Heart Transplantation With Older Donors: Should There Be an Age Cutoff?

Abstract

Purpose: Heart transplantation remains limited by donor availability. Currently, only some programs accept older donors, and their use remains contentious. We compared outcomes of heart transplant recipients who received donor hearts ≥55 years with those who received donor hearts <55 years.

Methods: Records of first-time adult heart transplant recipients between 2010 and 2019 were reviewed. Endpoints included 30-day and 1-, 3-, and 5-year survival; freedom from cardiac allograft vasculopathy; freedom from nonfatal major adverse cardiac events; and freedom from any rejections. The effect of donor age ≥55 years was analyzed with Cox proportional hazards modeling, 1:2 propensity score matching, and Kaplan-Meier survival analysis.

Results: Sixty-six patients received donor hearts ≥55 years and 766 received donor hearts <55 years. In the unmatched cohort, there was no significant difference in survival between the 2 groups at 30 days (93.9% vs 97.3%, P = .127), 1 year (87.9% vs 91.6%, P = .325), 3 years (86.4% vs 86.5%, P = .888), or 5 years (78.8% vs 83.8%, P = .497). The ≥55 years group had a significantly lower freedom from cardiac allograft vasculopathy and fatal major adverse cardiac events. In propensity-matched patients, recipients of donors ≥55 years had similar survival and freedom from cardiac allograft vasculopathy but significantly lower 1-year (76.7% vs 88.3%, P = .026), 3-year (68.3% vs 84.2%, P = .010), and 5-year (63.3% vs 83.3%, P = .002) freedom from nonfatal major adverse cardiac events when compared to recipients of younger donors.

Conclusions: Carefully selected older donors can be considered for a carefully selected group of recipients with acceptable outcomes.

Fig 1.

Use of donor hearts at least 55 years between 2010 and 2019.

Fig 2.

Posttransplant survival in the unmatched cohort stratified by donor age. Recipients were stratified based on donor age <55 and donor age ≥55 years (left). To avoid masking the effect of donor age because of dichotomization, recipients were further stratified based on more granular donor age groups (<30 years, 30–39 years, 40–55 years, and ≥55 years, right). The number of subjects at risk and 95% confidence limits are also shown.

Fig 3.

Secondary posttransplant outcomes in the unmatched cohort stratified by donor age. CAV, cardiac allograft vasculopathy; ACR, acute cellular rejection; AMR, antibody-mediated rejection; ATR, any treated rejection; BNR, biopsy negative rejection; NF-MACE, nonfatal major adverse cardiac events.