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National Experience With Ex Vivo Machine Perfusion In Pediatric Heart Transplantation
Emily L. Larson, MD, Cathlyn K. Medina, MD, Seth E. M. Wolf, MD, Rebekah R. Boyd, MD, Neel Prabhu, MD, Douglas M. Overbey, MD MPH, Joseph W. Turek, MD MBA PhD.
Duke University Hospital, Durham, NC, USA.
Objective: Ex vivo machine perfusion (EVMP) in pediatric heart transplantation may help expand the donor pool, but understanding of its use is limited to single institution studies.
Methods: We retrospectively reviewed the UNOS/OPTN database to identify pediatric heart-only recipients from 2015-2025, comparing EVMP to non-EVMP recipients via descriptive statistics, Kaplan-Meier curves, and multivariable Cox regression.
Results: Of 5129 pediatric heart recipients, 84 (2%) used EVMP. Donation after cardiac death (DCD) was more common in the EVMP vs. non-EVMP group (33% vs. 1%, p<0.001). Organs were transported farther in the EVMP group (417 vs. 298 miles, p<0.001). EVMP recipients were older (11 vs. 6 years, p=0.005) and more likely to weigh >30 kilograms (55% vs. 40%, p=0.008). ECMO, inotrope, and ventilator use and waitlist times were similar between groups, while baseline creatinine was higher in EVMP recipients. One-year survival was 83% vs. 93% for EVMP vs. non-EVMP recipients; after adjusting for baseline characteristics, EVMP was associated with 85% increased mortality risk (aHR 1.85 [95% CI 1.001-3.42], p=0.049).
Conclusions: EVMP use in pediatric heart transplantation is increasing, enabling longer transport distances and transplant of DCD organs. EVMP was associated with increased mortality risk, which must be interpreted cautiously given the small EVMP cohort and higher-risk baseline. Prospective studies with refined donor-recipient selection criteria are needed to identify which pediatric patients derive net benefit from EVMP.
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