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Coronary atherosclerosis of the donor heart--impact on early graft failure
Onnen Grauhan1, Henryk Siniawski, Michael Dandel
1Department of Cardiothoracic and Vascular Surgery, German Heart Institute, Augustenburger Platz 1, 13353 Berlin, Germany. grauhan@dhzb.de
Insights
Donor hearts with coronary atherosclerosis are increasingly used. While single-vessel disease is acceptable, multi-vessel disease significantly increases early graft failure risk, necessitating donor screening.
Area of Science:
- Cardiology
- Transplantation Medicine
- Vascular Biology
Background:
- Donor heart shortages lead to expanded organ acceptance criteria.
- Donor grafts with pre-existing coronary atherosclerosis are now considered.
- Evaluating the safety and efficacy of using such grafts is crucial.
Purpose of the Study:
- To assess the impact of donor-transmitted coronary atherosclerosis (DCAS) on heart transplant outcomes.
- To determine acceptable levels of pre-existing atherosclerosis in donor hearts.
- To inform donor screening protocols for heart transplantation.
Main Methods:
- Retrospective analysis of 1253 heart transplant recipients.
- Definition of DCAS as stenosis ≥50% on post-transplant angiography or autopsy within 6 months.
- Kaplan-Meier analysis and log-rank tests to compare outcomes.
Main Results:
- 7.0% of patients had DCAS (82/1168 evaluable recipients).
- Single-vessel DCAS (53 patients) had similar 30-day mortality (13.2%) to no DCAS (12.2%).
- Double/triple-vessel DCAS (26 patients) showed significantly higher 30-day mortality (61.5%).
- Long-term outcomes beyond one year were comparable between healthy grafts and single-vessel DCAS grafts.
Conclusions:
- Standard donor screening overlooks significant coronary atherosclerosis in 7.0% of cases.
- Angiographic donor screening is recommended.
- Single-vessel DCAS grafts may be acceptable as marginal, with consideration for revascularization.
- Grafts with multi-vessel DCAS pose a high risk of early graft failure.
Objective:
Due to the shortage of donor hearts, the criteria for organ acceptability have been considerably extended and donor grafts with coronary atherosclerosis are among those offered. This study evaluated whether and to what degree pre-existing coronary atherosclerosis may be acceptable.
Methods:
A total of 1253 consecutive HTx recipients were investigated retrospectively for donor-transmitted coronary atherosclerosis (DCAS). Donor-transmitted coronary atherosclerosis was defined as focal atherosclerosis with stenosis of at least 50%. Inclusion criteria were absence of pre-HTx angiogram but performance of angiogram or autopsy within 6 months after heart transplantation. Kaplan-Meier analysis and log-rank test were used.
Results:
Eighty-five out of 1253 (6.8%) cases were excluded, since coronary evaluation was not performed within 6 months (n=45) or hearts had undergone pre-transplant angiography (n=40). In 1086 patients no donor-transmitted coronary atherosclerosis was found (NDCAS group) and in 82 patients (7%) donor-transmitted coronary atherosclerosis was diagnosed by angiography (n=49) or autopsy (n=33). Single-vessel donor-transmitted coronary atherosclerosis was found in 53/82 patients (DCAS1 group) and double- or triple-vessel donor-transmitted coronary atherosclerosis in 26/82 patients (DCAS2/3 group). Three of the 82 patients with donor-transmitted coronary atherosclerosis were excluded since the autopsy report was unclear regarding degree of atherosclerosis. Early after heart transplantation the 30-day mortality in the NDCAS and DCAS1 groups was 12.2% versus 13.2% whereas in the DCAS2/3 group it was 61.5%. Beyond the first year the annual decrease with and without donor-transmitted coronary atherosclerosis (single-vessel disease) is comparable.
Conclusions:
Donor screening without coronary angiogram overlooks significant atherosclerotic lesions in a considerable number of cases (7.0%). Therefore, angiographic donor screening should be performed. Donor grafts with single-vessel coronary atherosclerosis may be accepted as marginal hearts; however, in our opinion, revascularisation (CABG, PTCA) should be considered. Grafts with two- or even three-vessel coronary atherosclerosis seem to have a serious risk for early graft failure. Beyond the first year the outcome of healthy grafts and grafts with donor-transmitted coronary atherosclerosis seems to be comparable.
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