Controlled Hypothermic Preservation of Donor Hearts and Posttransplant Outcomes: A Propensity-Score Analysis With Cost Modeling.

BACKGROUND: The economic burden of heart disease has increased substantially over the past decade. Although advancements in heart preservation have led to improvements in posttransplant outcomes, their impact on posttransplant costs in the first year remains unclear. METHODS: We compared propensity-matched cohorts from donation after brain death donors at 18 US centers in the retrospective GUARDIAN-Heart Registry using ice (ICE, n = 662) or the SherpaPak Cardiac Transport System (SCTS, n = 807), matching on exact site, era, presence of any mechanical circulatory support, donor age, ischemic time, IMPACT (Index for Mortality Prediction After Cardiac Transplantation) score, and preoperative mechanical ventilation. Costs were derived from hospital-specific cost-to-charge ratios from the 2023 American Hospital Directory database and the Medicare Physician Fee Schedule (2025), including both hospital and professional costs. A Monte Carlo simulation was run on the variables affecting costs when using either ICE or SCTS with a variation of ±25% to determine the robustness of findings and at which point either ICE or SCTS became the less-expensive alternative. RESULTS: SCTS was associated with significant clinical improvements, such as decreased severe primary graft dysfunction, lower severe right ventricular dysfunction, and less need for mechanical support. Within 1 year, SCTS was linked to greater survival rates, fewer rejections, and fewer hospital readmissions. Clinical improvements appeared to translate into average per-patient cost reductions of $34,174, or a net $14,982, including device cost. SCTS was less expensive 72% of the time over 10,000 iterations. CONCLUSIONS: These data suggest that SCTS is associated with improved outcomes and lower modeled costs across multiple analytic approaches. Given fiscal pressures, strategies that improve outcomes and costs are particularly relevant.