Pick Your Perfusion: National Outcomes of Normothermic Regional Perfusion versus Direct Procurement and Perfusion in Donation After Circulatory Death Cardiac Transplants.

OBJECTIVE: Donation after circulatory death (DCD) cardiac transplantation has substantially expanded the donor pool; however, the optimal procurement strategy - direct procurement and perfusion (DPP) or normothermic regional perfusion (NRP) - remains actively debated. We compared contemporary national outcomes of NRP versus DPP using the United Network for Organ Sharing (UNOS) registry. METHODS: We analyzed first-time, isolated adult DCD heart transplants performed in the United States between January 1, 2019, and March 31, 2026, using the UNOS Standard Transplant Analysis and Research database. DPP and NRP were defined as a death-to-cross-clamp interval ≤30 and >30 minutes, respectively. Primary outcomes were 1-month, 1-year, and 3-year all-cause mortality. One-to-one propensity score matching (PSM) was performed to compare differences in outcomes between DPP and NRP. RESULTS: The analytic cohort comprised 2,831 DCD heart transplant recipients: 1,737 (61.4%) DPP and 1,094 (38.6%) NRP. DCD comprised 24.6% of all adult heart transplants performed in the United States. After propensity score matching, 939 DPP-NRP pairs were identified. In the matched cohort, survival was lower after DPP than after NRP at 1-month (95.8% vs 97.9%; p=0.01), one year (90% vs 92%, p=0.05), and three years (83.5% vs 86.9%, p=0.04). One year survival was similar on those surviving the first month (94.0% for both groups), as was three year survival conditional on surviving one year (92.7% vs 94.4%, p=0.52). CONCLUSIONS: NRP was associated with a modest short-term perioperative survival benefit compared to DPP. Among recipients who survived the first month, one and three year survival was equivalent.