Strain Echocardiography for Assessment of Cardiac Graft Function following Donation after Circulatory Death Heart Transplantation

Abstract Introduction DCD heart transplantation demonstrates preserved conventional ventricular and valvular function through 1-year follow-up. However, strain imaging identifies subtle but persistent abnormalities in myocardial deformation, suggesting distinct myocardial recovery patterns and possible subclinical ischemia-related graft injury after DCD transplantation. Methods This single-center retrospective cohort study compared DCD and DBD heart transplant recipients from 2016-2022, at 1-, 3-, 6-, and 12-months post-transplantation. Conventional echocardiographic variables, valvular function, and speckle-tracking strain analysis including left ventricular global longitudinal strain (LVGLS), right ventricular global longitudinal strain (RVGLS), and right ventricular free wall strain (RVFWS) were compared between DCD and DBD recipients. Multivariable linear regression, chi-squared/Fisher Exact testing, and linear mixed-effects modeling were used to evaluate longitudinal outcomes. Exploratory multivariable analyses evaluated associations between GLS and perioperative variables. Results 51 DCD and 201 DBD hearts were transplanted. Conventional echocardiography demonstrated no significant differences in LVEF or presence of valvular dysfunction at any timepoint. The treatment group-by-time interaction was not significant (p=0.566). However, DCD recipients demonstrated significantly less negative LVGLS at 3 months (-13.9±3.54 vs -18.0±3.19, p<0.0001) and 12 months (-16.0±3.08 vs -18.1±3.17, p=0.0007). Early RV dysfunction was also observed in DCD recipients at 3 months by RVGLS and RVFWS analysis. Longitudinal mixed-effects modeling demonstrated a significant donor type-by-timepoint interaction for GLS (p=0.034). Exploratory multivariable modeling demonstrated that DCD donor status (β=1.52, p=0.021) and total ischemic interval (β=0.0057, p=0.034) remained independently associated with impaired GLS. Conclusion DCD heart transplantation demonstrates preserved conventional ventricular and valvular function through 1-year follow-up. However, strain imaging identifies subtle but persistent abnormalities in myocardial deformation, suggesting distinct myocardial recovery patterns and possible subclinical ischemia-related graft injury after DCD transplantation.