Evaluating the donor pool: impact of using hearts from donors over the age of 49 years

Abstract

The shortage of hearts for transplantation has led to the use of organs from older donors in many centres. Despite the lack of coronary angiography on potential organ donors, hearts from carefully selected donors over 49 years of age have been used at this centre since 1988. In the study reported here looked at the impact of this strategy on morbidity and mortality. Between May 1988 and August 1996, 400 first heart transplants were performed, 35 recipients (31 male, 4 female; age 51 +/- 5.9 years) received hearts from donors over 49 years of age (group 1) while 365 (310 male, 55 female; age 49 +/- 9.7 years) had younger donors (group 2). The mean ischaemic time was 189 min (+/- 63.1) in group 1 and 180 min (+/- 59.2) in group 2 (n.s.). The main aetiology of heart failure in groups 1 and 2 was coronary artery disease in 46% and 51%, and dilated cardiomyopathy in 40% and 45% respectively (n.s.). There were no differences in the duration of stay on the intensive care unit or in hospital between the groups. One-year survival was 79% in group 1 and 82% in group 2 (n.s.) and actuarial 5-year survival 69% and 67%, respectively. Six patients in group 1 (17%) and 45 patients in group 2 (12%) died in the first 3 months; of these primary donor organ failure accounted for 50% in group 1 and 13.3% in group 2 (n.s.). Episodes of acute rejection (in the first 3 months) were similar in the two groups: 1.4 and 1.6 per 100 patient days, respectively. Infection rates were also similar: 0.5 and 0.6 per 100 patient days, respectively. The prevalence of coronary artery disease on surveillance coronary angiography at 2 years was 23% in group 1 and 9% in group 2 (P < 0.005). There was a greater proportion of CMV antibody donors in the older donor group, but the association between donor age and coronary artery disease persisted after adjusting for CMV status in multivariate analysis. Too few patients underwent angiography thereafter for valid comparisons. In summary, recipients of organs from donors aged 49 years and over can expect comparable survival rates and morbidity levels to recipients of organs from younger donors, at least in the first 2 years postoperation. There is evidence that older donors confer a significantly higher risk of cardiac allograft vasculopathy which may result in a greater attrition rate thereafter. Careful follow-up of these patients after 2 years is required.

Analysis of the Complex Effect of Donor’s Age on Survival of Subjects Who Underwent Heart Transplantation

“…In fact, the incidence of cardiovascular diseases is higher in men than in women (21), and male sex is itself a major risk factor for atherosclerosis (22). A study by Mercer shows that atherosclerosis is a major cause of failure of transplants using hearts from older donors (23).…”

The policy of placing older donors into older recipients: is it worth the risk?

“…A retrospective single-center analysis by Del Rizzo et al (15) of 372 patients found the highest risk ratio of lower one-yr survival to be in patients receiving older donor hearts (risk ratio = 2.20; p = 0.004); in the context of advanced recipient age, this study also found it to increase the risk of mortality among other factors. However, we accept that not all studies concur on the topic: Several smaller single-center retrospective analyses have found no correlation between increased donor age and reduced survival (16)(17)(18); this may be a function of their small numbers.…”

Long-Term Results of Cardiac Transplantation

“…Thirtyday and six-year survival rates were 91.0% and 75.0%, respectively, which is comparable to our other patients and to that reported by other centers. [31][32][33] Regarding short-term heart transplant survivors where rejection, infection, and technical graft failure play a dominant role in mortality and morbidity, the predominant causes of death in longer-term survivors are coronary artery disease and side effects of immunosuppresive medication. Intravascular ultrasound will allow a more precise judgment of this most important long-term transplant sequela.…”