Outcomes of pediatric heart transplantation patients bridged with extracorporeal membrane oxygenation by cardiomyopathy type
Rohit Ganduboina1,2
, Palak Dutta3, Sandeep Sainathan4
Contributions: (I) Conception and design: R Ganduboina, S Sainathan; (II) Administrative support: S Sainathan; (III) Provision of study materials or patients: R Ganduboina, S Sainathan; (IV) Collection and assembly of data: R Ganduboina; (V) Data analysis and interpretation: R Ganduboina, S Sainathan; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Background: Pediatric heart transplantation often requires bridge to heart transplant (BTT) with mechanical circulatory support (MCS) due to donor heart scarcity or poor condition of the patient. With a resurgence in the use of extracorporeal membrane oxygenation (ECMO) as BTT, its role is especially vital given the limited applicability of ventricular assist devices (VADs) in restrictive cardiomyopathy (RCM) compared to dilated cardiomyopathy (DCM). This study examines post-transplant survival, morbidity, waitlist characteristics, and era-related trends in DCM and RCM patients with ECMO-BTT.
Methods: Retrospective cohort study was conducted using the OPTN registry (1987–2024) to evaluate pediatric patients with cardiomyopathy with BTT using ECMO. A total of 206 pediatric patients were dichotomized into the RCM (n=14) and DCM (n=192) groups. Demographics, clinical characteristics, and post-transplant outcomes were analyzed. Statistical tests included logistic regression and Cox proportional hazards regression, with significance set at P<0.05.
Results: Only 7% of the cardiomyopathy patients with RCM underwent ECMO-BTT, but other demographics were similar. DCM was more frequently listed initially as Status 1A. There were no differences in preoperative hemodynamics or waitlist times between the groups. Post-transplant morbidity and survival rates, ranging from 30 days to 15 years, were comparable [hazard ratio (HR): 0.77, 95% confidence interval (CI): 0.33–1.78; P=0.54]. Higher serum creatinine levels (P=0.003), initial lower listing status (P<0.001), transplant era before 2008 (P<0.001), post-transplant rejection (P<0.001), dialysis use (P<0.001), and pacemaker insertion (P=0.002) were associated with inferior survival and not the type of cardiomyopathy.
Conclusions: Cardiomyopathy type does not impact outcomes among patients using ECMO as a BTT. Survival with ECMO-BTT has improved after 2008.
Keywords: Pediatric heart transplants; extracorporeal membrane oxygenation bridge (ECMO bridge); cardiomyopathy; mechanical circulatory support (MCS)
Submitted Mar 04, 2025. Accepted for publication Nov 14, 2025. Published online Dec 24, 2025.
doi: 10.21037/asj-25-27
Highlight box
Key findings
• Extracorporeal membrane oxygenation bridge (ECMO) as a bridge to transplant (BTT) showed no significant difference in post-transplant survival between pediatric dilated cardiomyopathy (DCM) and restrictive cardiomyopathy (RCM) patients.
• RCM patients, despite limited ventricular assist device options, had comparable outcomes to DCM when supported with ECMO BTT.
What is known and what is new?
• ECMO is used as temporary support for critically ill pediatric heart transplant candidates.
• This study highlights ECMO’s role in reducing waitlist times and improving post-transplant outcomes in pediatric cardiomyopathy.
What is the implication, and what should change now?
• ECMO should be considered for high-priority pediatric transplant candidates.
• Findings support refining transplant allocation policies to optimize outcomes.
Introduction
Heart transplantation is required for pediatric patients with end-stage heart failure (1). While primary heart transplantation is ideal, some of the patients may need to be bridged to a heart transplant (BTT) with mechanical circulatory support (MCS) such as a ventricular assist device (VAD) or with extracorporeal membrane oxygenation (ECMO) due to the scarcity of donor hearts or poor initial condition of the patient.
Historical data has suggested suboptimal outcomes when ECMO is used as a BTT, especially when compared to a VAD in pediatric patients (2). Also, pediatric patients with cardiomyopathy have a disadvantage as compared to congenital heart disease patients for priority for organ allocation for heart transplantation unless they have MCS use as BTT (3). Incidentally, in adult heart transplant patients, there has been a resurgence in the use of ECMO as BTT since the new heart allocation policy change favoring such patients over VAD BTT patients (4).
The two major pediatric cardiomyopathies in pediatric patients undergoing heart transplantation are dilated cardiomyopathy (DCM) and restrictive cardiomyopathy (RCM) (5). RCM patients generally have limited options for MCS with VAD as compared to DCM patients as a BTT due to anatomical factors such as a non-dilated ventricle (6). While DCM patients may be able to get a VAD if continued MCS is needed, such options may be limited for RCM as previously alluded and ECMO as MCS may be the only option. In addition, DCM tend to have higher incidence of pulmonary hypertension which may impact transplantation outcomes (5).
With an increasing interest in ECMO as a BTT and its usefulness particularly in RCM is appealing due to limited applicability of VAD in RCM due to anatomic constraints as compared to the DCM. In this study, we analyzed the status of ECMO BTT in pediatric patients stratified by the type of cardiomyopathy. We present this article in accordance with the STROBE reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-27/rc) (7).
Methods
We used a retrospective cohort design to analyse data from OPTN registry until April 2024, focusing on pediatric heart transplant recipients bridged with ECMO. This study evaluated heart transplant outcomes among pediatric population on ECMO bridge with cardiomyopathy.
Data source and study population
The OPTN database contains information on all transplant candidates, recipients, and donors, as well as waitlist and post-transplant outcomes in the United States. The study uses data from 1987 to 2024.
The OPTN database was retrospectively reviewed to identify all pediatric (aged ≤18 years) heart transplant candidates on ECMO bridge till April 2024 (Figure 1). Patients with underlying cardiac diagnosis other than cardiomyopathy were excluded and remainder were dichotomised into RCM, DCM, survivor and non-survivor groups based on cardiomyopathy type and survival post-transplant respectively.
Data collection & outcomes
Patient demographics, transplant related clinical data, post-transplant morbidity and mortality outcomes were collected. The primary outcomes were 30-day, 1-year, 5-year, 10-year and 15-year post-transplant survival. The secondary outcomes were rejection requiring treatment, stroke, new-onset dialysis, and pacemaker insertion. Continuous variables were categorized based on distribution and clinical relevance, with parametric variables reported as mean ± SD and nonparametric as median (IQR). Kaplan-Meier curves illustrated post-transplant survival at 30-day, 1, 5, 10, and 15 years. The Year of Transplant was grouped into four eras (1987–1997, 1998–2007, 2008–2017, 2018–2024) to reflect advancements in transplant practices, ECMO technology, and listing criteria.
Ethical consideration
This study used de-identified data from the OPTN registry and the study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was exempted from ethical approval by the Institutional Ethics Committee of University of Miami and individual consent for this retrospective analysis was waived.
Statistical analysis
A demographic analysis was performed to compare patients having dilated and restrictive types of cardiomyopathies. Parametric continuous, nonparametric continuous, and categorical variables were reported as mean ± SD, median (interquartile range [IQR]), and number (percent), respectively. Student’s t-tests for parametric continuous variables, Wilcoxon rank-sum tests for nonparametric continuous variables, and χ2 or Fisher’s exact categorical variables were used for comparison. Logistic regression analysis is performed to evaluate the post-transplant outcomes. Multivariable Cox proportional hazards regressions were used to investigate 15-year unconditional survival. The Cox regression method enables the examination of the influence of covariates on the outcome of time-to-first event. The cumulative hazard Kaplan-Meier curve was used to visually present the survival outcomes. These visual aids facilitated a comprehensive understanding of the correlation between the cardiomyopathy type and the post-transplant survival.
The statistical analysis was conducted using R software (version 4.4.0) and RStudio, with a specified significance level of two-sided P value <0.05 applied to all statistical tests.
Results
Cardiomyopathy
A total of 206 cardiomyopathy patients underwent heart transplantation on ECMO bridge. Majority had DCM, at 93% as compared to the remaining 7% which belonged to the RCM (Table 1). Groups did not differ in age (median 2.5 vs. 3 years, P=0.96), gender (male, 43% vs. 53.6%, P=0.67), ethnicity, blood type, and body mass index (BMI). DCM patients were more likely to be initially listed as Status 1A (75% vs. 57%, P=0.01) as compared to RCM at the time of listing. Additionally, there were no differences in the preoperative hemodynamics such as pulmonary artery pressure, wedge pressure and cardiac output. Serum bilirubin and creatinine were similar between the groups. The waitlist times, distance between the donor and recipient hospital was similar in both groups. While no RCM patients were transplanted in the early era, there has been a gradual increase over time (Figure 2). There were no significant differences in the donor cause of death between these groups.
Table 1
| Variable | RCM (n=14, 7%) | DCM (n=192, 93%) | P value |
|---|---|---|---|
| Recipient, age (years) | 3.00 [1.00, 7.75] | 2.50 [0.00, 12.00] | 0.96 |
| Donor, age (years) | 3.50 [1.00, 17.50] | 5.00 [1.00, 19.00] | 0.98 |
| Recipient, male | 6 (42.9) | 101 (52.6) | 0.67 |
| Donor, male | 7 (50.0) | 108 (56.2) | 0.86 |
| Gender mismatch | 9 (64.3) | 87 (45.3) | 0.27 |
| Ethnicity | 0.38 | ||
| Caucasian | 9 (64.3) | 101 (52.6) | |
| African American | 2 (14.3) | 45 (23.4) | |
| Hispanic/Latino | 0 (0.0) | 28 (14.6) | |
| Other | 3 (21.4) | 18 (9.3) | |
| BMI (kg/m2) | 16.18 [14.70, 17.74] | 16.05 [14.52, 18.91] | 0.97 |
| Weight mismatch, >±20% | 8 (61.5) | 120 (63.2) | >0.99 |
| Height mismatch, >±5% | 11 (78.6) | 142 (78.0) | >0.99 |
| ABO | 0.99 | ||
| A | 5 (35.7) | 63 (32.8) | |
| B | 2 (14.3) | 30 (15.6) | |
| AB | 1 (7.1) | 11 (5.7) | |
| O | 6 (42.9) | 88 (45.8) | |
| Heart listing status | 0.01 | ||
| Status 1A | 8 (57.1) | 143 (74.5) | |
| Status 1B | 4 (28.6) | 15 (7.8) | |
| Status 2 | 2 (14.3) | 6 (3.1) | |
| Creatinine (mg/dL) | 0.30 [0.24, 0.78] | 0.50 [0.30, 0.86] | 0.11 |
| Total bilirubin (mg/dL) | 0.90 [0.80, 1.80] | 1.00 [0.50, 2.35] | 0.71 |
| Mean pulmonary artery pressure (mmHg) | 24.50 [22.00, 30.25] | 23.50 [18.00, 34.25] | 0.56 |
| Pulmonary capillary wedge pressure (mmHg) | 14.00 [11.50, 25.25] | 15.00 [9.00, 25.00] | 0.57 |
| Cardiac output (L/min) | 3.21 [3.16, 3.26] | 2.73 [1.72, 4.04] | 0.85 |
| Wait-list times (days) | 18.50 [10.25, 104.75] | 14.00 [7.00, 41.50] | 0.17 |
| Distance between donor and recipient hospital (miles) | 573.50 [170.25, 884.00] | 350.00 [164.00, 561.00] | 0.16 |
| Transplant era | 0.18 | ||
| 1987–1997 | 0 (0.0) | 29 (15.1) | |
| 1998–2007 | 6 (42.9) | 76 (39.6) | |
| 2008–2017 | 7 (50.0) | 55 (28.6) | |
| 2018–2024 | 1 (7.1) | 32 (16.7) | |
| Donor cause of death | 0.82 | ||
| Anoxia | 3 (21.4) | 66 (34.9) | |
| CVA | 2 (14.3) | 24 (12.7) | |
| Head trauma | 8 (57.1) | 83 (43.9) | |
| CNS tumor | 0 (0.0) | 4 (2.1) | |
| Other | 1 (7.1) | 12 (6.3) | |
Data are presented as median [interquartile range] or n (%). P value of <0.05 is considered statistically significant. BMI, body mass index; CNS, central nervous system; CVA, cerebrovascular accident; DCM, dilated cardiomyopathy; RCM, restrictive cardiomyopathy.
The ischemic times were similar between the groups. Post-transplant morbidity such as dialysis use, stroke, pacemaker use, and treated rejection were similar between the groups. The 30-day to 15-year survival were similar for both groups (Table 2). Kaplan-Meier survival showed overlap between the groups showing no significant survival disparities [hazard ratio (HR): 0.77, 95% confidence interval (CI): 0.33–1.78; P=0.54] (Figure 3).
Table 2
| Variable | RCM (n=14, 7%) | DCM (n=192, 93%) | P value |
|---|---|---|---|
| Ischemic times (hours) | 4.15 [3.03, 4.42] | 3.52 [2.83, 4.09] | 0.19 |
| Dialysis | 4 (28.6) | 17 (8.9) | 0.10 |
| Stroke | 2 (14.3) | 13 (6.8) | 0.60 |
| Pacemaker | 1 (7.1) | 2 (1.0) | 0.23 |
| Treated rejection rate (1 year) | 2 (14.3) | 36 (18.8) | 0.87 |
| 30-day survival | 13 (92.9) | 176 (91.7) | >0.99 |
| 90-day survival | 12 (85.7) | 163 (84.9) | >0.99 |
| 1-year survival | 11 (78.6) | 151 (78.6) | >0.99 |
| 5-year survival | 8 (57.1) | 104 (54.2) | >0.99 |
| 10-year survival | 3 (21.4) | 75 (39.1) | 0.30 |
| 15-year survival | 1 (7.1) | 39 (20.3) | 0.39 |
| Recipient cause of death | 0.12 | ||
| Cardiovascular | 1 (7.1) | 18 (9.4) | |
| Cerebrovascular | 1 (7.1) | 2 (1.0) | |
| Graft failure | 1 (7.1) | 19 (9.9) | |
| Infection | 0 (0.0) | 6 (3.1) | |
| Malignancy | 0 (0.0) | 13 (6.8) | |
| Respiratory | 2 (14.3) | 5 (2.6) | |
| Unknown | 9 (64.3) | 129 (67.2) | |
| Post transplant length of stay (days) | 39.00 [15.00, 51.25] | 29.00 [18.00, 50.50] | 0.70 |
Data are presented as median [interquartile range] or n (%). P value of <0.05 is considered statistically significant. DCM, dilated cardiomyopathy; RCM, restrictive cardiomyopathy.
Survivor groups
206 patients were divided into survivor group and non-survivor group based on patient survival status during follow-up, with 37% of the patients belonging to the non-survivor group (Table 3). Groups did not differ in age (median 2 vs. 3 years, P=0.99), gender (male, 49% vs. 57%, P=0.31), ethnicity, blood type, and BMI. The survivor group were more likely to have a higher listing status at the time of listing. Also, serum creatinine was higher among the non-survivor group as compared to the survivor group (0.70 vs. 0.30 mg/dL, P=0.003). There were no donor related disparities. The survival has improved with time, with inferior survival in the older era (Figure 4).
Table 3
| Variable | Survivors (n=129, 63%) | Non-survivors (n=77, 37%) | P value |
|---|---|---|---|
| Dilated cardiomyopathy | 121 (63) | 71 (37) | 0.88 |
| Restrictive cardiomyopathy | 8 (57) | 6 (43) | 0.88 |
| Recipient, age (years) | 2.00 [0.00, 12.00] | 3.00 [1.00, 11.00] | 0.99 |
| Donor, age (years) | 5.00 [1.00, 17.00] | 5.00 [1.00, 21.00] | 0.42 |
| Recipient, male | 63 (48.8) | 44 (57.1) | 0.31 |
| Donor, male | 77 (59.7) | 38 (49.4) | 0.19 |
| Gender mismatch | 56 (43.4) | 40 (51.9) | 0.30 |
| Ethnicity | 0.24 | ||
| Caucasian | 67 (51.9) | 43 (55.8) | |
| African American | 27 (20.9) | 20 (26.0) | |
| Hispanic/Latino | 22 (17.1) | 6 (7.8) | |
| Asian | 9 (7.0) | 5 (6.5) | |
| American Indian/Alaska Native | 1 (0.8) | 0 (0.0) | |
| Native Hawaiian/other Pacific Islander | 0 (0.0) | 2 (2.6) | |
| Multiracial | 3 (2.3) | 1 (1.3) | |
| BMI (kg/m2) | 16.17 [14.62, 19.06] | 15.97 [14.45, 18.34] | 0.45 |
| Weight mismatch, >±20% | 77 (60.6) | 51 (67.1) | 0.44 |
| Height mismatch, >±5% | 101 (80.2) | 52 (74.3) | 0.44 |
| ABO | 0.06 | ||
| A | 48 (37.2) | 20 (26.0) | |
| B | 24 (18.6) | 8 (10.4) | |
| AB | 6 (4.7) | 6 (7.8) | |
| O | 51 (39.5) | 43 (55.8) | |
| Heart listing status | <0.001 | ||
| Status 1A | 101 (78.3) | 50 (64.9) | |
| Status 1B | 16 (12.4) | 3 (3.9) | |
| Status 2 | 3 (2.3) | 5 (6.5) | |
| Serum creatinine (mg/dL) | 0.40 [0.30, 0.66] | 0.70 [0.37, 1.10] | 0.003 |
| Total bilirubin (mg/dL) | 1.00 [0.40, 2.10] | 1.10 [0.60, 2.70] | 0.08 |
| Mean pulmonary artery pressure (mmHg) | 24.00 [18.00, 35.00] | 23.00 [19.00, 30.50] | 0.65 |
| Pulmonary capillary wedge pressure (mmHg) | 15.00 [9.00, 25.00] | 17.00 [9.50, 26.00] | 0.75 |
| Cardiac output (L/min) | 3.05 [1.82, 3.96] | 2.73 [1.60, 4.00] | 0.66 |
| Wait-list times (days) | 17.00 [7.00, 49.00] | 14.00 [8.00, 34.00] | 0.64 |
| Distance between donor and recipient hospital (miles) | 348.00 [167.00, 561.00] | 379.50 [159.50, 613.75] | 0.86 |
| Donor cause of death | 0.25 | ||
| Anoxia | 49 (38.3) | 20 (26.7) | |
| CVA | 12 (9.4) | 14 (18.7) | |
| Head trauma | 56 (43.8) | 35 (46.7) | |
| CNS tumor | 3 (2.3) | 1 (1.3) | |
| Other | 8 (6.2) | 5 (6.7) | |
| Transplant era | <0.001 | ||
| 1987–1997 | 8 (6.2) | 21 (27.3) | |
| 1998–2007 | 42 (32.6) | 40 (51.9) | |
| 2008–2017 | 49 (38.0) | 13 (16.9) | |
| 2018–2024 | 30 (23.3) | 3 (3.9) | |
Data are presented as median [interquartile range] or n (%). P value of <0.05 is considered statistically significant. BMI, body mass index; CNS, central nervous system; CVA, cerebrovascular accident.
Post-transplant outcomes such as rejection requiring treatment (14% vs. 26%, P<0.001), dialysis use (6% vs. 17%, P<0.001), and pacemaker insertion (0.8% vs. 2.6%, P=0.002) were lower among the survivor group (Table 4). Regression analysis revealed a decreased rate of transplant rejection requiring treatment among survivors (odds ratio: 3.05, 95% CI: 1.19–7.84, P=0.02). Furthermore, the odds of survival improved significantly for transplants performed after the 2008 era (odds ratio: 0.11, 95% CI: 0.04–0.29, P<0.001). However, no significant disparities were observed in other outcomes, especially the cardiomyopathy type (Figure 5).
Table 4
| Variable | Survivors (n=129, 63%) | Non-survivors (n=77, 37%) | P value |
|---|---|---|---|
| Ischemic times (hours) | 3.52 [2.82, 4.14] | 3.65 [2.91, 4.12] | 0.57 |
| Dialysis | 8 (6.2) | 13 (16.9) | <0.001 |
| Stroke | 10 (7.8) | 5 (6.5) | 0.01 |
| Pacemaker | 1 (0.8) | 2 (2.6) | 0.002 |
| Treated rejection rate (1 year) | 18 (14.0) | 20 (26.0) | <0.001 |
Data are presented as median [interquartile range] or n (%). P value of <0.05 is considered statistically significant.
Discussion
DCM and RCM are the major types of cardiomyopathy in pediatric patients undergoing heart transplantation (5). DCM tend to have a more predictable course towards transplantation, with RCM often developing concerning pulmonary hypertension precluding heart transplantation (8). In both groups, primary transplantation may not be feasible either due to hemodynamic instability to wait till a suitable donor heart becomes available or initial poor condition with end-organ damage such as renal failure precluding a safe transplant. Such patients will need a VAD as either a bridge to transplant (BTT) or bridge to candidacy. Unlike DCM, RCM may not have the optimal cardiac anatomy for a VAD insertion due to small ventricular cavity size (9). Hence, ECMO may be the only feasible MCS. The prevalence of initial Status 1A heart listing status was more frequent among DCM (74%). This may either indicate a clinically much advanced state in DCM patients at the time of listing or conversely it may also indicate that the current listing status criteria are disadvantaged towards RCM patients to truly reflect the severity of the disease state (10). However, once on ECMO, the listing status changes to the highest (Status 1A) and this was reflective of no difference in the waitlist times, donor-to-recipient hospital distance and ischemic times between DCM and RCM.
It is to be noted that waitlist times were short in both DCM and RCM, with a median of 18 and 14 days, respectively. How many of those days were on ECMO before the heart transplant is not discernible from the database. Again, as being on ECMO elevates the listing status to the highest one (Status 1A) perhaps shortens the waitlist times, particularly for cardiomyopathy patients who are disadvantaged as compared to congenital heart disease patients to a lower listing status unless on MCS. Expedited transplant on ECMO use has led to better outcomes in these patients as evident in the adult patient with ECMO BTT with change in the listing system prioritizing patients on ECMO for organ allocation and advances in ECMO technology with less deleterious effects from the circuit and oxygenator membrane with prolonged support has led to improved post-transplantation outcomes (11). Interestingly, application of ECMO as BTT in RCM has increased in this study overtime, suggesting an increasing comfort to the use ECMO as BTT, likely due to better ECMO technology as the listing status of pediatric heart transplant candidates unlike the adult patients waiting on ECMO has not changed.
Pulmonary hypertension can be a limiting factor for successful outcomes in patients with RCM, as they are more prone to it than DCM (8). In this cohort, the mean pulmonary artery pressure was similar in both groups and was below the threshold of mild pulmonary hypertension (12). This perhaps explains lack of difference in survival outcomes post-transplant in both groups. The absence of survival difference between the groups was sustained to a follow-up of 15-years.
When the cohort as a whole was looked at survivor group versus non-survivor group, non-survivors tended to have a lower initial listing status, worse renal function as reflected by a higher serum creatinine level, were more likely to have post-operative complications such as dialysis need, stroke, pacemaker use, and treated rejection, and were transplanted in an earlier era. However, on logistic regression analysis, only treated rejection in the first year and transplant performed before 2008 were factors for non-survival. Again, cardiomyopathy type was not a predictor.
Limitations
The study findings are based on a national transplant registry, which enhances the external validity by including data from multiple centers across the U.S. However, inherent variability in ECMO utilization and transplant listing practices among these centers may limit the direct applicability of our findings to all settings, especially those with differing ECMO strategies. The relatively small sample size, particularly for patients with RCM, further restricts the generalizability of our results to broader pediatric transplant populations. Institutional variability in ECMO utilization, lack of ECMO configurations, and transplant listing practices may limit direct applicability to all settings. Additionally, the relatively small sample size, particularly for RCM patients, may restrict generalizability to broader pediatric transplant populations or centers with differing ECMO strategies.
The study has limitations inherent to the retrospective design of the study. Being an administrative database, there is a lack of granularity of important clinical data such as any cardiac arrest before ECMO application, exact days on ECMO before heart transplant, waitlist mortality on ECMO etc. There is a possibility of selection bias for the application ECMO bridge due to institutional preferences.
Conclusions
Cardiomyopathy type does not impact outcomes among patients using ECMO as a BTT. Survival with ECMO-BTT has improved since 2008. Although fewer patients with RCM underwent ECMO-BTT compared to those with DCM, their numbers have increased in the recent era. While VADs have traditionally been preferred over ECMO as BTT, this preference has changed in recent years, as seen in adult cardiac transplantation with the increasing use of ECMO as BTT due to improvements in ECMO technology and changes in organ allocation policies. Similarly, there may be an emerging role for ECMO in pediatric heart transplantation, especially for patients with cardiomyopathies such as RCM, which are difficult to support with VADs due to anatomical constraints.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-27/rc
Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-27/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-27/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study used de-identified data from the OPTN registry and the study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was exempted from ethical approval by the Institutional Ethics Committee of University of Miami and individual consent for this retrospective analysis was waived.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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