Routine Screening of Donor Hearts by Coronary Angiography Is Feasible

Routine Screening of Donor Hearts by Coronary Angiography Is Feasible

Routine Screening of Donor Hearts by Coronary Angiography Is Feasible O. Grauhan, C. Wesslau, and R. Hetzer ABSTRACT Background. Because of the shorta...

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Routine Screening of Donor Hearts by Coronary Angiography Is Feasible O. Grauhan, C. Wesslau, and R. Hetzer ABSTRACT Background. Because of the shortage of donor hearts, the criteria for acceptance have been considerably extended. Meanwhile every fourth heart donor in Europe is over 50 years old. As we have previously demonstrated, transmission of preexisting coronary atherosclerosis (CAS) by means of transplantation is not rare. Transmitted CAS results in a 2- to 3-fold increased risk for early graft failure after heart transplantation (HTX). Nevertheless, in most cases donor angiograms are not considered feasible. Methods. In May 2003 in the northeast region of the Deutsche Stiftung Organtransplantation (DSO-NO), we introduced the guideline that every donor over 40 years old must be screened by angiography. Results. Up to May 2003, fewer than 5% of donors had been screened by angiography; this situation is the rule in most Eurotransplant regions at present. Since May 2003 in the DSO-NO region, 85% of all donors over 40 years old were screened by angiography. Seventy percent of all donor hospitals— offering 90% of all donors— had an angiography facility. The additional costs of approximately € 800 per donor angiogram were compensated by fewer fruitless airplane missions when CAS was diagnosed by the surgeon on the spot, which cost on average about € 5,000 each. In conclusion, from a logistical as well as from a financial point of view, almost comprehensive angiographic donor screening is feasible. It reduces the risk of a recipient suffering from early graft failure.

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ECAUSE OF the general shortage of donor hearts, the criteria for organ acceptance have been considerably extended. At present every fourth heart donor (23.2%) in Europe is over 50 years old.1 It is well known from pathologic studies that coronary atherosclerosis occurs long before clinical coronary artery disease, namely, in young and healthy individuals.2– 4 According to these studies, one has to assume a 20% prevalence of significant atherosclerotic lesions, which are defined as at least 50% stenosis, in the donor pool.2– 4 As we demonstrated previously, donor screening without angiography overlooks significant coronary atherosclerosis, which is defined as at least 50% stenosis of at least one major epicardial vessel, in about 7% of heart transplantations.5 Furthermore, transmitted coronary atherosclerosis results in a 2- to 3-fold increase in risk for early graft failure after heart transplantation.6 Nevertheless, in most cases donor angiograms are not considered to be feasible. METHODS In May 2003 the northeast region of the Deutsche Stiftung Organtransplantation (DSO-NO), which is responsible for donor 0041-1345/06/$–see front matter doi:10.1016/j.transproceed.2006.01.063 666

management, at our suggestion introduced the guideline that every donor over 40 years old must be screened by angiography.

RESULTS

Before May 2003, less than 5% of donors were screened by angiography. This is still the rule in most Eurotransplant regions. From May 2003 in the DSO-NO region, 85% of all donors over 40 years old have been screened by angiography. Meanwhile, the angiograms are judged by the harvesting surgeon on the coordinator’s laptop computer. Seventy percent of all donor hospitals, which offered 90% of all donors, had an angiography facility. From the Deutsches Herzzentrum Berlin (O.G., R.H.), and the Deutsche Stiftung Organtransplantation (C.W.), Region Norlost, Berlin, Germany. Address reprint requests to O. Grauhan, MD, PhD, Deutsches Herzzentrum Berlin, Department of Cardiothoracic and Vascular Surgery, Augustenburger Platz 1, 13353 Berlin, Germany. E-mail: [email protected] © 2006 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 38, 666 – 667 (2006)

DONOR HEART SCREENING

The additional costs of approximately € 800 per donor angiogram were compensated by fewer fruitless airplane missions, in cases where coronary atherosclerosis was diagnosed by the surgeon on the spot, because the average cost of these missions was about € 5,000 each.

DISCUSSION

The data show that from a logistical as well as from a financial point of view, almost comprehensive angiographic donor screening is feasible. The reasons that donor-screening angiography had not been performed before May 2003 were in most cases that (1) the coordinators simply did not request the procedure in time or the donor hospital was not aware of the necessity of the procedure or (2) the cardiologist at the donor hospital was unprepared to perform angiography (DSO-NO transplant coordinators, personal communication). A further reason may have been the concern of transplant nephrologists, that administration of contrast medium during angiography might impair donor kidney function. However, this concern has been excluded by a recent investigation by Grosse et al.7 Despite the fact that inadvertently transmitted coronary atherosclerosis represents a risk for early graft failure,5 some authors have reported cases of successful transplantation with concomitant coronary revascularization.8,9 In the DSO-NO region, the harvesting surgeon judges the donor angiograms on the coordinator’s laptop computer. When visible or palpable coronary atherosclerosis is present, the surgeon has the option to reject the graft or to accept it for transplantation with concomitant revascularization. Therefore, because it is necessary to make use of so-called marginal organs whenever possible, comprehensive donor-screening angiography may enable the donor pool to be more exhaustively used, as well as to contribute to patient safety. Meanwhile, donor-screening angiography

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has been included in the guidelines of the German Transplant Society (DTG).10 We have concluded that comprehensive donor-screening angiography, which is essential for medical reasons, was also feasible from both logistical and the financial points of view. A prerequisite is the continuing education of those involved in the early phases of organ donation to increase awareness of the importance of donor angiography. ACKNOWLEDGMENTS We are grateful for editorial assistance from A. Gale.

REFERENCES 1. Quarterly data report of the International Society for Heart and Lung transplantation (ISHLT): Donors between 1/1/2004 and 6/30/2004. Available: www.ishlt.org 2. McNamara JJ, Molot MA, Stremple JF, et al: Coronary artery disease in combat casualties in Vietnam. JAMA 216:1185, 1971 3. Virmani R, Robinowitz M, Geer JC, et al: Coronary atherosclerosis revisited in Korean war combat casualties. Arch Pathol Lab Med 111:972, 1987 4. Joseph A, Ackerman D, Talley JD, et al: Manifestations of coronary atherosclerosis in young trauma victims—an autopsy study. J Am Coll Cardiol 22:459, 1993 5. Grauhan O, Pazurek J, Hummel M, et al: Donor-transmitted coronary atherosclerosis. J Heart Lung Transplant 22:568, 2003 6. Grauhan O, Hetzer R: Impact of donor-transmitted coronary atherosclerosis. J Heart Lung Transplant 23:S260, 2004 7. Grosse K, Kücük O, Krüger R, et al: Does the administration of contrast medium in the multi-organ donor impair the early graft function after renal transplantation? Transplant Proc 38:668, 2006 8. Musci M, Pasic M, Grauhan O, et al: Orthotopic heart transplantation with concurrent coronary artery bypass grafting or previous stent implantation. Z Kardiol 93:971, 2004 9. Laks H, Gates RN, Ardehali A, et al: Orthotopic heart transplantation and concurrent coronary bypass. J Heart Lung Transplant 12:810, 1993 10. Grauhan O, Hetzer R, Hirt S, et al: Wie man potenzielle Spenderherzen beurteilt. Auszug aus den “Richtlinien zur Beurtei¨ rzteblatt 102:2370, lung (marginaler) Spenderherzen.” Deutsches A 2005