Effects of Older Donor Age and Cold Ischemic Time on Long-Term Outcomes of Heart Transplantation

Abstract

Using older donor hearts in cardiac transplantation may lead to inferior outcomes: older donors have more comorbidities that reduce graft quality, including coronary artery disease, hypertension, diabetes mellitus, and dyslipidemia. Shorter cold ischemic times might overcome the detrimental effect of older donor age. We examined the relationship between donor allograft age and cold ischemic time on the long-term outcomes of heart transplant recipients. rom 1994 through 2010, surgeons at our hospital performed 745 heart transplantations. We retrospectively classified these cases by donor ages of <50 years (younger) and ≥50 years (older), then by cold ischemic times of <120 min (short), 120 to 240 min (intermediate), and >240 min (long). Endpoints included recipient and graft survival, and freedom from cardiac allograft vasculopathy, nonfatal major adverse cardiac events, and rejection. For intermediate ischemic times, the 5-year recipient survival rate was lower when donors were older (70% vs 82.6%; =0.02). This was also true for long ischemic times (69.8% vs 87.6%;=0.09). For short ischemic times, we found no difference in 5-year recipient or graft survival rates (80% older vs 85.6% younger; =0.79), in freedom from nonfatal major adverse cardiac events (83.3% vs 91.5%;=0.46), or in freedom from cardiac allograft vasculopathy (50% vs 70.6%; =0.66). Rejection rates were mostly similar. Long-term graft survival in heart transplantation patients with older donor allografts may improve when cold ischemic times are shorter.

Does donor‐recipient age difference matter in outcome of heart transplantation?

“…With the growing shortage of organ donors combined with the increasing demand for organs, more expanded criteria donors are being used. The use of cardiac allografts from older donors has thus also increased over time, and the percentage of donors above the age of 50 has more than tripled over the past three decades . Earlier ISHLT registry data reported that older donor age was a significant predictor of death at 1 year and 5 years after heart transplantation (HT), but not at 15 years; the correlation between older donor age and higher recipient mortality rates remained significant after multivariate analysis .…”

Variability in donor selection among pediatric heart transplant providers: Results from an international survey

“…Available evidence suggests inferior outcomes for both pediatric and adult recipients of older donor hearts, with a donor age >40 years commonly cited as the cutoff that portends worse survival . Older donor hearts are also more susceptible to ischemic challenges, and therefore, utilization of older donors with anticipated short ischemic times has been suggested as a viable approach to optimize utilization of these organs . Despite this, many pediatric centers reported much lower age cutoffs for adolescent recipients.…”

“…Therefore, isolated mortalities have a much greater impact 19,21,22 Older donor hearts are also more susceptible to ischemic challenges, 20,23 and therefore, utilization of older donors with anticipated short ischemic times has been suggested as a viable approach to optimize utilization of these organs. 24,25 Despite this, many pediatric centers reported much lower age cutoffs for adolescent recipients. While extension of this age cutoff may be warranted, concerns about the possibility of donor transmitted atherosclerosis and the potential association with allograft vasculopathy 26-28 may continue to dissuade utilization of these organs in pediatric recipients.…”

Clinical outcome of donor heart with prolonged cold ischemic time: A single‐center study

“…The decision to accept donor hearts from remote places with expected long period of ischemia should be a deliberate process based on a detailed assessment of the specific donor and recipient factors . Variables such as recipient comorbidities, particularly donor age, hepatic and renal dysfunction, donor's inotropic use, and left ventricular function should be considered in the decision‐making process . The prolonged cold ischemic time itself should not be the decisive factor for not accepting the donor's heart.…”