Abstract
Objective
Donor hearts that have undergone cardiopulmonary resuscitation (CPR) were previously considered marginal donors. We aimed to determine how donor CPR influences recipient outcomes (CPR+ vs CPR−). Additionally, we evaluated the overall use of CPR+ donor hearts in the modern era.
Methods
All single heart organ transplants in the United States from 2014 to 2023 were obtained for adults older than age 18 years. Survival curves were built for overall and graft survival using a Kaplan-Meier method with a log-rank test used to test for differences. Multivariate Cox-regression was performed on recipient survival with CPR status and other recipient variables as covariates.
Results
From 2014 to 2023, there were 13 994 CPR− donors and 15 601 CPR+ donors throughout the study period. There was no significant difference in patient survival at 30 days, 1 year, and 5 years (P = .09). Graft survival over 5 years was similar between subgroups of CPR ≤15 minutes, 16 to 30 minutes, or >30 minutes (P = .94). Use of heart transplants from donors resuscitated using CPR increased throughout the study, with CPR+ donors representing >50% of all donors since 2017.
Conclusions
Heart donors who are CPR+ are being used at an increased frequency and now represent most donors. CPR+ hearts have statistically equivalent patient and graft survival outcomes over 5 years. Hearts that have undergone CPR, even for periods of >30 minutes, can be safely utilized.
Key Words: heart transplant, cardiopulmonary resuscitation, organ donation, cardiac arrest
Graphical Abstract
Hearts from CPR+ donors demonstrate similar long-term survival to CPR− donors. Shaded regions represent 95% CI.
Central Message.
Hearts from CPR+ donors are increasingly used, showing comparable outcomes to donation after cardiac and brain death donors, even after CPR durations exceeding 30 minutes.
Perspective.
Previous studies have shown that hearts from donors who have undergone cardiopulmonary resuscitation can be utilized with comparable outcomes. However, there's been limited evidence since 2018 regarding the overall usage of these donors We investigated the outcomes and trends of transplanting hearts from donors who previously underwent cardiopulmonary resuscitation in the modern era.
As heart transplantations (HTs) become increasingly performed, we continue to face a shortage of donor organs.1 To meet these demands, initial suggestions to utilize only optimal donor hearts have been challenged.2 Some examples of marginal donors include those older than age 55 years,3 tested positive for hepatitis C,4 have a history of cocaine use,5 ejection fraction <45%,6 body mass index (BMI) mismatch,7,8 donation after circulatory death (DCD),9 and donor hearts that have previously received cardiopulmonary resuscitation (CPR).2,10, 11, 12 In the setting of the opioid epidemic since 2000, there has been an approximately 10-fold increase in overdose death donors (ODD).13 For these patients, the depressed respiratory function results in cardiac arrest, anoxic brain injury, and higher rates of cardiopulmonary resuscitation (CPR) compared with other donors.13 As the opioid epidemic continues, we may expect to evaluate donors who underwent CPR more frequently.
A recent extensive review of donor heart selection criteria provided class IIa recommendations in support of using donor hearts that underwent CPR.11 This recommendation has been extended for prolonged CPR lasting >30 minutes when echocardiographic and hemodynamic function remain stable.11 Single-institution studies have supported this, and retrospective reviews of United Network for Organ Sharing (UNOS) registry support similar graft function and survival in hearts recovered after CPR.10,12,14,15 Despite this, hearts resuscitated by CPR (CPR+) have previously been shown to be underutilized, with only 28.8% of potential CPR+ donors being procured between 1998 and 2012.16 Here, we provide an updated analysis of the UNOS database between 2014 and 2023 regarding the outcomes of utilizing CPR donor hearts.
Methods
Data Source
We retrospectively reviewed the Standard Analysis and Research files within the UNOS registry, which include prospectively collected deidentified, patient-level data on all organ transplants in the United States. Thus, this study was deemed exempt from the Virginia Commonwealth University Institutional Review Board.
Study Population
We identified records of all adult patients (older than age 18 years) listed for HT in the United States from January 2014 to June 2023. Recipients were grouped by whether CPR was performed on their donors (CPR+) versus donor who did not undergo CPR (CPR−). Patients with simultaneous multiorgan transplants and BMI >55 or <18.5 were excluded from this study. Patients were further separated into groups based on the duration of CPR, including ≤15 minutes, 16 to 30 minutes, and >30 minutes.
Statistical Analysis
Analysis was performed to evaluate donor, recipient, and outcome data. Categorical variables between CPR+ and CPR− were compared using a χ2 or Fischer exact test. Continuous variables were assessed using a Welch 2 sample t test or Wilcoxon-rank sum test, depending on whether the variable was normally distributed. The Kaplan-Meier method was used to plot and analyze overall survival between CPR+ and CPR− donor cohorts, and a log-rank test was used to test for differences between groups. The primary outcomes were posttransplantation patient survival at 30 days, 1 year, and 5 years. Secondary outcomes were graft survival at 30 days, 1 year, and 5 years, duration of CPR, and rates of acute rejection. Adjusted multivariable Cox regression was performed on recipient survival with CPR status and other recipient variables as covariates. The 95% CI was reported for all relevant variables. All statistical analyses were conducted using R version 4.3.0 (R Foundation for Statistical Computing). All P values were based on 2-sided statistical tests.
Results
Donor Characteristics
A total of 15 601 CPR+ donors (52.7%) were utilized for HT during the study period (Table 1). Donors from the CPR+ group were slightly younger, with a mean age of 28.2 ± 13.29 years CPR+ versus 30.09 ± 12.96 years for the CPR− group (P < .001). CPR+ donors were less likely to have experienced head trauma 21% CPR+ versus 68% CPR−, and more likely to have had anoxic brain injury 73% CPR+ versus 6.2% CPR−. CPR− donors were more likely to require inotropic support, 37% versus 34% (P < .001). Hepatitis C was seen more commonly in CPR+ donors at 9.1% versus 2.8%. Cigarette use was noted to be more common in CPR+ donors at 11% versus 8.7% CPR− (P < .001). Cocaine use was also noted to be higher in CPR+ donors at 28% versus 16% in CPR− donors (P < .001). Additionally, history of other drug use was higher in the CPR+ donor group at 58% versus 47% in the CPR− group (P < .001). More CPR+ donors used other drugs during the past 6 months, 48% versus 35% (P < .001). Notably, heavy alcohol use, diabetes, and DCD use were similar between groups. CPR+ donors had slightly lower left ventricular ejection fraction (LVEF) of 61.8% ± 6.93% CPR+ versus 62.18% ± 6.66% CPR−. Mean ischemia time was slightly shorter at 3.35 ± 1.16 hours for CPR+ versus 3.41 ± 1.16 hours for CPR−. The mean duration of CPR was 23.54 ± 17.04 minutes. Between groups, 5380 underwent CPR ≤15 minutes (42%), 4475 underwent CPR for 16 to 30 minutes (35%), and 324 underwent CPR for >30 minutes (24%). The duration of CPR was unknown in 2659 patients (17%).
Table 1.
Baseline recipient and donor characteristics by donor cardiopulmonary resuscitation (CPR) status
| Characteristic | Overall (N = 29,595) |
No CPR (n = 13,994) |
Yes CPR (n = 15,601) |
P value∗ |
|---|---|---|---|---|
| Recipient | ||||
| Age (y) | 46.64 ± 20.41 | 47.72 ± 19.14 | 45.67 ± 21.44 | <.001 |
| BMI | 26.43 ± 5.92 | 26.66 ± 5.67 | 26.22 ± 6.14 | <.001 |
| Females | 8717 (29) | 3987 (28) | 4730 (30) | <.001 |
| Diabetes | 7293 (25) | 3559 (25) | 3734 (24) | .003 |
| Blood group | .62 | |||
| A | 11,499 (39) | 5442 (39) | 6057 (39) | |
| AB | 1518 (5.1) | 729 (5.2) | 789 (5.1) | |
| B | 4427 (15) | 2121 (15) | 2306 (15) | |
| O | 12,151 (41) | 5702 (41) | 6449 (41) | |
| Creatinine (mg/dL) | 1.12 ± 0.65 | 1.15 ± 0.64 | 1.10 ± 0.66 | <.001 |
| Pre-HT IABP | 4455 (15) | 1989 (14) | 2466 (16) | <.001 |
| Pre-HT ECMO | 1030 (3.5) | 484 (3.5) | 546 (3.5) | .80 |
| PCWP | 17.45 ± 8.66 | 17.57 ± 8.72 | 17.34 ± 8.61 | .03 |
| MPAP | 26.46 ± 10.15 | 26.57 ± 10.12 | 26.37 ± 10.17 | .10 |
| Allocation status at transplant | <.001 | |||
| Prior status 1A | 5954 (20) | 2790 (20) | 3164 (20) | |
| Prior status 1B | 7117 (24) | 3719 (27) | 3398 (22) | |
| Prior status 2 | 3996 (14) | 2039 (15) | 1957 (13) | |
| Status 1 | 724 (2.4) | 342 (2.4) | 382 (2.4) | |
| Status 2 | 3755 (13) | 1646 (12) | 2109 (14) | |
| Status 3 | 1499 (5.1) | 644 (4.6) | 855 (5.5) | |
| Status 4 | 4042 (14) | 1717 (12) | 2325 (15) | |
| Status 5 | 13 (<0.1) | 8 (<0.1) | 5 (<0.1) | |
| Status 6 | 2120 (7.2) | 891 (6.4) | 1229 (7.9) | |
| Donor | ||||
| Age (y) | 29.08 ± 13.17 | 30.09 ± 12.96 | 28.18 ± 13.29 | <.001 |
| Female | 9018 (30) | 3906 (28) | 5112 (33) | <.001 |
| Cause of death | <.001 | |||
| Anoxia | 12,192 (41) | 863 (6.2) | 11,329 (73) | |
| Cerebrovascular/stroke | 3875 (13) | 3093 (22) | 782 (5.0) | |
| CNS tumor | 122 (0.4) | 97 (0.7) | 25 (0.2) | |
| Head trauma | 12,727 (43) | 9524 (68) | 3203 (21) | |
| Other | 679 (2.3) | 417 (3.0) | 262 (1.7) | |
| Inotropes | 10,377 (36) | 5119 (37) | 5258 (34) | <.001 |
| Cigarette use | 2900 (10.0) | 1202 (8.7) | 1698 (11) | <.001 |
| Cocaine use | 6415 (22) | 2240 (16) | 4175 (28) | <.001 |
| Heavy alcohol use | 4665 (16) | 2270 (17) | 2395 (16) | .06 |
| CDC high risk | 7624 (26) | 2518 (18) | 5106 (33) | <.001 |
| Diabetes | 1024 (3.5) | 461 (3.3) | 563 (3.6) | .13 |
| Blood group | .50 | |||
| A | 10,365 (35) | 4949 (35) | 5416 (35) | |
| AB | 603 (2.0) | 287 (2.1) | 316 (2.0) | |
| B | 3193 (11) | 1479 (11) | 1714 (11) | |
| O | 15,434 (52) | 7279 (52) | 8155 (52) | |
| Hypertension | 3980 (14) | 2059 (15) | 1921 (12) | <.001 |
| LVEF (%) | 62.00 ± 6.81 | 62.18 ± 6.66 | 61.84 ± 6.93 | <.001 |
| CPR duration (min) | NA | 23.54 ± 17.04 | ||
| CPR duration group (min) | >.9 | |||
| ≤15 | 0 | 5380 (42) | ||
| 16-30 | 0 | 4475 (35) | ||
| >30 | 0 | 3087 (24) | ||
| Ischemia time (h) | 3.38 ± 1.16 | 3.35 ± 1.16 | 3.41 ± 1.16 | <.001 |
| DCD | 843 (2.8) | 390 (2.8) | 453 (2.9) | .5 |
| HEP C+ | 1822 (6.2) | 397 (2.8) | 1425 (9.1) | <.001 |
| Other drug use | 15,615 (53) | 6614 (47) | 9001 (58) | <.001 |
| Continued use of other drugs during the past 6 mo | 12,367 (42) | 4907 (35) | 7460 (48) | <.001 |
| >3 Inotropes at transplant | 21 (<0.1) | 13 (<0.1) | 8 (<0.1) | .21 |
Values are presented as mean ± SD or n (%). BMI, Body mass index; HT IABP, heart transplant intra-aortic balloon pump; HT ECMO, heart transplant extracorporeal membrane oxygenation; PCWP, pulmonary capillary wedge pressure; MPAP, mean pulmonary artery pressure; CNS, central nervous system; CDC, Centers for Disease Control and Prevention; LVEF, left ventricular ejection fraction; NA, not available; DCD, donation after circulatory death; HEP C+, positive for hepatitis C.
Welch 2-sample t test, Pearson χ2 test, or Fisher exact test.
Recipient Demographics and Characteristics
Recipients of CPR+ donors appeared slightly younger, with a mean age of 45.67 ± 21.44 years versus 47.72 ± 19.14 years CPR− (P < .001). Female recipients were slightly more common in the CPR+ group 30% versus 28% in the CPR− group. Diabetes, blood grouping, and BMI were similar between groups. CPR+ recipients were more likely to have had intra-aortic balloon pump support at 16% versus 14% (P < .001). Mean pulmonary artery pressure and extracorporeal membrane oxygenation bridging to transplant between groups was insignificant. There was a statistically significant difference between all listing statuses and CPR+ recipients (P < .001), although the relative rate of CPR+ to CPR− for each status was similar across both the prior statuses and the post-2018 statuses. Before 2018 status 1a had a relative rate of 53.1% CPR+, 47.7% for status 1b, and 49% for status 2. For the most recent status listings relative rates of CPR+ donor utilization was 52.8% for status 1, 56.1% for status 2, 57% for status 3, 57.5% for status 4, 38.4% for status 5, and 58% for status 6. The percentage of CPR+ hearts transplanted significantly increased over the study period ranging from 41.9% during 2014 to 59.6% during the first half of 2023 (Figure 1). Since the allocation system change in October 2018, the number of HTs with CPR+ donor hearts have continued a similar upward trend.
Figure 1.
Cardiopulmonary resuscitation (CPR) status of heart transplants by transplant year.
Posttransplant Outcomes
Both patient and graft survival at 30 days, 1 year, and 5 years was neither clinically nor statistically significant. Recipients of CPR+ donors had nearly equivalent survival at 30 days (96.9% vs 97.0%), 1 year (91.5% vs 91.2%), and 5 years (79.9% vs 78.9%) (P = .09) (Table 2 and Figure 2). Graft survival showed a similar trend with 30-day survival (96.5% vs 96.7%), 1 year (91.2% vs 91.0%), and 5-year graft survival (79.2% vs 78.1%) (P = .07). Graft survival over 5 years was similar between subgroups of CPR+ ≤15 minutes, 16 to 30 minutes, or >30 minutes (P = .94) (Figure 3). Acute rejection during the first year was equal between groups at 18.01% CPR+ versus 18.56% (P = .24). Transplantation of CPR+ donors had no significant association with recipient survival (hazard ratio, 0.97; P = .276) (Table 3). The strongest predictors of mortality were recipient extracorporeal membrane oxygenation before transplant (hazard ratio, 1.69; P < .001), recipient diabetes (hazard ratio, 1.32; P < .001), and DCD (hazard ratio, 1.31; P = .018).
Table 2.
Survival and clinical outcomes of heart transplant from a donor who was resuscitated by cardiopulmonary resuscitation (CPR)
| Characteristic | No CPR (n = 13,994) |
Yes CPR (n = 15,601) |
P value∗ |
|---|---|---|---|
| Kaplan-Meier (%) | |||
| 30 d | 97.0 (96.7-97.3) | 96.9 (96.6-97.2) | .09 |
| 1 y | 91.2 (90.8-91.7) | 91.5 (91.0-91.9) | |
| 5 y | 78.9 (78.1-79.7) | 79.9 (79.1-80.8) | |
| Kaplan-Meier graft (%) | |||
| 30 d | 96.7 (96.4-97.0) | 96.5 (96.2-96.8) | .08 |
| 1 y | 91.0 (90.5-91.5) | 91.2 (90.7-91.7) | |
| 5 y | 78.1 (77.2-78.9) | 79.2 (78.4-80.1) | |
| Acute rejection | 2554 (18.56) | 2749 (18.01) | .24 |
Values are presented as survival estimate (95% CI) or n (%).
Welch 2-sample t test, Pearson χ2 test, or Fisher exact test.
Figure 2.
Overall survival with a donor who was resuscitated by cardiopulmonary resuscitation (CPR+) versus a donor was not resuscitated by CPR (No CPR).
Figure 3.
Graft survival stratified by cardiopulmonary resuscitation time.
Table 3.
Multivariate Cox regression analyses on the risk of mortality
| Predictor | Hazard ratio | 95% CI | P value |
|---|---|---|---|
| DCD | 1.31 | 1.05-1.65 | .018 |
| CPR | 0.97 | 0.92-1.02 | .276 |
| Recipient age | 1.01 | 1.00-1.01 | <.001 |
| Recipient male | 0.98 | 0.92-1.04 | .567 |
| Recipient ECMO | 1.69 | 1.46-1.96 | <.001 |
| Recipient IABP | 0.99 | 0.91-1.08 | .827 |
| Recipient diabetes | 1.32 | 1.24-1.40 | <.001 |
DCD, Donation after cardiac death; CPR, cardiopulmonary resuscitation; ECMO, extracorporeal membrane oxygenation; IABP, intra-aortic balloon pump.
Discussion
Expanding the donor pool is essential to meet rising demand for HT.17 Growing evidence that hearts from CPR+ donors perform comparably has spurred their acceptance.10,12,18,19 CPR+ grafts now account for >50% of US transplants—up from just 4.7% reported for 1994-2012.12 This proportion remains unchanged by the 2018 allocation revision, indicating an already stable practice. Although the 2018 allocation changes primarily targeted recipient prioritization, it is plausible that they influenced donor selection by broadening geographic sharing and increasing the proportion of recipients with higher acuity.20 These shifts often necessitate faster decision making and may reduce donor selectivity, contributing to greater acceptance of previously underutilized donor categories, including CPR+ hearts. Published estimates of potential CPR+ donors vary widely—11% of all donors in 1998-2012 and 51% of donors aged ≤40 years during 2001-2021.16,21 This high utilization suggests an even larger reservoir of suitable CPR+ hearts may remain untapped.
Our findings are consistent with several recent studies that have reaffirmed the safety and efficacy of utilizing donor hearts that have undergone CPR. For example, Kulshrestha and colleagues21 reported that even up to 1 hour of donor resuscitation did not adversely influence pediatric HT survival, reinforcing the concept that CPR duration alone should not preclude use of otherwise suitable organs. Similarly, Yang and colleagues22 and Rajsic and colleagues23 analyzed large multi-institutional datasets and demonstrated no significant difference in graft or recipient survival between CPR+ and CPR− donor hearts, echoing our findings across multiple timepoints. Most recently, Iyanna and colleagues24 analyzed the influence of CPR on DCD HT using the UNOS registry and found that CPR preceding DCD procurement did not adversely influence posttransplant survival or primary graft dysfunction (PGD). Their results suggest that the additional ischemic insult from CPR in the context of DCD does not significantly compromise myocardial viability, provided graft function and hemodynamics remain acceptable before recovery.24 This aligns with our broader findings that CPR+ donor hearts, whether from donation after brain death or DCD sources, demonstrate survival outcomes comparable to CPR− donors even when CPR duration exceeds 30 minutes. Although our study encompassed both donor types across a wider time frame, the work by Iyanna and colleagues24 reinforces the physiologic resilience of CPR+ grafts and supports expanding acceptance criteria to include CPR-exposed DCD donors, a population that continues to grow in the United States. Our study extends this literature by analyzing the largest contemporary national cohort to date, encompassing both short- and long-term outcomes over nearly a decade and capturing the post-2018 allocation era, thereby providing a more comprehensive view of evolving CPR+ donor utilization trends.
Prior evaluation of potential CPR donors revealed multiple factors that led to increased procurement rates, including shorter CPR duration (≤15 minutes), increased LVEF, and younger age.16 Of these potential mediating factors, the duration of CPR >30 minutes has repeatedly been shown to be noninferior, which is again noted in our study.10,21 Donors who experienced >30 minutes of CPR made up 24% of all CPR+ donors, which was the smallest of the 3 groups. This may be because more potential donors were rejected from this group or there were fewer potential members. Indeed, even in-hospital CPR, when prolonged beyond 39 minutes, has been shown to have an exceeding low survival rate below 1%, leading to termination of resuscitation efforts.25 Physiologically, ischemic time during cardiac arrest before CPR results in both direct injury to the myocardium and reperfusion injury after return of circulation.26 From a biochemical standpoint, CPR is associated with a significant rise in troponin.27 However, both in CPR+ and CPR− donors, peak troponin levels have shown no significant association with recipient outcomes at up to 5 years.10,19,27
Prior analysis noted higher listing status was associated with higher rates of CPR+ donors, suggesting that sicker and less stable patients may be allocated these organs due to need.19 Because allocation change rates were comparable across statuses and peaked in status 4 and status 2, this indicates that CPR+ hearts are no longer preferentially allocated to the sickest candidates. Galeone and colleagues19 noted a 10-year survival rate of 69.4% for recipients of CPR+ donor hearts compared with 50.4% for those receiving CPR− donor hearts. However, this may be due to the younger age of CPR+ donors,19 which we have also shown in our cohort. Donors younger than age 50 years have previously been shown to have survival benefits.28 Of note, a 1-year decrease in donor age has previously been associated with a 1% increase in 10-year survival.28 Physiologically, CPR+ hearts may exhibit transient postischemic myocardial stunning that can recover with adequate hemodynamic support.25 CPR itself initiates partial coronary perfusion early in the arrest, often within 1 to 2 minutes, which may preserve myocardial oxygenation despite low overall flow.29 Elevated troponin levels in CPR+ donors reflect transient myocardial injury but are not associated with worse outcomes posttransplant, consistent with previous reports.10,27 Experimental and clinical data indicate that warm ischemia during arrest and the mechanical trauma of CPR are often offset by shorter ischemic times and donor youth, resulting in preserved function.25,29 An interplay between age and donor ischemia time has been previously described, with younger donors able to tolerate ischemia better, resulting in improved survival.28,30,31 Our study further indicates that CPR+ donors experienced shorter ischemia time compared with CPR− donors, which may explain why CPR+ grafts demonstrate comparable survival outcomes.
A prior concern regarding transplanting hearts from CPR+ donors is the risk of PGD. Rates of mild to severe PGD have previously been noted to be close to 15% in some studies, with severe PGD said to have up to 50% rate of mortality or retransplantation.32 Because UNOS only began to mandate reporting of PGD as of 2023, we could not report these outcomes for CPR+ donors. However, 30-day survival may offer a reasonable approximation for severe dysfunction rates and our study demonstrates high rates of survival at 30 days for recipients of CPR+ donor hearts. Another metric that may better assess meaningful recovery after HT is evaluating days out of the hospital. A single-center retrospective review by Roth and colleagues14 found statistically similar rates of days out of hospital at 1 year compared with recipients of CPR+ and CPR− donor hearts. This further supports the use of CPR+ donor hearts and suggests that these patients may not be dependent on in-hospital mechanical support devices.
Furthermore, during our study period, CPR+ donors were more likely to have experienced anoxic brain injury than CPR− donors, which was a departure from Quader and colleagues.12 This may be partially be attributed to the opioid epidemic and increased rates of ODD, who are more likely to have experienced cardiac arrest and subsequent anoxic injury.13 Other drug use during the 6 months leading up to donation, which includes opioid use, was higher in the CPR+ group. Of note, the Centers for Disease Control and Prevention recently found that rates of injection overdose are decreasing; however, rates of smoking overdoses continue to increase.33 Previously, Phillips and colleagues13 found that potential ODD cardiac donors were more likely to be discarded for other reasons, such as hepatitis status or LVEF <50%, and not due to CPR status.
Despite positive results of our study, we may yet be underutilizing marginal CPR+ donors,2,11,12 especially those older and with mildly reduced EF. Cardiac arrest during CPR can result in temporary, reversible depression of LVEF to <50%, with 1 study reporting more than half of these patients having an LVEF >50% at 6 months.29 For young CPR− donors with an initially low LVEF <45%, it is currently recommended that they undergo dobutamine stress echocardiography because ventricular wall augmentation predicts improvement in survival.11,34 However, these recommendations do not exist for CPR+ donors. As such, some proportion of CPR+ donors may have been missed. In addition, there were only 453 CPR+ DCD donors during the study period. This will likely increase substantially as DCD becomes more widely accepted and utilized across the United States, especially as more is published in support of utilization of these donors.32,33,35 However, at this point, the amount of potential DCD CPR + donors remain unclear. It is also important to consider the role of the donors’ families. One study found that families of donors were more likely to authorize donation if the potential donor had undergone CPR.34 Thus, our updated data demonstrate that, during the post-2018 allocation change era, hearts from CPR+ donors may be utilized with comparable outcomes to hearts from CPR− donors even with prolonged duration of CPR >30 minutes.
Limitations
First, our study relies on an extensive retrospective database, introducing selection bias. Second, it is not possible to identify all PGD using the UNOS database. Third, it is possible that down time before the initiation of CPR was longer than documented. This may have resulted in significantly different times despite similar reported times of CPR, although the true times would be longer than reported. CPR duration was not documented for 2659 cases, which is 17% of the CPR+ sample. Fourth, we were unable to examine the interval between donor arrest and organ procurement because this variable is not captured in UNOS datasets. This represents an important physiologic factor that may influence outcomes. We are also unable to account for any discrepancies in donor LVEF between the time of initial presentation and organ procurement. This is largely due to the lack of serial donor echocardiograms, which limits our ability to study the reversibility of depressed EF after CPR. Finally, without access to the list of all potential donors, it is not possible to say how many CPR+ donors were underutilized, especially among DCD candidates.
Conclusions
During the past decade, CPR+ donor hearts have demonstrated comparable patient and graft survival outcomes over 5 years. Given current recommendations to utilize only ideal CPR+ donors, we may be failing to optimize their potential. However, donor hearts that have undergone CPR, even for prolonged periods beyond 30 minutes, can be safely utilized if hemodynamics and EF are preserved.
Conflict of Interest Statement
The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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