Original clinical science
Stress Echocardiography as a Gatekeeper to Donation in Aged Marginal Donor Hearts: Anatomic and Pathologic Correlations of Abnormal Stress Echocardiography Results

https://doi.org/10.1016/j.healun.2009.05.029Get rights and content

Background

Owing to the shortage of donor hearts, the criteria for acceptance have been considerably expanded. Pharmacologic stress echocardiography is highly accurate in identifying prognostically significant coronary artery disease, but brain death and catecholamine storm in potential heart donors may substantially alter the cardiovascular response to stress. This study assessed correlates of an abnormal resting/stress echocardiography results in potential donors.

Methods

From April 2005 to December 2007, 18 marginal candidate donors (9 men) aged 58 ± 5 years were initially enrolled. After legal declaration of brain death, all marginal donors underwent bedside echocardiography, with baseline and (when resting echocardiography was normal) dipyridamole (0.84 mg/kg in 6 min) or dobutamine (up to 40 μg/kg/min) stress echo. Non-eligible hearts (with abnormal rest or stress echo findings) were excluded and underwent cardioautoptic verification.

Results

Resting echocardiography showed wall motion abnormalities in 5 patients (excluded from donation). Stress echocardiography was performed in the remaining 13 (dipyridamole in 11; dobutamine in 2). Results were normal in 7, of which 6 were uneventfully transplanted in marginal recipients. Results were abnormal in 6, and autoptic verification performed showed coronary artery disease in 5, and initial cardiomyopathy in 1.

Conclusions

Bedside pharmacologic stress echocardiography can safely be performed in candidate heart donors, is able to unmask occult coronary artery disease or cardiomyopathy, and shows potential to extend donor criteria in heart transplantation. Further experience with using marginal donors is needed before exact guidelines can be established.

Section snippets

Marginal Donor Recruitment

This study defined a marginal candidate donor as a patient aged between 55 and 65 years, or < 55 but with concomitant risk factors, including possible cocaine use, > 2 risk factors such as hypertension, hyperlipidemia, smoking, or diabetes. From April 2005 to 2008, 18 marginal candidate donors (9 men) with a mean age of 58 ± 5 years were initially enrolled (Figure 1).

After legal declaration of brain death, all marginal donors underwent a baseline echocardiogram for evaluation of regional

Results

After legal declaration of brain death, the 18 marginal donors enrolled in the study underwent bedside transthoracic or transesophageal echocardiography. Resting echocardiography showed wall motion abnormalities in 5 hearts and they were removed from the stress echo protocol. Stress echo was performed in the remaining 13, using dipyridamole in 11, and dobutamine in 2. Seven donors had maximal stress with normal LV WMSI (rest = peak = 1), peak stress LV elastance > rest, and 6 hearts were

Discussion

Age restrictions (< 55 years) in cardiac donors are being relaxed because of limited donor supply. Close examination of the potential cardiac donor pool is necessary to understand and alleviate the shortage of these donor organs. In this preliminary pilot study, 18 marginal candidate donors were screened by pharmacologic stress echo. Five were not eligible by baseline echocardiography, and 6 that were still eligible at rest were excluded by the stress echo results. Morphopathology in aged donor

Disclosure Statement

Partial funding for this project was provided by Heart and Lung Transplantation Program, Regione Emilia–Romagna (1ASTEARP).

None of the authors has a financial interest or other potential conflict of interest related to the subject matter or materials mentioned in the manuscript.

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