Impact of Donor Left Ventricular Hypertrophy on Survival After Heart Transplant

Abstract

Left ventricular hypertrophy (LVH) of the donor heart is believed to increase the risk of allograft failure after transplant. However this effect is not well quantified, with variable findings from single-center studies. The United Network for Organ Sharing database was used to analyze the effect of donor LVH on recipient survival. Three cohorts, selected in accordance with the American Society of Echocardiography guidelines, were examined: recipients of allografts without LVH (<1.1 cm), with mild LVH (1.1–1.3 cm) and with moderate–severe LVH (≥1.4 cm). The study group included 2626 patients with follow-up of up to 3.3 years. Mild LVH was present in 38% and moderate-severe LVH in 5.6% of allografts. Predictors of mortality included a number of donor and recipient characteristics, but not LVH. However, a subgroup analysis showed an increased risk of death in recipients of allografts with LVH and donor age >55 years, and in recipients of allografts with LVH and ischemic time ≥4 h. In the contemporary era, close to half of all transplanted allografts demonstrate LVH, and survival of these recipients is similar to those without LVH. However, the use of allografts with LVH in association with other high-risk characteristics may result in increased mortality.

Assessment of Heart Transplant Waitlist Time and Pre- and Post-transplant Failure

“…However, this decrease in the use of donor hearts with one or more “high risk” features did not result in substantially improved transplant outcomes. In fact, many previous studies have demonstrated a lack of association between donor characteristics and recipient outcomes after heart transplantation 8,12,23–25 with several notable exceptions, including older donor age, especially in the setting of a prolonged ischemic time 6 .…”

“…There is also potential risk aversion, as transplant centers are primarily judged on short-term outcomes, and hearts with undesirable features such as older donor age or echocardiographic abnormalities are often turned down for concern that their use may result in adverse recipient outcomes 5,6 .…”

Donor selection in the modern era

“…For example, an analysis of the United Network for Organ Sharing (UNOS) heart transplant registry in the United States showed equivalent 30-day to 3-year survival in recipients of donor hearts without left ventricular hypertrophy (LVH, <1.1 cm), mild LVH (1.1-1.3 cm) and moderate-severe LVH (≥1.4 cm); however, subgroup analyses showed an increased risk of death in recipients of allografts with LVH and donor age >55 years or ischemic time ≥4 hours, which highlights the need to carefully evaluate donor risk factors in aggregate (10). Donor/recipient size matching has also been relaxed.…”

Matching the Market for Heart Transplantation

“…30, 31 Left ventricular hypertrophy >1.3 cm and allograft ischemic times ≥ 4 hours is associated with high mortality while mild left ventricular hypertrophy ≤1.3 cm and long ischemic times are not (see Figure 2). 32 Diabetes mellitus or hypertension in male donors has a higher risk than when present in female donors (see Figure 3). Finally, under-sizing the donor heart is most concerning when donor age > 30 yo in male donors/recipients and donor age > 40 yo in female donors/recipients.…”