To transplant or not to transplant ‘marginal’ donor hearts: is machine perfusion the answer? Free

This commentary refers to ‘Disparities in donor heart acceptance between the USA and Europe: clinical implications’, by B. Wayda et al., https://doi.org/10.1093/eurheartj/ehad684 and the discussion piece ‘Machine perfusion of marginal donor hearts—a valuable tool, but where and for whom?’, by B. Wayda et al., https://doi.org/10.1093/eurheartj/ehae063.

With great interest, we read the study of Wayda et al.¹ recently published in the European Heart Journal, which delves into the disparities in heart transplant (HT) donor utilization between the United States (USA) and Eurotransplant (ET) region. The study, which is the largest to date comparing HT donor characteristics across regions, reveals intriguing differences in selection criteria and their potential impact on addressing the persistent shortage of donor organs.

The study highlights a significantly older potential donor pool, with a greater cardiovascular risk profile, in the ET region. Also, ET reported donors, despite being older and having more cardiovascular risk factors, demonstrated a higher utilization rate (70% vs. 44%) than their counterparts in the USA.¹ Unfortunately, no outcome data were reported in the current study. However, clinical studies consistently show that older donor hearts worsen post-transplantation prognosis² thus posing a trade-off in which clinicians must weigh the increased risk of accepting an older donor heart against the benefit of a shorter time on the HT waiting list. Optimizing graft assessment strategies is therefore critical to more effectively select hearts in which adequate quality is achievable. We believe that machine perfusion can play a central role in doing so, and that the future of HT involves advanced preservation strategies moving beyond the limitations of the traditional ice box. Machine perfusion for HT enables an opportunity to assess the graft’s viability and function prior to transplantation. Yet, novel ex situ assessment strategies of cardiac function during ex situ heart perfusion need to be developed.³ Furthermore, the study of Wayda et al. did not include donated after circulatory death (DCD) hearts. Considering the significant increase in transplantation activity associated with DCD donors,⁴ we wonder how the utilization of these donors for HT differs between ET and the USA. Applying a progressive approach concerning DCD donation, combined with machine perfusion and advanced graft function assessment, could even further enlarge the donor pool.⁵ As such, machine perfusion provides a toolbox to convincingly utilize ‘marginal’ brain-death and DCD donors and might promote HT of more donors in the USA, but also HT programmes worldwide.

Declarations

Disclosure of Interest

All authors declare no disclosure of interest for this contribution.

References