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Cardiac allografts from high-risk donors: excellent clinical results
G Y Ott1, R E Herschberger, R R Ratkovec
1Oregon Cardiac Transplant Program, Oregon Health Sciences University, Portland 97201-3098.
Insights
Utilizing high-risk donor hearts for cardiac transplants shows comparable survival rates to low-risk donors. However, long-term survivors face a higher risk of developing graft coronary disease.
Area of Science:
- Cardiology
- Transplantation Surgery
- Organ Donation
Background:
- Increasing demand for donor organs necessitates expanding criteria for cardiac graft evaluation.
- Traditional donor selection criteria may limit the pool of available organs, impacting waiting list mortality.
Purpose of the Study:
- To assess the outcomes of cardiac transplantation using grafts from donors considered high-risk.
- To compare the perioperative and long-term results of high-risk donor grafts versus low-risk donor grafts.
Main Methods:
- Retrospective analysis of 188 cardiac grafts transplanted between December 1985 and June 1992.
- Categorization of donors into high-risk and low-risk groups based on predefined criteria.
- Comparison of perioperative morbidity, survival rates, and long-term graft vasculopathy between the groups.
Main Results:
- No significant difference in 30-day, 1-year, or 5-year survival between high-risk (95.5%, 86.1%, 77.3%) and low-risk (93.7%, 86.0%, 67.2%) donor groups.
- No significant differences in postoperative inotrope use, ICU stay, hospital stay, or costs.
- A significantly higher incidence of graft coronary disease was observed in the high-risk donor group (47.1%) compared to the low-risk group (17.4%) (p = 0.0005).
Conclusions:
- Selective use of high-risk cardiac donors is compatible with excellent short-term survival and cardiac function.
- Long-term follow-up reveals a higher incidence of graft vasculopathy in recipients of high-risk donor hearts, potentially leading to significant late morbidity.
Abstract:
Rising waiting list mortality and increasing demand for donor organs have led to extension of traditionally accepted criteria for evaluation of cardiac grafts. From December 1985 to June 1992, 188 cardiac grafts were orthotopically transplanted into 178 recipients. Of these grafts, 38.3% (72/188) were defined as high-risk donors. Risk criteria included prolonged cardiopulmonary resuscitation, age greater than 40 years, high inotrope requirements, undersizing by more than 20% body weight, significant wall motion impairment by echocardiography, elevation of myocardial enzyme levels, and cold ischemia time greater than 4 hours. There were no recipient deaths attributable to primary graft failure in the perioperative period. Operative (30-day), 1-year and 5-year survival was 95.5%, 86.1%, and 77.3%, respectively, in the high-risk group compared with 93.7%, 86.0%, and 67.2%, respectively, in the low-risk donor cohort (p = 0.94). Comparison of duration of postoperative inotrope use, intensive care unit stay, total hospital stay, and in-hospital costs revealed no significant trends favoring either group in postoperative morbidity. Among long-term survivors, development of graft coronary disease was noted in 47.1% (24/51) of the high-risk donor group and only 17.4% (12/69) of the remaining group (p = 0.0005). Left ventricular ejection fractions in the high risk donor group were 0.58 +/- 0.01 at 2 years. Review of this series suggests that selective use of apparently compromised cardiac donors is compatible with excellent cardiac function and survival. Higher incidence of graft vasculopathy may cause significant morbidity during late follow-up.