Underutilization of Donor Hearts: An Observational Study

Variability in Heart Yield From Donation After Brain Death Between Organ Procurement Organizations: An Opportunity for Improvement

Increasing the number of available hearts for transplantation is the best strategy to decrease waitlist mortality. This study examines organ procurement organizations (OPOs) and their role in the transplantation network to determine whether variability in performance exists across them. Adult deceased donors who met the criteria for brain death between 2010 and 2020 (inclusive) in the United States were examined. A regression model was fitted and internally validated using donor characteristics available at the time of organ recovery to predict the likelihood of heart transplantation. Subsequently, an expected heart yield was calculated for each donor using this model. Observed-to-expected (O/E) heart yield ratios for each OPO were calculated by dividing the number of hearts recovered for transplantation by the expected number of recoveries. There were 58 OPOs active during the study period, and on average, OPO activity grew over time. The mean O/E ratio among OPOs was 0.98 (standard deviation ± 0.18). Twenty-one OPOs consistently performed below the expected level (95% confidence intervals < 1.0) and generated a deficit of 1,088 expected transplantations during the study period. The proportion of hearts that were recovered for transplantation varied significantly by OPO categories: low tier 31.8%, mid tier 35.6%, and high tier 36.2% (p < 0.01), even as the expected yield was similar across tiers (p = 0.69). OPO performance accounts for 28% of the variability in successfully transplanting a heart after accounting for the role of referring hospitals, donor families, and transplantation centers. In conclusion, there is significant variability in volume and heart yield from brain-dead donors across OPOs.

Coronary angiography utilization in the evaluation of a potential heart donor by age: a narrative review

Heart transplant is the gold standard treatment for patients with heart failure. The limitation to providing heart transplantation to patients suffering from end stage heart disease is the stable organ supply within the United States despite increasing demand. Transplant centers across the United States have begun to expand traditional cardiac donor selection metrics previously utilized. As a result, the use of extended criteria donors, such as older donors, those with longer ischemic times, and donors considered high risk has increased. Current guidelines suggest that coronary angiography be performed when evaluating a donor above the age of 45. Angiographic guidelines for evaluation of the donor heart are based specifically on age, with little evidence based guidance surrounding the use of angiography in a younger donor with comorbidities or increased risk behavior which may lead to premature coronary artery disease. Recently, we have seen an increase in younger heart donors, many of whom have succumbed due to drug overdose with ensuing high risk behaviors. Given the increased risk nature of these donors, consideration of performing coronary angiography is determined by clinical “gestalt” of the transplant center evaluating the heart for use, which may lead to underutilization of donor organs without evidence to support the practice. Here, we review the guidelines, literature, and controversy surrounding the use of coronary angiography in evaluating donor hearts for transplantation.

Donor Heart Utilization in Korea

Background and Objectives

Donor heart utilization patterns in Korea are not well known. We aimed to analyze the current utilization rate of donor heart and to evaluate the reason for non-utilization in Korea.

Methods

Brain death donors were identified from the Korean Network for Organ Sharing registry from November 2009 to December 2019. Baseline characteristics and heart transplant related parameters were compared between transplanted and discarded donor hearts.

Results

Among 4,401 donors, 1,383 (31.4%) hearts were utilized. Hearts from younger, male donors without history of hypertension or diabetes mellitus were utilized more frequently. The most common blood type in the transplanted group was O, while blood type A was the most common blood type in the discarded group. The ejection fraction in the discarded group were significantly lower (57.0 ± 13.5% vs. 61.7 ± 7.0%, p<0.001). Reasons for non-utilization were as follows: medical condition (34.4%), old age (31.8%), refused by all candidates (22.5%), refused to donate (11.0%), and others (0.2%). The most common cause of brain death was cerebrovascular disease in both the transplanted and discarded groups, but the incidence was significantly higher in the discarded group (46.8% vs. 37.5%, p<0.001). In multivariate analysis, old age, small body surface area, rapid heart rate, blood type other than O, abnormal echocardiography findings were independent predictors for non-utilization.

Conclusions

Average donor heart utilization rate was 31.4% and it improved to 42.9% in 2019. However, substantial numbers of donor hearts are still discarded. A strategic approach to improve donor heart utilization is necessary.