INTRODUCTION
Heart transplantation is the gold standard treatment for patients with end-stage heart failure. However, the last decade experienced a plateau in the number of heart transplants1, despite some promising results in North America lately2. As a consequence, the number of heart failure patients who would benefit from heart transplantation far exceeds the number of transplants performed.
Shortage of viable donors is certainly the most important limiting factor, leading to higher death rates3 on the waiting list in developed countries and jeopardizing heart transplantation as an intention to treat principle. This shortage is magnified because many hearts are discarded as a consequence of strict selection criteria and concern for regulatory reprimand for less-than-optimal post-transplant outcomes4. On the contrary, in countries with well-established mechanical circulatory support programs, the bridge to transplant strategy is usually associated with long waiting lists. Last year, about half of transplants performed in developed countries5 had a ventricular assist device placed at the time of transplant, and only 28% get transplanted by the end of the first year6. For that reason, donor allocation policies need to be constantly revisited7 in order to provide a fair access to this therapy.
Economic, religious, and cultural differences amongst countries and regions in the same country prevail and they account for very different realities that explain the unequal access to heart transplantation. Lastly, and not least important, intensive care related to donor is probably less developed8, which determines a very low rate of donor acceptance among the potential donor pool. Reasons for refusal vary considerably according to the individual transplant center, including medical and non-medical issues. There is no standardized approach to donor selection despite proposals to liberalize acceptance criteria. Available donor risk scoring system9 may help in the decision-making process, eventually expanding donor pool to marginal donors.
The objectives of this study are 1) to determine whether the shortage of viable donors in Mid-West of Brazil limits heart transplantation; 2) to correlate donor risk scoring to donor acceptance in order to determine the influence of donor profile on the decision to transplant; 3) to delineate reasons for donor refusal and 4) to correlate donor risk scoring with post-transplant primary graft dysfunction and long-term survival.