ORIGINAL RESEARCH article
Front. Transplant.
Sec. Thoracic Transplantation
Double Whammy: Increased Severe Primary Graft Dysfunction After Prolonged Warm Ischemia and Inadequate Oxygen Delivery During Heart Transplant
Provisionally accepted
Chen Chia Wang*
Awab AhmadMark PetrovicWalter NavidChristian EidsonJohn TrahanasAaron WilliamsSwaroop BommareddiDuc NguyenTarek AbsiEric QuintanaStephen DeVriesJoey LeporeMatthew WarhooverAniket RaliKelly SchlendorfMatthew BacchettaAshish Shah
Brian Lima*- Vanderbilt University Medical Center, Nashville, United States
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Objective: This exploratory study examined the relationship between oxygen delivery index (DO2i) during DCD heart transplant (HT), warm ischemic time, and posttransplant outcomes. Methods: All DCD HT between 10/2021-12/2024 using normothermic regional perfusion (NRP) at our institution were included. Multiorgan transplants and congenital heart disease patients were excluded. Critical areas—sum of magnitude and duration of DO2i under specific thresholds—were calculated for thresholds 300, 280, and 260mL/min/m2. Receiver operating characteristics (ROC) analysis dichotomized the critical area into high area (low DO2i) and low area (high DO2i) groups. Patients were then stratified into 4 groups based on high/low functional warm ischemic time (FWIT), and high/low DO2i. Outcomes were compared across groups. Results: The critical area under 260mL/min/m2 was the best predictor of severe primary graft dysfunction (PGD). 102 patients met inclusion criteria, and were stratified into four groups based on FWIT above/below 23 mins and critical area below/above 1424 mL/m2 (identified by ROC analysis). 39 (38.2%) patients had low FWIT/ high DO2i, 18 (17.6%) had low FWIT/ low DO2i, 24 (23.5%) had high FWIT/high DO2i, and 21 (20.6%) had high FWIT/low DO2i. Rates of severe PGD were greater in the high FWIT/low DO2i group compared to the low FWIT/high DO2i group (23.8% vs 0%, p=0.004). Rates of 30-day mortality were higher in the high FWIT/low DO2i group compared to the low FWIT/high DO2i group (14.3% vs 0%, p=0.039). Conclusions: Higher oxygen delivery during HT was associated with improved short-term outcomes, and may counteract the myocardial damage from warm ischemia during DCD.
Keywords: DCD transplant, goal directed perfusion, Heart transplant, oxygen delivery, Warm Ischemia
Received: 01 Nov 2025; Accepted: 02 Feb 2026.
Copyright: © 2026 Wang, Ahmad, Petrovic, Navid, Eidson, Trahanas, Williams, Bommareddi, Nguyen, Absi, Quintana, DeVries, Lepore, Warhoover, Rali, Schlendorf, Bacchetta, Shah and Lima. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence:
Chen Chia Wang
Brian Lima
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