Selective Angiography of Stimulant-Exposed Cardiac Donors Following Circulatory Death Does Not Impact Post-Transplant Outcomes

<b>Background/Objectives</b>: Donation after circulatory death (DCD) has emerged to expand the heart-donor pool, but many DCD donors have risk factors such as cocaine or methamphetamine use. Stimulant use can cause coronary vasospasm and premature coronary artery disease, leading to routine donor coronary angiography (left heart catheterization, LHC) for coronary screening. However, performing LHC in DCD donors is challenging. We examined whether omitting LHC in stimulant-exposed DCD donors affects outcomes. <b>Methods</b>: A retrospective analysis was performed using the United Network for Organ Sharing (UNOS) database (2019-2024) to identify adult heart transplant recipients from DCD donors with documented cocaine or amphetamine use. Donors were stratified by whether antemortem LHC was performed. The primary outcome was 1-year recipient survival; secondary outcomes included graft failure and acute rejection. Kaplan-Meier survival curves and Cox regression analyses were performed. <b>Results</b>: A total of 485 DCD heart transplant recipients were identified; 135 (28%) donors underwent LHC and 350 (72%) did not. Recipient characteristics were similar between groups. No significant differences in 30-day (6% vs. 3%; <i>p</i> = 0.11), 90-day (6% vs. 3%; <i>p</i> = 0.21), or 1-year survival (7% vs. 6%; <i>p</i> = 0.48) were observed between the LHC and non-LHC cohorts. Graft failure and complication rates were also similar. However, among stimulant-exposed DCD donors with diabetes, an absence of LHC was associated with higher recipient mortality (HR 5.86, 95% CI: 1.57-21.87; <i>p</i> = 0.008). <b>Conclusions</b>: Routine donor coronary angiography may be unnecessary for stimulant-exposed DCD donors without additional risk factors. Omitting LHC did not compromise transplant outcomes. A selective LHC approach for high-risk DCD donors (e.g., diabetic donors) could safely expand the donor pool.