Screening and assessment of the donor heart

Why screening?Thirty years ago most donors suffered from head trauma (“Morbus Kawasaki”) and a donor older than 35 years was beyond the pale, i.e. donors were young and healthy, and since these early days of transplantation donor hearts have been regarded as healthy “per definitionem” (1). However, due to the general organ shortage the criteria for the acceptance of donor hearts have been widely liberalized. According to the current quarterly data report of the International Society for Heart and Lung Transplantation (ISHLT) nearly two thirds of donors in Europe (64.3%) were older than 35 years, more than a quarter (26.0%) were even older than 50 years and less than 10% of organ donors suffered from head trauma (2). Meanwhile the average (European) donor is 45 years old and is suffering from intracranial bleeding, i.e. the so-called “donor pool” represents a subpopulation with significantly elevated risk for cardiac diseases such as coronary atherosclerosis and hypertension-related myocardial hypertrophy (Fig. 1). Unfortunately, daily experience shows that donor heart screening has not been adapted to this development (3). Therefore, the question “Why screening?” is not as trivial as it may look: Donor coronary angiography is still an exception (performed in 5-10% of donors) despite the fact that [1] the prevalence of significant atherosclerotic coronary artery disease (CAD) in the donor pool is about 20%, [2] the risk of CAD transmission without angiography is about 5% to 10% despite organ inspection by the harvesting surgeon and [3] the risk for early graft failure with transmitted significant CAD is three times as high (4,5).