Cardiac Allograft Vasculopathy and Secondary Outcomes at 1-year in Heart Transplantation from Circulatory Death Donors.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is a leading cause of graft-failure and mortality beyond the first year after heart-transplantation (HT). As use of donation after circulatory-death (DCD) donors increases, it remains unclear whether one-year CAV risk differs from donation after brain-death (DBD) donors or varies by DCD procurement technique (direct procurement and perfusion [DPP] vs normothermic-regional-perfusion [NRP]). METHODS: Using the UNOS registry, adult heart transplants performed between January 2020 and June 2024 with follow-up through June 2025 were analyzed. One-year CAV was compared between DBD and DCD recipients using unadjusted and adjusted logistic regression analyses. Propensity-scores were used to create matched DBD and DCD-HT cohorts within the same HT centers to account for center-level variability in CAV diagnostic modalities and immunosuppression practices. Additional matched cohorts compared DPP and NRP procurement techniques for DCD-HTs against DBD-HTs. RESULTS: Among 12,630 eligible transplants with one-year survival (11,393 DBD; 1,237 DCD), one-year CAV rates were similar [6.22% vs 5.90%; adjusted OR 0.99 (95% CI: 0.77-1.28), p=0.94], a finding consistent across multiple adjusted models. Secondary outcomes (chronic dialysis, hospitalization for infection or rejection, impaired functional status) were also comparable. In 1,106 propensity-matched pairs of DBD and DCD-HTs from the same centers, CAV remained similar [6.51% vs 5.61%; OR 0.85 (95% CI: 0.60-1.21), p=0.37). Analyses stratified by DCD procurement method (DPP and NRP) likewise showed no significant differences in CAV risk. CONCLUSION: One year CAV and other key secondary clinical outcomes were similar DBD and DCD-HT recipients, irrespective of DPP or NRP procurement method. Intermediate and long-term CAV risk in DCD-HT needs to be further clarified.