=2,3R=3) and any rejection score (ARS; 0R=0,1R=1,2R=1,3R=), normalized for total endomyocardial biopsies.

Results:

The TBD group included 105 recipients, 85 recipients were classified as NTBD. Pre-operative and operative characteristics of the recipients were similar in both groups . Donors of the TBD group were younger (27.9± vs. 37.4±13.1 years, p<0.001), characterized by shorter hospitalization (3.9±2.1 vs. 5.7±2.3 days, p<0.001), shorter brain injury interval until BD determination (86.3±45.6 vs. 131.9±86.2 hours, p=0.001), reduced incidence of cardio-pulmonic resuscitation (5.81% vs. 22.5%,p=0.005) and lower blood pressure on admission (systolic 121.4±34.1 vs 140.7±38.9,p=0.002; diastolic 69.2±21.4 vs. 85.3±25.8,p<0.001). TBD group suffered less rejections (TRS 0.44±0.32 vs. 0.51±0.38,p=0.04; ARS 0.38±0.26 vs. 0.45±0.31,p=0.03). Kaplan-Meier survival analysis showed that overall survival was significantly higher among the TBD (10 years survival 58% vs. 38% p=0.044; Figure). Consistently, multivariate analysis showed that TBD was independently associated with a significant 42% reduction (HR=0.58;p=0.033) in mortality. These findings were further validated by propensity score analysis.

Conclusions: Mode of BD has significant influence on HTx outcomes. Traumatic BD is associated with reduced mortality and rejections.