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Correspondence and Reprint Requests :
Arman Kilic, MD
Division of Cardiothoracic Surgery
Medical University of South Carolina
30 Courtenay Drive, MSC 295, Suite BM279
Charleston, SC 29425
Email: kilica@musc.edu
Tel: 843-876-4841
Fax: 843-876-4866
We are very appreciative of the thoughtful comments and insights raised
by Piperata and colleagues1 into our manuscript titled
“Impact of Center Donor Acceptance Patterns on Utilization of
Extended-Criteria Donors and Outcomes”.2 We too hope
this manuscript will support the further consideration of
extended-criteria donors (ECD) for heart transplantation.
Without a doubt, we are facing a shortage of available cardiac donors to
meet the needs of an ever-increasing heart failure population. In the
wake of an evolving candidate waitlist, with increasing age and
complexity of medical comorbidity, we are also witnessing an evolution
within our available donor populations. In North America and Europe,
median age and medical complexity of available donors are also
increasing.3 In order to meet the increasing demands
for heart donations, it is important to give thorough consideration of
donors outside the box of normal acceptance standards.
ECD donation has certainly been a controversial topic since its
conception. As Piperata and colleagues have stated1,4,
ECD donation has been previously been linked to increased risk of
primary graft failure, as features such as increasing age and/or left
ventricular hypertrophy have been associated with this
outcome.5 Additionally, multiple studies have reported
reduced survival with ECD donation, especially when high-risk donors are
paired with high-risk recipients.6–8 However, it is
important to note that these outcomes are still far better than the
natural history of heart failure without transplantation.
As the heart failure population continues to grow, and the supply-demand
balance continues to tip in the wrong direction, transplanting centers
must start looking outside the box of normal conventions. While it is
simply unethical to demand surgeons to accept unsuitable organs to keep
up with a rising demand, we must therefore work towards optimization of
the current donor pool. One method, as suggested by
Piperata4, may be to perform concomitant procedures
such as coronary revascularization and/or valvular intervention during
transplantation in order to optimize donor grafts. Another method may be
to focus on the development of better diagnostic tools for centers to
critically evaluate, and in some instances resuscitate, organs outside
normal acceptance criteria. Though still in early phase of clinical
practice, pretransplant ex vivo perfusion and evaluation of
marginal hearts has shown promise. Several centers have published their
results of normothermic, ex vivo perfusion of marginal hearts. In these
reports, short- and mid-term outcomes have been comparable to non-ECD
transplants performed at these centers9,10, all while
increasing transplant volumes.11 While we cannot
increase the number of donors, we can certainly take steps towards a
more critical evaluation and more efficient usage of our available donor
pool.