Transient Systolic Dysfunction in Donor Hearts

Study Questions:

What are the outcomes of donor hearts with left ventricular (LV) systolic dysfunction on initial transthoracic echocardiogram (TTE) that resolved during donor management?

Methods:

The study authors reviewed echocardiograms of all cardiac donors (age ≥18 years) in the United Network of Organ Sharing (UNOS) database that were transplanted from January 1, 2007, to September 30, 2015. From all the donors who had multiple TTEs during donor management, they identified 472 donor hearts with LV systolic dysfunction (LV ejection fraction [LVEF] ≤40%) on initial TTE that resolved (LVEF ≥50%) during donor management on a subsequent TTE. These patients comprised the improved donor LVEF group. The authors compared these to donor hearts with normal LVEF (LVEF ≥55%) on the initial TTE for recipient mortality, cardiac allograft vasculopathy, and primary graft failure. The primary outcome of the study was all-cause mortality during up to 5 years of follow-up. Secondary outcomes assessed included primary graft failure up to 90 days, cardiac allograft vasculopathy up to 5 years, and post-transplant length of stay in the hospital. Main exclusion criteria included multi-organ transplants, repeat transplants, donor age >55 years, structural abnormality or significant coronary artery disease in the donor heart, missing TTE information, or LVEF <55% (if there was only one donor TTE). They did not include donor hearts with ‘low-normal’ or ‘borderline’ LVEF (50% to <55%) in the normal donor LVEF group.

Results:

The study cohort consisted of 17,584 adult heart transplants during the study period and 15,853 met the initial inclusion/exclusion criteria. Of the 4,449 donor hearts with ≥2 TTEs performed during donor listing and management, the authors identified 472 donor hearts with LV systolic dysfunction on initial TTE (LVEF ≤40%) that improved to LVEF ≥50% on a follow-up TTE (the improved donor LVEF group). The normal-donor LVEF group consisted of 11,223 donor hearts with normal LVEF (≥55%) on the single TTE done during donor listing and management. Compared to the normal donor LVEF group, the donors in the improved donor LVEF group were younger (25 years [range 20-32] vs. 30 years [range 22-41]; p < 0.001), had a lower LVEF at transplant (57% [range 55%-60%] vs. 61% [range 60%-65%]; p < 0.001), and a higher prevalence of brain anoxic injury as a cause of death (35.38% vs. 17.78%; p < 0.001). Kaplan-Meier estimates of 30-day, 1-year, 3-year, and 5-year recipient survival for the overall cohort were 96.0%, 90.1%, 83.5%, and 76.8%, respectively. Using Cox models, there was no significant difference in mortality between the ‘normal’ donor and ‘improved’ donor LVEF groups at 30 days (4.0% vs. 4.1%), 1 year (9.9% vs. 10.6%), 3 years (16.5% vs. 16.9%), and 5 years (23.2% vs. 24.4%) of follow-up. The results were consistent in Cox models adjusted for differences in baseline characteristics and for recipient and donor characteristics known to affect post-transplant outcomes. Kaplan-Meier analysis of recipient survival also showed no significant difference in recipient mortality after up to 5 years of follow-up (p = 0.630 for log rank test). The study authors found no significant difference in rates of primary graft failure at 90 days and cardiac allograft vasculopathy at 5 years between recipients of donor hearts with improved LVEF and recipients of donor hearts with initially normal LVEF. Post-transplant length of stay was also similar between the two groups. After propensity matching, 461 transplants in the improved donor LVEF group were matched to 461 transplants in the normal-donor LVEF group. There was no significant difference in primary graft failure at 90 days or recipient mortality after up to 5 years of follow-up.

Conclusions:

The study authors concluded that donor hearts with transient LV systolic dysfunction can be successfully resuscitated and transplanted without increasing recipient mortality, coronary artery vasculopathy, or primary graft failure.

Perspective:

LV systolic dysfunction accounts for 20-35% of nonacceptance of potential donor hearts. Earlier smaller studies have reported that LV systolic dysfunction following brain death may be transient and such hearts can be successfully resuscitated with resolution of LV systolic dysfunction, then transplanted. This large study confirms that donor hearts with transient LV systolic dysfunction can be transplanted with outcomes comparable to donor hearts with normal LV systolic function. These findings are important because it potentially can increase donor utilization by approximately 25%.

Clinical Topics: Cardiac Surgery, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Cardiac Surgery and Heart Failure, Lipid Metabolism, Acute Heart Failure, Chronic Heart Failure, Heart Transplant, Interventions and Coronary Artery Disease, Interventions and Imaging, Echocardiography/Ultrasound

Keywords: Allografts, Cardiac Surgical Procedures, Coronary Artery Disease, Echocardiography, Heart Failure, Heart Failure, Systolic, Heart Transplantation, Outcome Assessment (Health Care), Prostaglandins F, Stroke Volume, Systole, Tissue Donors, Ventricular Dysfunction, Left


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