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Donor shortage in heart transplantation. Is extension of donor age limits justified?
U Livi1, U Bortolotti, G B Luciani
1Department of Cardiovascular Surgery, University of Padova Medical School, Italy.
Insights
Extending donor age limits for heart transplantation is effective, showing comparable survival rates and graft performance. Older donors (over 40) can be safely used, justifying policy changes due to organ shortages.
Area of Science:
- Cardiology
- Transplantation Medicine
- Geriatric Medicine
Background:
- Chronic shortage of donor organs for heart transplantation necessitates exploring extended donor age criteria.
- Previous policies limited donor age, potentially excluding viable organs.
Purpose of the Study:
- To evaluate the effectiveness and outcomes of heart transplantation using donors over 40 years old compared to younger donors.
- To determine if extending donor age limits impacts patient survival and graft function.
Main Methods:
- Retrospective comparison of 45 heart transplant recipients with donors >40 years (Group 1) versus 72 recipients with younger donors (Group 2).
- Analysis of early (<30 days) and late outcomes, including survival, graft failure, coronary artery abnormalities, and conduction disturbances.
- Follow-up included echocardiographic and hemodynamic assessments.
Main Results:
- No significant difference in early mortality (13% vs 14%) or fatal acute graft failure (10% vs 5.5%) between groups.
- Comparable 5-year actuarial survival (80%) and graft performance in both groups.
- Higher incidence of coronary artery abnormalities (p<0.05) and major conduction disturbances (p=0.003) in the older donor group, though freedom from stenosis was similar.
Conclusions:
- Heart transplantation with donors over 40 years old yields comparable early and long-term results to using younger donors.
- Extending donor age limits, even to the sixth decade, is justified given organ scarcity.
- Further assessment is needed on the long-term impact of coronary abnormalities in older donor grafts.
Abstract:
Chronic shortage of donor organs for heart transplantation led us to extend donor age limits. To verify the effectiveness of such a policy we have compared the results of heart transplantation in 45 patients with donors more than 40 years of age (group 1) with those of 72 patients older than 50 years of age who had heart transplantation with younger donors (group 2) between November 1985 and December 1992. The two groups were comparable in terms of mean recipient age, recipient and donor sex, and indication for heart transplantation. Mean donor age was 46 +/- 4 years (range 41 to 59 years) in group 1 and 23 +/- 7 years (range 8 to 39 years) in group 2 (p < 0.001). In group 1 cerebrovascular accidents were more common as the cause of donor death (60% versus 16%, p = 0.001), and no difference was found in ischemic time (144 +/- 47 minutes versus 140 +/- 48 minutes, p = not significant). There were 6 early (< 30 days) deaths in group 1 (13%) and 10 in group 2 (14%; p = not significant). Fatal acute graft failure was more prevalent, but not significantly so, in group 1 (10% versus 5.5%, p = not significant). Mean follow-up was 29 +/- 20 months (range 3 to 78 months) in group 1 and 30 +/- 20 months (range 3 to 80 months) in group 2 (p = not significant). At 5 years actuarial survival was 80% +/- 6% in both groups with comparable graft performance at echocardiographic and hemodynamic control studies. A significant difference was found in freedom from any type of coronary artery abnormality between group 1 (49% +/- 13%) and group 2 (77% +/- 8%) at 5 years (p < 0.05); however, freedom from coronary stenotic lesions only was similar. Major conduction disturbances have occurred more frequently in patients of group 1 (37% versus 12%; p = 0.003) without any difference in the need for permanent pacing. Donors older than 40 years of age can be accepted for heart transplantation with early and long-term results comparable with those obtained with younger donors. The impact of a higher incidence of coronary abnormalities on late performance of older grafts must be assessed at longer follow-up. Our results indicate that, because of the current organ shortage, extension of donor age limits is justified, even up to the sixth decade of life in selected cases.