Long-term transplant outcomes of donor hearts with left ventricular dysfunction

Abstract

Objective: Despite small single-center reports demonstrating acceptable outcomes using donor hearts with left ventricular dysfunction, 19% of potential donor hearts are currently unused exclusively because of left ventricular dysfunction. We investigated modern long-term survival of transplanted donor hearts with left ventricular dysfunction using a large, diverse cohort.Methods: Using the United Network for Organ Sharing database, we reviewed all adult heart transplants between January 2000 and March 2016. Baseline and postoperative characteristics and Kaplan-Meier survival curves were compared. A covariates-adjusted Cox regression model was developed to estimate posttransplant mortality. To address observed variation in patient profile across donor ejection fraction, a propensity score was built using Cox predictors as covariates in a generalized multiple linear regression model. All the variables in the original Cox model were included. For each recipient, a predicted donor ejection fraction was generated and exported as a new balancing score that was used in a subsequent Cox model. Cubic spline analysis suggested that at most 3 and perhaps no ejection fraction categories were appropriate. Therefore, in 1 Cox model we added donor ejection fraction as a grouped variable (using the spline-directed categories) and in the other as a continuous variable.Results: A total of 31,712 donor hearts were transplanted during the study period. A total of 742 donor hearts were excluded for no recorded left ventricular ejection fraction, and 20 donor hearts were excluded for left ventricular ejection fraction less than 20%. Donor hearts with reduced left ventricular ejection fraction were from younger donors, more commonly male donors, and donors with lower body mass index than normal donor hearts. Recipients of donor hearts with reduced left ventricular ejection fraction were more likely to be on mechanical ventilation. Kaplan-Meier curves revealed no significant differences in recipient survival up to 15 years of follow-up (P ¼ .694 log-rank test). Cox regression analysis showed that after adjustment for propensity variation, transplant year, and region, ejection fraction had no statistically significant impact on mortality when analyzed as a categoric or continuous variable. Left ventricular ejection fraction at approximately 1 year after transplantation was normal for all groups.Conclusions: Carefully selected donor hearts with even markedly diminished left ventricular ejection fraction can be transplanted with long-term survival equivalent to normal donor hearts and therefore should not be excluded from 80 60

The adapted Heart Donor Score

“…Specifically, our group has shown that higher dose norepinephrine donor support is not associated with impaired survival or higher rates of primary graft dysfunction, prolonged ventilation, or renal replacement therapy after HTX [19]. Moreover, studies have shown that recipients of donors with even markedly reduced LVEF are not at risk of impaired long-term survival, dopamine donor support is actually associated with superior survival after HTX, and recipients of donor hearts with documented single-vessel disease have similar survival when compared with recipients of donor hearts without coronary atherosclerosis [20][21][22][23].…”

Commentary: Perfection is the enemy of good: Pushing the boundaries of donor heart criteria

“…Despite these limitations in the study design, the findings by Sibona and colleagues 5 are important observations that should be carefully applied to our clinical practice. These data once again demonstrate that our perceived notion of what constitutes acceptable donor criteria may no longer be valid assumptions.…”

Trends in the utilization of marginal donors for orthotopic heart transplantation

“…The use of extended criteria and marginal donors has expanded the donor pool for end‐stage heart failure patients with evidence of favorable outcomes in selected candidate populations. Prior studies have demonstrated comparable post‐OHT survival in recipients receiving organs with reduced ejection fraction compared to those with normal left ventricular function 4,5 . Furthermore, midterm mortality utilizing organs from older donors appears favorable 6‐8 .…”

“…Limited donor availability for orthotopic heart transplantation (OHT) has resulted in reexamination of historical contraindications for heart transplant donors. This includes recent incorporation of the use of hepatitis C positive donors, 1,2 older donors, 3 and donors with borderline left ventricular dysfunction 4 . The use of extended criteria and marginal donors has expanded the donor pool for end‐stage heart failure patients with evidence of favorable outcomes in selected candidate populations.…”