Background: The limited number of donor hearts relative to the number of waiting recipients is the major determinate of a growing inequity. Although a number of potential options are being vigorously pursued, the most effective immediate solution is to expand acceptance criteria for donor age and medical condition. This report is a review of our early and late results with the use of older donors, including simultaneously "bypassed" donor hearts.
Methods: Between April 1987 and September 1994, 52 patients received older donor hearts (older than 45 years) with a mean donor age of 51 years. Ten patients in this group received hearts simultaneously bypassed with from 1 to 4 grafts per patient. Donor and recipient age, diagnosis, and HLA match were compared between the older donor group and a contemporaneous younger (younger than 45) donor group (N = 324). Also compared was actuarial survival at up to 5 years of follow-up in addition to graft function, bypass graft patency, infection and rejection incidence at 1 year, and the prevalence of transplant-associated coronary artery disease in the two groups. Echocardiography, coronary angiography, and intravascular coronary ultrasonography were used for this assessment.
Results: One-year actuarial survival was 84% for the older donor group, which included 19 status 1 patients (survival 76%) and 23 status II patients (survival 90%). In the bypassed donor subgroup there was a 60% 1-year actuarial survival with 5 status 1 patients (survival 80%) and 5 status II patients (survival 40%). At 1 year, left ventricular function and the incidence of infection and rejection were equal between these two donor groups. Five-year actuarial survivals were the same between the overall older and younger donor groups. Finally, the development of transplant-associated coronary disease was similar in both groups up to 5 years after transplantation.
Conclusions: This initial review of heart transplantation with older donor hearts, including bypassed hearts, demonstrates similar early and late survival outcomes as compared with those of a contemporaneous younger donor group. Significantly, there appears to be no difference in the development of transplant-associated coronary artery disease during the follow-up period. The older donor represents a potential immediate increase in the number of suitable hearts for transplantation. Bypassed donor hearts represent a small but potentially significant subgroup that may be safely and effectively used when appropriately matched to the recipient by age and medical condition. Greater experience, particularly with this bypassed group, will help determine optimal donor-to-recipient matching for the future.