Transplantation with older donor hearts for presumed "stable" recipients: an analysis of the Joint International Society for Heart and Lung Transplantation/United Network for Organ Sharing Thoracic Registry

Abstract

Background: We have previously demonstrated that the use of older donor hearts (>45 years) increases the odds of death nearly twofold in the early posttransplantation period when compared with the use of hearts from younger donors. Before excluding this segment of the donor pool, however, the mortality risk for remaining on the waiting list compared with that of receiving an older donor heart should also be considered.

Methods: We examined all adult status 2 patients added to the United Network for Organ Sharing heart transplant waiting list for primary transplantation between 1992 and 1995 (n = 4681). To account for the transient increased risk after transplantation, we used a time-dependent nonproportional hazards model with an exponential decay component for the analysis. For patients with an equal time since listing, the resulting risk ratios represent the ratio of mortality risk for a patient who receives an older donor heart to the mortality risk for a patient who remains on the waiting list.

Results: After 30 days posttransplantation, the risk of death for recipients of 45- to 49-year-old donor hearts was lower than if they had remained on the waiting list, and by 6 months the relative risk was 0.37 (95% confidence interval: 0.22, 0.62). For recipients of hearts from donors 50 years or older, the risk after transplantation was lower after 64 days, and by 6 months the relative risk was 0.48 (95% confidence interval: 0.31, 0.75).

Conclusion: These results suggest that in spite of a high initial risk resulting from the transplant procedure, there was a clear long-term survival benefit for status 2 recipients of older donor hearts. Thus overall, in spite of the increased risk of death associated with receiving older donor hearts, the risk of death without a transplant was even greater. On the basis of this analysis we cannot support the exclusion of older donors from the donor pool.