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[Controversies in the selection of donors in heart transplants]
U Livi1, G B Luciani, G Thiene
1Istituto di Chirurgia Cardiovascolare, Università di Padova.
Insights
Extending donor criteria for heart transplantation, including older donors and those with minor issues, can safely expand the donor pool. This approach improves outcomes for heart transplant recipients awaiting organs.
Area of Science:
- Cardiology
- Transplantation Medicine
- Organ Donor Management
Context:
- Shortage of ideal donor hearts leads to recipient mortality on waiting lists.
- Classical donor criteria limit the available organ pool for cardiac transplantation.
- Need to evaluate extended donor criteria to increase heart availability.
Purpose:
- To present controversies and clinical results of using donor hearts outside standard criteria.
- To assess the impact of extended donor criteria on cardiac transplant outcomes.
- To analyze specific donor factors and their influence on graft performance.
Summary:
- Extended donor criteria, including age over 40 and certain comorbidities, can be safely used in cardiac transplantation.
- Donor age >35 years is feasible, with careful assessment of coronary artery disease risk factors.
- Factors like minor ECG/ECHO changes, localized infection, or trauma may not be absolute contraindications.
Impact:
- Expanded donor pool without compromising short- and medium-term cardiac transplant outcomes.
- Highlights the importance of case-by-case evaluation for donor selection.
- Identifies severe donor dysionemia as a significant risk factor and suggests dopamine infusion levels as predictive.
Abstract:
The shortage of ideal donor hearts has led to an increasing number of would-be heart transplant recipients who die while on the waiting list: an extension of the classical donor criteria seems necessary to expand the donor pool. In this paper, the major controversies on donor selection are presented, along with the clinical results obtained in cardiac transplantation with donor grafts not complying with standard criteria. The extension of donor age over 35 years is supported by the decreased incidence of coronary artery disease (CAD) in the Western world. In our experience, the number of donors over 40 years has increased steadily, without concomitant significant increase in postoperative short- and medium-term mortality after cardiac transplantation. The relative importance of CAD risk factors in the older heart donor is to be weighed out on a case-by-case basis. The performance of coronary angiography in 90% of the donor grafts over 50 years has led to more accurate selection. ECG minor alterations and ECHO diagnosed dyskynesias are of uncertain significance. Localized infection, transitory hypotension, brief cardiac arrest and thoracic trauma do not necessarily contraindicate heart donation. The importance of donor/recipient weight mismatch over 20% is critical only in face of high pulmonary vascular resistance. Prolonged dopamine infusion above 10 micrograms/kg/min may predict poorer function outcome. From our data, severe donor dysionemia may be very hazardous. In conclusion, our experience demonstrates that extended donor criteria do not compromise short- and medium-term clinical results of cardiac transplantation. Nevertheless, several controversial aspects of donor graft selection remain open.