Transplanting the unexpected: what happens when donors have coronary artery disease?

Heart transplantation remains the definitive treatment for patients with end-stage heart failure, significantly improving survival rates and quality of life.[1,2] However, the demand for donor hearts far exceeds the supply, leading to prolonged waitlist times and increased mortality among patients awaiting transplants.[3,4] This scarcity has prompted transplant centers to consider extended criteria donors (ECDs), which include donors with comorbidities, such as advanced age, hypertension, and coronary artery disease (CAD).[5–7] Traditionally, hearts from donors with CAD are often rejected because of concerns about accelerated graft failure and postoperative complications. Recent advancements in medical management, including enhanced immunosuppression regimens and routine use of statins, have opened new possibilities for utilizing these donor hearts. Understanding the implications of transplanting hearts with CAD is crucial for optimizing organ utilization and expanding the donor pool without compromising patient outcomes. In a recent study by Shah et al., the impact of donor CAD on recipient outcomes using data from 12 230 heart transplant recipients. After adjusting for baseline characteristics through propensity score matching, the study found no significant differences in long-term outcomes between recipients of donor hearts with CAD and those without.[8] Specifically, with 10-year survival rates of 54.7% for the CAD group versus 55.8% for the non-CAD group, and freedom from graft failure was comparable between the two groups. Despite a slightly higher incidence of pacemaker implantation in recipients of CAD-positive hearts, these findings suggest that moderate CAD in donor hearts may not significantly affect recipient outcomes. This indicates that such hearts are viable options for transplantation in appropriately selected cases. The persistent shortage of donor hearts has led to a reevaluation of donor acceptance criteria. Utilizing ECDs has become a pivotal strategy for addressing organ shortages. Hearts from donors with certain comorbidities, when carefully assessed, were successfully transplanted without adversely affecting recipient survival. Advancements in donor heart evaluation, such as high-resolution imaging and better understanding of myocardial viability, have facilitated the safe use of marginal donor hearts.[9,10] Techniques like normothermic regional perfusion and ex vivo heart perfusion systems allow for functional assessment of donor hearts that might otherwise be deemed unsuitable, thereby increasing the donor pool.[11–14] Transplanting hearts with preexisting CAD requires meticulous perioperative and postoperative management to mitigate potential risks. The progression of atherosclerosis post-transplant is a significant concern, but modern immunosuppressive therapies and lipid-lowering agents can effectively manage CAD progression and reduce the risk of graft dysfunction.[15,16] Routine monitoring using imaging modalities, such as coronary angiography or intravascular ultrasound, can detect early signs of coronary allograft vasculopathy (CAV) or graft dysfunction, enabling timely interventions.[17,18] Close follow-up is essential to monitor for electrical disturbances and other potential complications, ensuring long-term graft survival. Advances in medical technologies and therapeutic strategies are expected to further improve the safety and efficacy of transplanting hearts with pre-existing conditions, such as CAD. Personalized immunosuppressive regimens and advanced post-transplant monitoring technologies will enhance outcomes in recipients of CAD-positive hearts. Optimizing donor-recipient matching criteria and refining post-transplant care protocols will be crucial for improving the management of these patients. Innovations in organ preservation methods are anticipated to improve graft function and expand the window for organ assessment and transport. In conclusion, the successful use of donor hearts with moderate coronary artery disease offers a promising avenue for expanding the donor pool for heart transplantation. With proper candidate selection, meticulous perioperative management, and diligent postoperative monitoring, these donor hearts can provide long-term outcomes comparable to those of non-CAD donors. This expansion of donor criteria could significantly reduce waitlist mortality and offer hope to patients with end-stage heart failure. As transplant medicine continues to evolve, embracing the use of CAD-positive donor hearts with appropriate safeguards will be essential for meeting the growing demand for heart transplants.