Heart transplantation allograft survival: donor atherosclerotic disease risk vs coronary angiography.

Abstract

Guidelines recommend coronary angiography in heart donors at increased risk of coronary artery disease (age >45 years, diabetes, tobacco, or drug use), but the yield is often low. The aim of this study was to evaluate the importance of estimated donor 10-year atherosclerotic cardiovascular disease (ASCVD) risk (≤5% vs >5%) vs coronary angiogram testing for predicting short- to mid-term survival free from graft failure in adult heart transplant recipients. Adult heart transplant recipients from the United Network for Organ Sharing database 18 October 2018, to 31 December 2023, who received hearts from donors aged >40 years, or >30 years with diabetes, hypertension, or smoking were included. The risk of a composite outcome (death or graft failure) up to 4 years post-transplant was assessed by multivariable Cox regression. Of 5152 recipients, 86.1% received hearts from donors with ASCVD risk ≤5%. Angiography was performed in 76.1% donors with ASCVD ≤5% and 92.9% of donors with ASCVD >5%. Using donors with ASCVD ≤5% and angiography as the reference group (n = 3378), adjusted hazard ratios for the composite outcome were .91 [95% confidence interval (CI) .74-1.11] for ASCVD ≤5% without angiography (n = 1060); 1.30 (95% CI 1.05-1.60) for ASCVD >5% with angiography (n = 663), and .88 (95% CI .36-2.13) for ASCVD >5% without angiography (n = 51). Findings were consistent when limited to donors meeting current angiography guideline criteria. Estimated ASCVD risk >5% independently predicts worse transplant outcomes, while routine coronary angiography in low-risk donors (ASCVD ≤5%) does not. These findings suggest that ASCVD-based risk stratification may be more useful than angiography as the initial step in donor heart selection.