The authors do not have any conflict of interest to declare.
We carefully read the recent paper by
N.R.
Hess et al. on the use of extended criteria donors (ECDs) to increase
the organ offers (1).
The heart transplantation (HT) is undoubtedly the best treatment for
end-stage heart failure patients (2). However, the organ shortage
remains a major challenge in cardiac surgery.
Facing this problem, the medical community starts to extend the donor
criteria to select more suitable organs for HT. The use of ECDs is still
controversial, since it is associated with a high incidence of primary
graft failure (3), and although it guarantees longer survival than
without transplantation, there is still some hesitation in accepting
this practice.
After a careful analysis of the characteristics of organ donors and the
acceptance criteria used by the various centres, the authors concluded
that the use of ECDs increases the number of HT without major impact on
outcomes. We believe that this article gives a big boost in the debate
on the use of ECDs for HT.
This is the latest demonstration that the use of ECDs in selected
scenarios is safe and can be applied without increasing the mortality.
This may be the results of an increased effort to improve the
association between recipients and donors. In fact, it has been shown
that recipient’s conditions have more impact on HT outcomes than those
of the donors. This strategy allows to improve the post-transplant
survival at 1 and 5 years, matching high-risk organs with low-risk
recipients (4).
In this context, we can also include in the ECDs group the hearts
affected by coronary arteries and valvular disease, or congenital heart
defects. This group of organs can successfully be transplanted with
additional procedures at the time of HT. This strategy aims to optimize
the performance of hearts that otherwise would not be used and that can
represent the only chance for patients awaiting transplant.
We have recently published a literature review regarding the use of ECDs
and concomitant procedure to increase the organ availability (5). All
these experiences suggest few more considerations.
Firstly: the use of ECDs is a fundamental resource for addressing the
shortage of organs.
Secondly: the profile of the recipients is constantly changing thanks to
the use of mechanical circulatory supports.
Thirdly: the HT with ECDs certainly ensure better hope for patients than
the absence of a transplantation.
Fourth: simple procedures including heart valve replacement or repair,
coronary artery bypass grafting, or congenital heart defect repair can
be successfully combined with the HT to improve the performance of these
organs.
However, we strongly believe that the use of ECDs should be
progressively considered by the future international recommendations and
guidelines to reduce the waiting lists of patients needing HT.
REFERENCES
- Hess NR, Seese LM, Sultan I,
Wang Y, Thoma F, Kilic A. Impact
of center donor acceptance patterns on utilization of
extended-criteria donors and outcomes. J Card Surg. 2021 Aug 8.
- Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update
of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A
Report of the American College of Cardiology/American Heart
Association Task Force on Clinical Practice Guidelines and the Heart
Failure Society of America. Circulation . 2017;136(6):e137-e161.
- Felker GM, Milano CA, Yager JE, et al. Outcomes with an alternate list
strategy for heart transplantation. J Heart Lung Transplant .
2005;24(11):1781-1786.
- Trivedi JR, Cheng A, Ising M, Lenneman A, Birks E, Slaughter MS. Heart
Transplant Survival Based on Recipient and Donor Risk Scoring: A UNOS
Database Analysis. ASAIO J . 2016;62(3):297-301.
- Piperata A, Caraffa R, Bifulco O, Avesani M, Apostolo A, Gerosa G,
Bottio T. Marginal donors and organ shortness: concomitant surgical
procedures during heart transplantation: a literature review. J
Cardiovasc Med (Hagerstown). 2021 Aug 20.