The following are key points to remember from this review on contemporary characteristics of heart transplant donors and recipients:

1. With the opioid epidemic, there has been a significant increase in the number of organ donors available. Prior to the advent of direct-acting antiviral agents for treatment of hepatitis C virus (HCV), studies reported accelerated coronary allograft vasculopathy (CAV) and reduced survival with hepatitis C donors.
2. Since newer antiviral agents for hepatitis C have an efficacy of >95%, there has been an increased use of HCV-infected donors. Studies have shown shorter waiting time with HCV donors and comparable 1-year survival. Longer-term outcomes are not yet reported.
3. HCV antivirals are only available in pill form, which is relevant for patients with delayed oral intake post-transplant. They also have significant drug interactions with medications used routinely in transplant recipients such as statins and calcineurin inhibitors.
4. Newer techniques are being used for organ preservation such as targeted cold preservation. This technique uses a sterile box that maintains donor heart temperature between 4-8°C. It is Food and Drug Administration approved for cold storage and useful when longer transport times are expected.
5. Cold storage of donor organs is associated with reperfusion injury and ischemia with longer waiting time. Accordingly, ex vivo preservation with normothermia has emerged where the donor organ is perfused ex vivo with oxygen and nutrient-rich blood in a warm state. In a multicenter trial, outcomes among recipients using organs preserved in cold storage versus ex vivo normothermia were comparable at 30 days. These techniques have led to expansion of available organs.
6. Traditionally, heart transplants have been performed using brain dead donors. There is an increased interest in retrieval of organs from donors with circulatory death (DCD). These donors are not brain dead but have poor chances of recovery. Initial reports with use of DCD donors have had comparable short-term outcomes in heart transplant recipients compared to conventional donors with brain death.
7. Data suggest that use of hearts from donors with a past or current history of cocaine use is safe with no difference in survival. Donation from cocaine users has increased from 11%–27% from 2000–2018.
8. Median donor age has increased over time. Donor age ≥50 years is associated with reduced 30-day survival.
9. Ensuring that donor and recipient size match is important for transplant to be successful. Instead of matching based on body weight, predicted heart mass has emerged as a better technique for organ matching and can be calculated online.
10. All donors need to be tested for COVID-19 in the 72 hours prior to donation. Risk of transmission is unlikely if a donor tests positive 21-90 days after date of COVID-19 infection onset. For those who test positive 10-21 days after onset of COVID-19 infection, but after infection has resolved or if donors test positive in the absence of known history of infection, safety is unknown, and donation may be considered in select cases.
11. As of October 2018, the new heart transplant allocation policy has been implemented, which broadens the listing system to six tiers with patients on extracorporeal membrane oxygenation and non-dischargeable biventricular support being the highest priority. Early studies show a decrease in waiting time with the new policy but also a decrease in post-transplant survival as recipients are sicker. The proportion of recipients on durable left ventricular assist devices receiving heart transplant is lower.
12. The proportion of recipients >70 years old has increased substantially over time. Recent reports show no difference in 5-year survival between older and younger recipients.
13. The frequency of multiorgan transplant has been increasing, with most common being heart–kidney transplantation. However, multiorgan transplants are associated with ethical challenges as younger, minority patients are unable to receive timely single organ transplants.
14. Desensitization of patients who are allosensitized has new and emerging pharmacological approaches. This includes proteosome inhibitors such as bortezomib and anti–interleukin-6 receptor blockers such as tocilizumab. The current allocation system in the United States does not incentivize sensitized patients.
15. Evolving areas include transplant in HIV-infected patients, as contemporary treatment for HIV is highly effective. The role of xenotransplantation is evolving. Recently, in January 2022, a man received a genetically modified pig heart and was treated with anti CD40 monoclonal antibodies in addition to standard immunosuppression. The patient lived for 2 months post-transplant and this field remains under development.

Clinical Topics: Cardiac Surgery, COVID-19 Hub, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Cardiac Surgery and Heart Failure, Novel Agents, Acute Heart Failure, Heart Transplant, Interventions and Vascular Medicine

Keywords: Allografts, Antibodies, Monoclonal, Antiviral Agents, Brain Death, Cocaine, COVID-19, Drug Interactions, Extracorporeal Membrane Oxygenation, Heart Failure, Heart Transplantation, Hepatitis C, Chronic, HIV Infections, Immunosuppression, Ischemia, Kidney Transplantation, Opioid Epidemic, Reperfusion Injury, Tissue Donors, Transplant Recipients, Transplantation, Heterologous

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