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Heart transplantation allograft survival: donor atherosclerotic disease risk vs coronary angiography
Filip Gnesin1, Mandeep R Mehra1, Jennifer Thomalla2
1Center for Advanced Heart Disease, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
Insights
Donor heart selection can be improved by assessing atherosclerotic cardiovascular disease (ASCVD) risk. Estimated ASCVD risk >5% predicts worse heart transplant outcomes, while routine coronary angiography in low-risk donors does not improve survival.
Area of Science:
- Cardiology
- Transplant Surgery
- Public Health
Background:
- Current guidelines recommend coronary angiography for heart donors at increased risk of coronary artery disease.
- However, the diagnostic yield of this practice is often low.
- This study evaluates donor atherosclerotic cardiovascular disease (ASCVD) risk stratification versus angiography for predicting heart transplant outcomes.
Purpose of the Study:
- To compare the effectiveness of estimated donor 10-year ASCVD risk (≤5% vs >5%) against coronary angiography in predicting short- to mid-term survival free from graft failure in adult heart transplant recipients.
- To determine if ASCVD risk stratification is a more useful initial step in donor heart selection than routine angiography.
Main Methods:
- Analysis of adult heart transplant recipients from the United Network for Organ Sharing database (October 2018 - December 2023).
- Inclusion criteria: donors aged >40 years, or >30 years with diabetes, hypertension, or smoking.
- Multivariable Cox regression assessed the risk of a composite outcome (death or graft failure) up to 4 years post-transplant.
Main Results:
- 86.1% of donors had an ASCVD risk ≤5%.
- Compared to low-risk donors who underwent angiography, donors with ASCVD risk >5% (regardless of angiography) had a higher risk of death or graft failure (adjusted hazard ratio 1.30).
- Routine angiography in donors with ASCVD risk ≤5% did not significantly alter transplant outcomes.
Conclusions:
- Estimated donor ASCVD risk >5% is an independent predictor of worse outcomes after heart transplantation.
- Routine coronary angiography in low-risk heart donors (ASCVD ≤5%) does not improve transplant recipient survival.
- ASCVD-based risk stratification may be a more effective initial strategy for donor heart selection than angiography.
Background And Aims:
Guidelines recommend coronary angiography in heart donors at increased risk of coronary artery disease (age >45 years, diabetes, tobacco, or drug use), but the yield is often low. The aim of this study was to evaluate the importance of estimated donor 10-year atherosclerotic cardiovascular disease (ASCVD) risk (≤5% vs >5%) vs coronary angiogram testing for predicting short- to mid-term survival free from graft failure in adult heart transplant recipients.
Methods:
Adult heart transplant recipients from the United Network for Organ Sharing database 18 October 2018, to 31 December 2023, who received hearts from donors aged >40 years, or >30 years with diabetes, hypertension, or smoking were included. The risk of a composite outcome (death or graft failure) up to 4 years post-transplant was assessed by multivariable Cox regression.
Results:
Of 5152 recipients, 86.1% received hearts from donors with ASCVD risk ≤5%. Angiography was performed in 76.1% donors with ASCVD ≤5% and 92.9% of donors with ASCVD >5%. Using donors with ASCVD ≤5% and angiography as the reference group (n = 3378), adjusted hazard ratios for the composite outcome were .91 [95% confidence interval (CI) .74-1.11] for ASCVD ≤5% without angiography (n = 1060); 1.30 (95% CI 1.05-1.60) for ASCVD >5% with angiography (n = 663), and .88 (95% CI .36-2.13) for ASCVD >5% without angiography (n = 51). Findings were consistent when limited to donors meeting current angiography guideline criteria.
Conclusions:
Estimated ASCVD risk >5% independently predicts worse transplant outcomes, while routine coronary angiography in low-risk donors (ASCVD ≤5%) does not. These findings suggest that ASCVD-based risk stratification may be more useful than angiography as the initial step in donor heart selection.
