Coronary Artery Disease in Hearts Donated for Transplantation

In spite of recent initiatives, in particular, the introduction into clinical practice of donation after circulatory death (DCD), there is a persistent mismatch between the demand for donor hearts for transplantation and their supply \[1\]. This mismatch is accentuated by the relatively low rate of utilisation of hearts donated for transplantation, i.e. the proportion of organs transplanted divided by the number of donations. In the UK between 2016 and 2018 this ranged from 25.7 to 30.8% \[2\]. For the year 2022/23, a total of 207 heart transplants (DBD and DCD) were performed out of 1429 donations giving a utilisation rate of 14.5% \[3\]. The rigorous assessment of donor heart quality prior to, and during donor organ retrieval, which is a crucial determinant of recipient outcome, accounts for the low utilisation rate. In both the donation after brain(stem) death (DBD) and DCD settings, pre-retrieval echocardiography is the principal method of anatomical and functional assessment. In the DCD setting, where normothermic organ perfusion (either in situ or ex situ) is mandatory to restore myocardial function, additional functional and biochemical assessments are available. In addition to recipient risk factors, donor age and comorbidity burden continue to limit the applicability and effectiveness of heart transplantation. Older donors are both associated with an increased comorbidity burden and prevalence of coronary artery disease (CAD). Donor-transmitted CAD is of particular concern due to the significant association with early graft dysfunction when multi-vessel disease is present \[4,5\]. Guidelines recommend that donor hearts with obstructive CAD in any major coronary artery be declined for transplantation \[4\]. However, there is evidence that single vessel CAD neither alters short- nor long term recipient prognosis \[6\]. The short and long term risks to the recipient of donor heart CAD needs to be carefully evaluated in relation to the risk of a transplant ca