Brain Death versus Circulatory Death: How Functional Warm Ischemia and Cold Storage Shape Myocardial Repair and Damage in Human Donor Hearts

This study compares myocardial injury responses in human donor hearts from donation after brain death (DBD) and donation after circulatory death (DCD), with a focus on myocardial membrane integrity, pyroptosis, and damage. Unlike DCD hearts, which are exposed to varying durations of functional warm ischemic times (fWITs), DBD hearts - never subjected to warm ischemia - served as controls. A total of twenty-four human hearts were procured, consisting of six from the DBD group and eighteen from the DCD group. All procured hearts were placed in cold normal saline and stored for up to six hours. Left ventricular biopsies were performed at 0, 2, 4, and 6 hours to assess plasma membrane repair proteins (Annexin A1, Dysferlin), pyroptosis markers (NLRP3, caspase-1, GSDMD-NT), and to evaluate edema and injury scores. Data suggest that DBD hearts maintained stable levels of plasma membrane repair proteins and showed no evidence of pyroptosis activation or significant injury throughout cold storage. In contrast, DCD hearts exhibited profound Annexin A1 depletion, early and progressive pyroptosis, elevated edema, and worsening histopathological injury - directly correlated with fWITs. These findings underscore that warm ischemia is a critical determinant of pyroptotic damage in donor hearts, and highlight the relative resistance of DBD hearts to such injury during preservation. For DCD hearts, strategies to enhance membrane repair capacity and inhibit pyroptosis should focus on the fWIT phase to assess donor heart quality and suitability for transplantation. New & NoteworthyThis study demonstrates that donor hearts procured after circulatory death (DCD) exhibit early Annexin A1 depletion and activation of the NLRP3/caspase-1/GSDMD-mediated pyroptosis pathway during cold storage - a phenomenon absent in brain-dead (DBD) donors. We establish a direct correlation between warm ischemia time and pyroptotic damage in DCD hearts. These findings identify Annexin A1 as a key mediator of ischemia injury and a promising therapeutic target to improve viability in marginal donor hearts.