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The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

Donor heart selection: Evidence-based guidelines for providers

Published:September 20, 2022DOI:https://doi.org/10.1016/j.healun.2022.08.030
      The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.

      Keywords

      Abbreviations:

      ACAOS (anomalous origination of a coronary artery from the opposite sinus), ACC (American College of Cardiologists), BMI (body mass index), BNP (B-type natriuretic peptide), CABG (coronary artery bypass graft), CAD (coronary artery disease), CAV (cardiac allograft vasculopathy), CNS (central nervous system), CO (carbon monoxide), COVID-19 (coronavirus disease 2019), CPR (cardiopulmonary resuscitation), CT (computed tomography), ECG (electrocardiogram), ECMO (extracorporeal membrane oxygenation), HIV (human immunodeficiency virus), HLA (human leukocyte antigens), INTERMACS (interagency registry for mechanically assisted circulatory support), ISHLT (International Society for Heart and Lung Transplantation), INH (isonicotinic acid hydrazide), LV (left ventricle), LVEF (left ventricular ejection fraction), LVH (left ventricular hypertrophy), MRI (magnetic resonance imaging), NT-proBNP (N-terminal prohormone of B-type natriuretic peptide), OPO (organ procurement organization), OPTN (organ procurement and transplantation network), PCI (percutaneous coronary intervention), PGD (primary graft dysfunction), pHM (predicted heart mass), PLSVC (persistent left superior vena cava), SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), TTE (transthoracic echocardiography), UNOS (united network for organ sharing), VA (veno-arterial), VAD (ventricular assist device), VV (veno-venous), WHO (World Health Organization)
      In 1995, Dr J. Copeland noted that “only optimal donors should be accepted for heart transplantation,” implying that extended-criteria donor organs may not be viable.
      • Copeland JG.
      Only optimal donors should be accepted for heart transplantation: protagonist.
      Despite this awareness raised from over 25 years ago, this topic has remained much debated. While older donors are more routinely used in Europe, younger donors with short ischemic times are more commonly used in the United States. Mortality rates differ worldwide, and some of these differences are due to donor selection and/or recipient urgency. Seeking a balance between maximizing the number of transplants (by taking greater risk) and minimizing the risk to meet societal needs, while controlling cost, is difficult and frequently related to a lack of reliable data regarding both donors and recipients. The issue is further complicated by the fact that the peri-operative surgical risk is a combination of risk factors that include donor, recipient, and ischemic time. Lastly, meaningful comparisons of transplant outcomes across countries require proper risk-adjustment.
      The proposed guidelines provide evidence-based as well as expert-consensus recommendations for the selection of donors following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review. Controversial subjects are dealt with one by one and current state-of-the-art information is provided to help define risk. The strength of each recommendation and the corresponding level of available evidence were classified following the International Society for Heart and Lung Transplantation protocol for developing guideline documents.

      International Society for Heart Lung Transplantation. Protocol and policies for developing standards statements, guidelines, and consensus documents and for conducting consensus conferences. 2017; https://ishlt.org/ishlt/media/documents/STANDARDS_AND_GUIDELINES_DEVELOPMENT_PROTOCOL_FINAL.pdf

      Task forces were established with an international panel of experts. The task forces reviewed donor characteristics (Task force 1), international donor practices (Task force 2), donor and recipient matched characteristics (Task force 3), extended donor characteristics (Task force 4), and donor risk scores (Task force 5).

      Clinical stability of the donor

      Factors considered in the clinical stability of the cardiac donor are hemodynamics, hormonal resuscitation,
      • Dhar R
      • Cotton C
      • Coleman J
      • et al.
      Comparison of high- and low-dose corticosteroid regimens for organ donor management.
      • Dupuis S
      • Amiel JA
      • Desgroseilliers M
      • et al.
      Corticosteroids in the management of brain-dead potential organ donors: a systematic review.
      • Pinsard M
      • Ragot S
      • Mertes PM
      • et al.
      Interest of low-dose hydrocortisone therapy during brain-dead organ donor resuscitation: the CORTICOME study.
      • Buchanan IA
      • Mehta VA.
      Thyroid hormone resuscitation after brain death in potential organ donors: a primer for neurocritical care providers and narrative review of the literature.
      • Cooper LB
      • Milano CA
      • Williams M
      • et al.
      Thyroid hormone use during cardiac transplant organ procurement.
      • Holndonner-Kirst E
      • Nagy A
      • Czobor NR
      • et al.
      The impact of l-thyroxine treatment of donors and recipients on postoperative outcomes after heart transplantation.
      • Mi Z
      • Novitzky D
      • Collins JF
      • Cooper DK.
      The optimal hormonal replacement modality selection for multiple organ procurement from brain-dead organ donors.
      • Novitzky D
      • Mi Z
      • Sun Q
      • Collins JF
      • Cooper DK
      Thyroid hormone therapy in the management of 63,593 brain-dead organ donors: a retrospective analysis.
      • Roels L
      • Spaight C
      • Smits J
      • Cohen B.
      Critical care staffs' attitudes, confidence levels and educational needs correlate with countries' donation rates: data from the donor action database.
      and the restoration of intravascular volume and electrolyte imbalance,
      • Al-Khafaji A
      • Elder M
      • Lebovitz DJ
      • et al.
      Protocolized fluid therapy in brain-dead donors: the multicenter randomized MOnIToR trial.
      • Barklin A.
      Systemic inflammation in the brain-dead organ donor.
      • Kuecuek O
      • Mantouvalou L
      • Klemz R
      • et al.
      Significant reduction of proinflammatory cytokines by treatment of the brain-dead donor.
      • McKeown DW
      • Ball J.
      Treating the donor.
      • Abdelnour T
      • Rieke S.
      Relationship of hormonal resuscitation therapy and central venous pressure on increasing organs for transplant.
      • Dimopoulou I
      • Tsagarakis S
      • Anthi A
      • et al.
      High prevalence of decreased cortisol reserve in brain-dead potential organ donors.
      • Plurad DS
      • Bricker S
      • Neville A
      • Bongard F
      • Putnam B.
      Arginine vasopressin significantly increases the rate of successful organ procurement in potential donors.
      • Hadjizacharia P
      • Salim A
      • Brown C
      • et al.
      Does the use of pulmonary artery catheters increase the number of organs available for transplantation?.
      • Novitzky D
      • Mi Z
      • Videla LA
      • Collins JF
      • Cooper DK.
      Hormone resuscitation therapy for brain-dead donors - is insulin beneficial or detrimental?.
      • Stoica SC
      • Satchithananda DK
      • Charman S
      • et al.
      Swan-Ganz catheter assessment of donor hearts: outcome of organs with borderline hemodynamics.
      • Saner FH
      • Kavuk I
      • Lang H
      • Radtke A
      • Paul A
      • Broelsch CE.
      Organ protective management of the brain-dead donor.
      as well as donor metabolism.

      Recommendations for donor hemodynamics:
      • Stoica SC
      • Satchithananda DK
      • Charman S
      • et al.
      Swan-Ganz catheter assessment of donor hearts: outcome of organs with borderline hemodynamics.
      ,
      • Raichlin E
      • Villarraga HR
      • Chandrasekaran K
      • et al.
      Cardiac allograft remodeling after heart transplantation is associated with increased graft vasculopathy and mortality.
      • Santise G
      • D'Ancona G
      • Falletta C
      • et al.
      Donor pharmacological hemodynamic support is associated with primary graft failure in human heart transplantation.
      • Angleitner P
      • Kaider A
      • Gökler J
      • et al.
      High-dose catecholamine donor support and outcomes after heart transplantation.
      • von Ziegler F
      • Helbig S
      • Kreissl N
      • Meiser B
      • Becker A
      • Kaczmarek I.
      Norepinephrine versus dopamine pretreatment of potential heart donors - impact on long-term outcome.
      • Zaroff JG
      • Rosengard BR
      • Armstrong WF
      • et al.
      Consensus conference report: maximizing use of organs recovered from the cadaver donor: cardiac recommendations, March 28-29, 2001, Crystal City, Va.
      • Chamorro C
      • Silva JA
      • Segovia J
      • Romera MA.
      Use of catecholamines in cardiac donors: what is the real limit?.
      • Nixon JL
      • Kfoury AG
      • Brunisholz K
      • et al.
      Impact of high-dose inotropic donor support on early myocardial necrosis and outcomes in cardiac transplantation.
      • Aliabadi-Zuckermann AZ
      • Gökler J
      • Kaider A
      • et al.
      Donor heart selection and outcomes: an analysis of over 2,000 cases.
      • Benck U
      • Hoeger S
      • Brinkkoetter PT
      • et al.
      Effects of donor pre-treatment with dopamine on survival after heart transplantation: a cohort study of heart transplant recipients nested in a randomized controlled multicenter trial.

      Class I

      • 1.
        Donors receiving low dose norepinephrine (e.g., ≤0.1 µg/kg/min) may be considered suitable for transplantation if (other) inotropes are not required. In general, the higher the dose of norepinephrine in the donor, the poorer the expected outcome after transplant. Level of Evidence: C.

      Class IIa

      • 1.
        If inotropes and/or vasopressors are required to maintain adequate circulatory function in the donor, placement of a Swan-Ganz catheter and goal-directed therapy should be considered to maximize the likelihood of donor heart utilization. Level of Evidence: C.
      • 2.
        Suggested hemodynamic targets for donor hearts include the following:
        • Mean arterial pressure >60 mm Hg
        • Cardiac index >2.4 liter/min/m2
        • Central venous pressure <12 mm Hg
        • Pulmonary capillary wedge pressure <12 mm Hg
        • Left ventricular (LV) stroke work index >15 g·min/m2
      Level of Evidence: C.

      Recommendations considering donor metabolism:
      • Zaroff JG
      • Rosengard BR
      • Armstrong WF
      • et al.
      Consensus conference report: maximizing use of organs recovered from the cadaver donor: cardiac recommendations, March 28-29, 2001, Crystal City, Va.
      ,
      • Aliabadi-Zuckermann AZ
      • Gökler J
      • Kaider A
      • et al.
      Donor heart selection and outcomes: an analysis of over 2,000 cases.
      ,
      • Hoefer D
      • Ruttmann-Ulmer E
      • Smits JM
      • Devries E
      • Antretter H
      • Laufer G.
      Donor hypo- and hypernatremia are predictors for increased 1-year mortality after cardiac transplantation.
      • Kaczmarek I
      • Tenderich G
      • Groetzner J
      • et al.
      The controversy of donor serum sodium levels in heart transplantation–a multicenter experience.
      • Sally MB
      • Ewing T
      • Crutchfield M
      • et al.
      Determining optimal threshold for glucose control in organ donors after neurologic determination of death: A United Network for Organ Sharing Region 5 Donor Management Goals Workgroup prospective analysis.

      Class IIa

      • 1.
        Use of hearts from donors with moderately abnormal serum sodium (outside the 135-145 mEq/liter range) may be considered. Level of Evidence: C.
      • 2.
        Hearts from donors with extreme hypo- or hypernatremia (serum sodium <129 or ≥170 mEq/liter, respectively) should not be used. Level of Evidence: C.
      • 3.
        Donor hyperglycemia should not be a contraindication to use for heart transplantation. Level of Evidence: C.

      Mechanisms of donor death

      The mode of brain death affects clinical outcomes following heart transplantation.
      • Raichlin E
      • Villarraga HR
      • Chandrasekaran K
      • et al.
      Cardiac allograft remodeling after heart transplantation is associated with increased graft vasculopathy and mortality.
      ,
      • Cantin B
      • Kwok BW
      • Chan MC
      • et al.
      The impact of brain death on survival after heart transplantation: time is of the essence.
      • Cohen O
      • De La Zerda DJ
      • Beygui R
      • Hekmat D
      • Laks H.
      Donor brain death mechanisms and outcomes after heart transplantation.
      • Mehra MR
      • Uber PA
      • Ventura HO
      • Scott RL
      • Park MH.
      The impact of mode of donor brain death on cardiac allograft vasculopathy: an intravascular ultrasound study.
      Recommendations are provided for donor death by carbon monoxide (CO) poisoning, explosive brain death, and unexplained causes. Furthermore, the pathophysiology of brain death includes neurohormonal and inflammatory changes that may result in donor organ injury. Beneficial effects of corticosteroid administration to brain-dead donors (hormonal resuscitation therapy) in terms of organ recovery, graft survival, and graft function have been reported, but there are many confounding factors that preclude definitive assessment of the utility of steroid administration during donor management.
      • Dhar R
      • Cotton C
      • Coleman J
      • et al.
      Comparison of high- and low-dose corticosteroid regimens for organ donor management.
      • Dupuis S
      • Amiel JA
      • Desgroseilliers M
      • et al.
      Corticosteroids in the management of brain-dead potential organ donors: a systematic review.
      • Pinsard M
      • Ragot S
      • Mertes PM
      • et al.
      Interest of low-dose hydrocortisone therapy during brain-dead organ donor resuscitation: the CORTICOME study.

      Recommendations regarding donor death by CO poisoning:
      • Bentley MJ
      • Mullen JC
      • Lopushinsky SR
      • Modry DL.
      Successful cardiac transplantation with methanol or carbon monoxide-poisoned donors.
      • Iberer F
      • Königsrainer A
      • Wasler A
      • Petutschnigg B
      • Auer T
      • Tscheliessnigg K.
      Cardiac allograft harvesting after carbon monoxide poisoning.
      • Karwande SV
      • Hopfenbeck JA
      • Renlund DG
      • Burton NA
      • Gay WA
      An avoidable pitfall in donor selection for heart transplantation. Utah Heart Transplant Program.
      • Koerner MM
      • Tenderich G
      • Minami K
      • et al.
      Extended donor criteria: use of cardiac allografts after carbon monoxide poisoning.
      • Luckraz H
      • Tsui SS
      • Parameshwar J
      • Wallwork J
      • Large SR.
      Improved outcome with organs from carbon monoxide poisoned donors for intrathoracic transplantation.
      • Martìn-Suàrez S
      • Mikus E
      • Pilato E
      • et al.
      Cardiac transplantation from a carbon monoxide intoxicated donor.
      • Roberts JR
      • Bain M
      • Klachko MN
      • Seigel EG
      • Wason S.
      Successful heart transplantation from a victim of carbon monoxide poisoning.
      • Rodrigus IE
      • Conraads V
      • Amsel BJ
      • Moulijn AC.
      Primary cardiac allograft failure after donor carbon monoxide poisoning treated with biventricular assist device.
      • Sezgin A
      • Akay TH
      • Ozkan S
      • Gültekin B.
      Successful cardiac transplantation from donor with carbon monoxide intoxication: A case report.
      • Smith JA
      • Bergin PJ
      • Williams TJ
      • Esmore DS.
      Successful heart transplantation with cardiac allografts exposed to carbon monoxide poisoning.
      • Satran D
      • Henry CR
      • Adkinson C
      • Nicholson CI
      • Bracha Y
      • Henry TD.
      Cardiovascular manifestations of moderate to severe carbon monoxide poisoning.

      Class IIa

      • 1.
        Donors with CO poisoning should be carefully screened. Risk factors for early heart allograft dysfunction include ischemic electrocardiogram (ECG) changes, troponin I elevations ≥0.7 ng/ml and left ventricular dysfunction. Level of Evidence: C.

      Class III

      • 1.
        Donors with CO poisoning and carboxyhemoglobin levels >40%, ischemic ECG changes, elevated levels of cardiac troponin (≥0.7 ng/ml) or ventricular dysfunction should generally be avoided. Level of Evidence: C.

      Recommendation regarding explosive brain death:
      • Raichlin E
      • Villarraga HR
      • Chandrasekaran K
      • et al.
      Cardiac allograft remodeling after heart transplantation is associated with increased graft vasculopathy and mortality.
      ,
      • Cantin B
      • Kwok BW
      • Chan MC
      • et al.
      The impact of brain death on survival after heart transplantation: time is of the essence.
      • Cohen O
      • De La Zerda DJ
      • Beygui R
      • Hekmat D
      • Laks H.
      Donor brain death mechanisms and outcomes after heart transplantation.
      • Mehra MR
      • Uber PA
      • Ventura HO
      • Scott RL
      • Park MH.
      The impact of mode of donor brain death on cardiac allograft vasculopathy: an intravascular ultrasound study.
      ,
      • Shivalkar B
      • Van Loon J
      • Wieland W
      • et al.
      Variable effects of explosive or gradual increase of intracranial pressure on myocardial structure and function.
      • Novitzky D.
      Detrimental effects of brain death on the potential organ donor.
      • Stoica SC
      • Satchithananda DK
      • White PA
      • et al.
      Brain death leads to abnormal contractile properties of the human donor right ventricle.
      • Fracasso T
      • Meyer P
      • Hullin R
      • Sauerland C
      • Schmeling A.
      Pathology of the right ventricle: a comparison between traumatic brain injury, afterload mismatch and cerebral hypoxia.
      • Berman M
      • Ali A
      • Ashley E
      • et al.
      Is stress cardiomyopathy the underlying cause of ventricular dysfunction associated with brain death?.

      Class IIa

      • 1.
        Donors with explosive brain death may be considered for transplantation. There is evidence suggesting reduced long-term survival of recipients of such donors, possibly due to increased cardiac allograft vasculopathy. Level of Evidence: C.

      Unexplained cause of donor death

      Few reports have been published detailing the outcomes of allografts taken from donors with an unexplained cause of death. When faced with such an offer, centers should consider the more common causes of sudden death in young persons.

      Recommendation for the evaluation of unexplained causes of death

      Class IIb

      • 1.
        Donors with unexplained cause of sudden death should be carefully screened with ECG and, when appropriate, coronary angiography for cardiac causes of death including hypertrophic cardiomyopathy, long-QT syndrome, Brugada syndrome, and congenital heart disease includes coronary anomalies. Donors with unexplained sudden death can be considered for transplant if the evaluation is negative. Level of Evidence: C.

      Donor demographics

      Recommendations for donor age:
      • Lund LH
      • Edwards LB
      • Kucheryavaya AY
      • et al.
      The registry of the International Society for Heart and Lung Transplantation: thirtieth official adult heart transplant report–2013; focus theme: age.
      • Smits JM
      • De Pauw M
      • de Vries E
      • et al.
      Donor scoring system for heart transplantation and the impact on patient survival.
      • Axtell AL
      • Fiedler AG
      • Chang DC
      • et al.
      The effect of donor age on post-transplant mortality in a cohort of adult cardiac transplant recipients aged 18-45.
      • Bergenfeldt H
      • Lund LH
      • Stehlik J
      • Andersson B
      • Höglund P
      • Nilsson J.
      Time-dependent prognostic effects of recipient and donor age in adult heart transplantation.
      • Foroutan F
      • Alba AC
      • Guyatt G
      • et al.
      Predictors of 1-year mortality in heart transplant recipients: a systematic review and meta-analysis.
      • Weiss ES
      • Allen JG
      • Kilic A
      • et al.
      Development of a quantitative donor risk index to predict short-term mortality in orthotopic heart transplantation.
      • Chew HC
      • Kumarasinghe G
      • Iyer A
      • et al.
      Primary graft dysfunction after heart transplantation.
      • Sabatino M
      • Vitale G
      • Manfredini V
      • et al.
      Clinical relevance of the International Society for Heart and Lung Transplantation consensus classification of primary graft dysfunction after heart transplantation: epidemiology, risk factors, and outcomes.
      • Lund LH
      • Khush KK
      • Cherikh WS
      • et al.
      The registry of the International Society for Heart and Lung Transplantation: thirty-fourth adult heart transplantation report-2017; focus theme: allograft ischemic time.
      • Costanzo MR
      • Dipchand A
      • Starling R
      • et al.
      The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients.
      • Weber DJ
      • Wang IW
      • Gracon AS
      • et al.
      Impact of donor age on survival after heart transplantation: an analysis of the United Network for Organ Sharing (UNOS) registry.
      • Reiss N
      • Leprince P
      • Bonnet N
      • et al.
      Results after orthotopic heart transplantation accepting donor hearts >50 years: experience at La Pitie Salpetriere, Paris.
      • Lietz K
      • John R
      • Mancini DM
      • Edwards NM.
      Outcomes in cardiac transplant recipients using allografts from older donors versus mortality on the transplant waiting list; Implications for donor selection criteria.
      • Roig E
      • Almenar L
      • Crespo-Leiro M
      • et al.
      Heart transplantation using allografts from older donors: multicenter study results.
      • Stehlik J
      • Feldman DS
      • Brown RN
      • et al.
      Interactions among donor characteristics influence post-transplant survival: a multi-institutional analysis.
      • Nagji AS
      • Hranjec T
      • Swenson BR
      • et al.
      Donor age is associated with chronic allograft vasculopathy after adult heart transplantation: implications for donor allocation.
      • Bruschi G
      • Colombo T
      • Oliva F
      • et al.
      Orthotopic heart transplantation with donors greater than or equal to 60 years of age: a single-center experience.

      Class I

      • 1.
        The use of donor hearts <45 years of age is recommended. Level of Evidence: C.
      • 2.
        Donors ≥45 years of age can be used after screening for significant coronary artery disease (e.g., ≤50% narrowing) and if short ischemic times (<4 hours) can be expected. Such screening criteria vary around the world based on risk factors and average population donor characteristics. Considerations should take into account estimated survival benefit, availability of organs, the severity of illness of the recipient, and whether the recipient is on mechanical circulatory support. No established upper age limit currently exists. Level of Evidence: C.

      Class IIa

      • 1.
        Donor selection should account for unique recipient characteristics such as older donors to be used in older or highly sensitized recipients (smaller compatible donor pool) who have a negative crossmatch (either prospective or virtual depending on needs of recipient and/or institution) to the prospective older donor. Level of Evidence: C.

      Donor size

      Factors considered in developing guidelines on donor size were sex matching,
      • Khush KK
      • Kubo JT
      • Desai M.
      Influence of donor and recipient sex mismatch on heart transplant outcomes: analysis of the International Society for Heart and Lung Transplantation Registry.
      • Martinez-Selles M
      • Almenar L
      • Paniagua-Martin MJ
      • et al.
      Donor/recipient sex mismatch and survival after heart transplantation: only an issue in male recipients? An analysis of the Spanish Heart Transplantation Registry.
      • Kaczmarek I
      • Meiser B
      • Beiras-Fernandez A
      • et al.
      Gender does matter: gender-specific outcome analysis of 67,855 heart transplants.
      • Reed RM
      • Netzer G
      • Hunsicker L
      • et al.
      Cardiac size and sex-matching in heart transplantation: size matters in matters of sex and the heart.
      • Bergenfeldt H
      • Stehlik J
      • Hoglund P
      • Andersson B
      • Nilsson J.
      Donor-recipient size matching and mortality in heart transplantation: influence of body mass index and gender.
      donor weight and height,
      • Weber DJ
      • Wang IW
      • Gracon AS
      • et al.
      Impact of donor age on survival after heart transplantation: an analysis of the United Network for Organ Sharing (UNOS) registry.
      ,
      • Martinez-Selles M
      • Almenar L
      • Paniagua-Martin MJ
      • et al.
      Donor/recipient sex mismatch and survival after heart transplantation: only an issue in male recipients? An analysis of the Spanish Heart Transplantation Registry.
      ,
      • Reed RM
      • Netzer G
      • Hunsicker L
      • et al.
      Cardiac size and sex-matching in heart transplantation: size matters in matters of sex and the heart.
      ,
      • Correia P
      • Prieto D
      • Batista M
      • Antunes MJ.
      Gender mismatch between donor and recipient is a factor of morbidity but does not condition survival after cardiac transplantation.
      • Fonarow GC.
      How old is too old for heart transplantation?.
      • Everett JE
      • Djalilian AR
      • Kubo SH
      • Kroshus TJ
      • Shumway SJ.
      Heart transplantation for patients over age 60.
      predicted heart mass (pHM),
      • Costanzo MR
      • Dipchand A
      • Starling R
      • et al.
      The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients.
      ,
      • Nagji AS
      • Hranjec T
      • Swenson BR
      • et al.
      Donor age is associated with chronic allograft vasculopathy after adult heart transplantation: implications for donor allocation.
      ,
      • Gong TA
      • Joseph SM
      • Lima B
      • et al.
      Donor predicted heart mass as predictor of primary graft dysfunction.
      the role of body mass index,
      • Bergenfeldt H
      • Stehlik J
      • Hoglund P
      • Andersson B
      • Nilsson J.
      Donor-recipient size matching and mortality in heart transplantation: influence of body mass index and gender.
      ,
      • O'Neill TJ
      • Pisani B.
      Size matching in heart transplantation donor selection: "Too big to fail"?.
      oversizing for pulmonary hypertension,
      • Correia P
      • Prieto D
      • Batista M
      • Antunes MJ.
      Gender mismatch between donor and recipient is a factor of morbidity but does not condition survival after cardiac transplantation.
      ,
      • Jasseron C
      • Legeai C
      • Jacquelinet C
      • et al.
      Optimization of heart allocation: the transplant risk score.
      ,
      • Russo MJ
      • Iribarne A
      • Hong KN
      • et al.
      Factors associated with primary graft failure after heart transplantation.
      and extreme donor-recipient size mismatch.
      • Costanzo MR
      • Dipchand A
      • Starling R
      • et al.
      The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients.
      ,
      • Reed RM
      • Netzer G
      • Hunsicker L
      • et al.
      Cardiac size and sex-matching in heart transplantation: size matters in matters of sex and the heart.
      ,
      • Jasseron C
      • Legeai C
      • Jacquelinet C
      • et al.
      Optimization of heart allocation: the transplant risk score.
      ,
      • Madan S
      • Patel SR
      • Vlismas P
      • et al.
      Outcomes of early adolescent donor hearts in adult transplant recipients.
      While there currently is no consensus as to best method of determining size matching, pHM is gaining in popularity.

      Recommendations regarding donor size

      Class I

      • 1.
        Allocation of female donors to male recipients may be done safely, especially in recipients without pulmonary hypertension and when adequate donor/recipient weight ratio and/or pHM are ensured. A value of pHM within 20% to 30% of recipient is considered acceptable. Level of Evidence: C.

      Class IIb

      • 1.
        Due to the impact on right ventricular dysfunction of the donor allograft, pulmonary hypertension in the intended recipient should be taken into consideration when determining the degree of acceptable size and sex mismatch. Level of Evidence: C.

      Recommendation on anti-human leukocyte antigens (HLA) compatibility:
      • Stehlik J
      • Feldman DS
      • Brown RN
      • et al.
      Interactions among donor characteristics influence post-transplant survival: a multi-institutional analysis.
      ,
      • Bergenfeldt H
      • Stehlik J
      • Hoglund P
      • Andersson B
      • Nilsson J.
      Donor-recipient size matching and mortality in heart transplantation: influence of body mass index and gender.
      ,
      • Correia P
      • Prieto D
      • Batista M
      • Antunes MJ.
      Gender mismatch between donor and recipient is a factor of morbidity but does not condition survival after cardiac transplantation.
      ,
      • Stehlik J
      • Islam N
      • Hurst D
      • et al.
      Utility of virtual crossmatch in sensitized patients awaiting heart transplantation.

      Class IIa

      • 1.
        The presence of preformed human leukocyte antigens (HLA) antibodies should be ascertained and compared against the donor HLA, at least virtually, prior to acceptance for organ transplant. Level of Evidence: C.
      • 2.
        There currently is no agreed-upon standard for which HLA antibodies can be crossed and which should be avoided. Center practice varies based on magnitude, strength of antibodies, whether they are C1q positive (e.g., complement-fixing), and the level of experience with managing sensitization and ability to absorb transplant center risk. Level of Evidence: C.

      Recommendations on blood group compatibility between donor and recipient:
      • Bergenfeldt H
      • Stehlik J
      • Hoglund P
      • Andersson B
      • Nilsson J.
      Donor-recipient size matching and mortality in heart transplantation: influence of body mass index and gender.
      ,
      • Jawitz OK
      • GJ N
      • Yuh DD
      • Bonde P.
      Impact of ABO compatibility on outcomes after heart transplantation in a national cohort during the past decade.
      • Neves C
      • Prieto D
      • Sola E
      • Antunes MJ.
      Heart transplantation from donors of different ABO blood type.
      • Foreman C
      • Gruenwald C
      • West L.
      ABO-incompatible heart transplantation: a perfusion strategy.

      (See also Table 1.)
      Table 1Compatible Blood Groups
      Recipient blood typeCompatible donor
      AA, O
      BB, O
      ABA, B, AB, O
      OO

      Class I

      • 1.
        ABO blood group compatibility should be confirmed. Level of Evidence: C.
      • 2.
        Systems of care should be implemented to assure that blood group compatibility is not violated without a specific reason (ABO-incompatible pediatric transplantation). Level of Evidence: C.

      Recommendations regarding ischemic time:
      • Weiss ES
      • Allen JG
      • Kilic A
      • et al.
      Development of a quantitative donor risk index to predict short-term mortality in orthotopic heart transplantation.
      ,
      • Lund LH
      • Khush KK
      • Cherikh WS
      • et al.
      The registry of the International Society for Heart and Lung Transplantation: thirty-fourth adult heart transplantation report-2017; focus theme: allograft ischemic time.
      ,
      • Stehlik J
      • Feldman DS
      • Brown RN
      • et al.
      Interactions among donor characteristics influence post-transplant survival: a multi-institutional analysis.
      ,
      • Pflugfelder PW
      • Singh NR
      • McKenzie FN
      • Menkis AH
      • Novick RJ
      • Kostuk WJ.
      Extending cardiac allograft ischemic time and donor age: effect on survival and long-term cardiac function.
      • Charniot JC
      • Bonnefont-Rousselot D
      • Albertini JP
      • et al.
      Oxidative stress implication after prolonged storage donor heart with blood versus crystalloid cardioplegia and reperfusion versus static storage.
      • Marasco SF
      • Esmore DS
      • Negri J
      • et al.
      Early institution of mechanical support improves outcomes in primary cardiac allograft failure.
      • Russo MJ
      • Chen JM
      • Sorabella RA
      • et al.
      The effect of ischemic time on survival after heart transplantation varies by donor age: an analysis of the United Network for Organ Sharing database.
      • Hong KN
      • Iribarne A
      • Worku B
      • et al.
      Who is the high-risk recipient? Predicting mortality after heart transplant using pretransplant donor and recipient risk factors.
      • González-Vílchez F
      • Almenar-Bonet L
      • Crespo-Leiro MG
      • et al.
      Spanish Heart Transplant Registry. 29th official report of the Spanish Society of Cardiology working group on heart failure.
      • Reich HJ
      • Kobashigawa JA
      • Aintablian T
      • Ramzy D
      • Kittleson MM
      • Esmailian F.
      Effects of older donor age and cold ischemic time on long-term outcomes of heart transplantation.
      • Gaffey AC
      • Chen CW
      • Chung JJ
      • et al.
      Extended distance cardiac allograft can successfully be utilized without impacting long-term survival.
      • Kur F
      • Beiras-Fernandez A
      • Meiser B
      • Uberfuhr P
      • Reichart B.
      Clinical heart transplantation with extended preservation time (>5 hours): experience with University of Wisconsin solution.
      • Mitropoulos FA
      • Odim J
      • Marelli D
      • et al.
      Outcome of hearts with cold ischemic time greater than 300 minutes. A case-matched study.
      • Morgan JA
      • John R
      • Weinberg AD
      • et al.
      Prolonged donor ischemic time does not adversely affect long-term survival in adult patients undergoing cardiac transplantation.
      • Yeen W
      • Polgar A
      • Guglin M
      • et al.
      Outcomes of adult orthotopic heart transplantation with extended allograft ischemic time.
      • Banner NR
      • Thomas HL
      • Curnow E
      • Hussey JC
      • Rogers CA
      • Bonser RS.
      The importance of cold and warm cardiac ischemia for survival after heart transplantation.
      • Conway J
      • Chin C
      • Kemna M
      • et al.
      Donors' characteristics and impact on outcomes in pediatric heart transplant recipients.
      • Ford MA
      • Almond CS
      • Gauvreau K
      • et al.
      Association of graft ischemic time with survival after heart transplant among children in the United States.
      • Haneya A
      • Haake N
      • Diez C
      • et al.
      Impact of the Eurotransplant high-urgency heart allocation system on the outcome of transplant candidates in Germany.
      • Goff RR
      • Uccellini K
      • Lindblad K
      • et al.
      A change of heart: preliminary results of the US 2018 adult heart allocation revision.
      • Segovia J
      • Cosio MD
      • Barcelo JM
      • et al.
      RADIAL: a novel primary graft failure risk score in heart transplantation.
      • Wever Pinzon O
      • Stoddard G
      • Drakos SG
      • et al.
      Impact of donor left ventricular hypertrophy on survival after heart transplant.
      • García Sáez D
      • Zych B
      • Sabashnikov A
      • et al.
      Evaluation of the organ care system in heart transplantation with an adverse donor/recipient profile.
      • Ardehali A
      • Esmailian F
      • Deng M
      • et al.
      Ex-vivo perfusion of donor hearts for human heart transplantation (PROCEED II): a prospective, open-label, multicentre, randomised non-inferiority trial.
      • Kaliyev R
      • Bekbossynov S
      • Nurmykhametova Z.
      Sixteen-hour ex vivo donor heart perfusion during long-distance transportation for heart transplantation.

      Class I

      • 1.
        Target total organ ischemic time for cardiac transplantation should be ≤4 hours, to reduce the risk of primary graft dysfunction and early death. Level of Evidence: C.

      Class IIa

      • 1.
        A transplant center may allow the total organ ischemic time to exceed 4 hours for donors <45 years of age without compromising early outcomes after heart transplantation. With older donors, it is specifically recommended to avoid long-distance transportation or other factors (e.g., redo sternotomy, ventricular assist device (VAD) explantation, which can cause prolonged operative times) that could result in total donor ischemic times >4 hours. Level of Evidence: C.
      • 2.
        Ex-vivo normothermic heart perfusion platforms can be safely used to decrease ischemic time for distant procurements and potentially to expand the procurement of marginal donors based on metabolic evaluation during ex-vivo perfusion. Level of Evidence: C.

      Donor comorbidities

      Recommendations for left ventricular hypertrophy (LVH)
      • Smits JM
      • De Pauw M
      • de Vries E
      • et al.
      Donor scoring system for heart transplantation and the impact on patient survival.
      ,
      • Weiss ES
      • Allen JG
      • Kilic A
      • et al.
      Development of a quantitative donor risk index to predict short-term mortality in orthotopic heart transplantation.
      ,
      • Jasseron C
      • Legeai C
      • Jacquelinet C
      • et al.
      Optimization of heart allocation: the transplant risk score.
      ,
      • Wever Pinzon O
      • Stoddard G
      • Drakos SG
      • et al.
      Impact of donor left ventricular hypertrophy on survival after heart transplant.
      ,
      • Goland S
      • Czer LS
      • Kass RM
      • et al.
      Use of cardiac allografts with mild and moderate left ventricular hypertrophy can be safely used in heart transplantation to expand the donor pool.
      • Marelli D
      • Laks H
      • Fazio D
      • Moore S
      • Moriguchi J
      • Kobashigawa J.
      The use of donor hearts with left ventricular hypertrophy.
      • Ferrera R
      • Hadour G
      • Tamion F
      • et al.
      Brain death provokes very acute alteration in myocardial morphology detected by echocardiography: Preventive effect of beta-blockers.
      • Kuppahally SS
      • Valantine HA
      • Weisshaar D
      • et al.
      Outcome in cardiac recipients of donor hearts with increased left ventricular wall thickness.
      • Aziz S
      • Soine LA
      • Lewis SL
      • et al.
      Donor left ventricular hypertrophy increases risk for early graft failure.
      • Lang RM
      • Bierig M
      • Devereux RB
      • et al.
      Recommendations for chamber quantification.
      and hypertension:
      • Lund LH
      • Edwards LB
      • Kucheryavaya AY
      • et al.
      The registry of the International Society for Heart and Lung Transplantation: thirtieth official adult heart transplant report–2013; focus theme: age.
      ,
      • Stehlik J
      • Feldman DS
      • Brown RN
      • et al.
      Interactions among donor characteristics influence post-transplant survival: a multi-institutional analysis.
      ,
      • Kuppahally SS
      • Valantine HA
      • Weisshaar D
      • et al.
      Outcome in cardiac recipients of donor hearts with increased left ventricular wall thickness.
      ,,
      • Khush KK
      • Menza R
      • Nguyen J
      • Zaroff JG
      • Goldstein BA.
      Donor predictors of allograft use and recipient outcomes after heart transplantation.

      (See Table 2 for the gradation of left ventricular hypertrophy (LVH).)
      Table 2LVH Determined by Measurement of the Interventricular Septum
      Level of LVHIntraventricular septum
      Mild11-13 mm
      Moderate14-16 mm
      Severe≥17 mm

      Class I

      • 1.
        LVH should be assessed by measuring the thickness of the interventricular septum or the posterior wall on echocardiography. Level of Evidence: C.

      Class IIa

      • 1.
        Carefully selected donor hearts with LVH >13 mm (measured as outlined above) may be considered, particularly with younger (donors ≤40 years of age) and/or shorter ischemic time (<4 hours). Level of Evidence: C.
      • 2.
        Chronic hypertension (defined by contemporary guidelines) or the use of hearts from donors being treated for hypertension in the absence of LVH do not appear to impact post-transplant outcomes. Level of Evidence: C.

      Recommendations regarding donors with coronary artery disease (CAD):
      • Smits JM
      • De Pauw M
      • de Vries E
      • et al.
      Donor scoring system for heart transplantation and the impact on patient survival.
      ,
      • Gao HZ
      • Hunt SA
      • Alderman EL
      • Liang D
      • Yeung AC
      • Schroeder JS.
      Relation of donor age and preexisting coronary artery disease on angiography and intracoronary ultrasound to later development of accelerated allograft coronary artery disease.
      • Yamasaki M
      • Sakurai R
      • Hirohata A
      • et al.
      Impact of donor-transmitted atherosclerosis on early cardiac allograft vasculopathy: new findings by three-dimensional intravascular ultrasound analysis.
      • Grauhan O
      • Siniawski H
      • Dandel M
      • et al.
      Coronary atherosclerosis of the donor heart–impact on early graft failure.
      • Deng MC
      • De Meester JM
      • Smits JM
      • Heinecke J
      • Scheld HH.
      Effect of receiving a heart transplant: Analysis of a national cohort entered on to a waiting list, stratified by heart failure severity. Comparative Outcome and Clinical Profiles in Transplantation (COCPIT) Study Group.
      • Lechiancole A
      • Vendramin I
      • Sponga S
      • et al.
      Influence of donor-transmitted coronary artery disease on long-term outcomes after heart transplantation - a retrospective study.
      • Ivanes F
      • Cantrelle C
      • Genet T
      • et al.
      Performing diagnostic coronary angiography to evaluate high-risk cardiac donors: a French nationwide cohort study.
      • Grosse K
      • Brauer B
      • Kücük O
      • et al.
      Does contrast medium administration in organ donors affect early kidney graft function?.

      (Table 3 illustrates how recommendations have varied over time and across geographic regions.)
      Table 3Recommended Age Criteria for the Use of Coronary Angiography in Donor Evaluation Across Time and Geographic Region (Class IIa/b; Level of Evidence: C)
      PublicationRecommended age for menRecommended age for womenRegionYear
      ACCRecommendations
      • Baldwin JC
      • Anderson JL
      • Boucek MM
      • et al.
      24th Bethesda conference: cardiac transplantation. Task Force 2: donor guidelines.
      • Age >45 years

      • Lower by 5-10 years if risk factors present
      • Age >50 years

      • Lower by 5-10 years if risk factors present
      US1993
      Maximizing Use of Organs Recovered From the Cadaver Donor Consensus Conference
      • Zaroff JG
      • Rosengard BR
      • Armstrong WF
      • et al.
      Consensus conference report: maximizing use of organs recovered from the cadaver donor: cardiac recommendations, March 28-29, 2001, Crystal City, Va.
      • Age >55 years: mandatory

      • Age >45 years: recommended

      • Age >35 years if cocaine or 3 risk factors
      • Age >55 years: mandatory

      • Age >50 years: recommended

      • Age >40 years if cocaine or 3 risk factors
      US2002
      United Network for Organ Sharing
      • Organ OPTN/UNOS
      Procurement Organization Committee. Guidance on requested deceased donor information; 2018.
      • Age >40 years

      • Younger with risk factors
      • Age >45 years

      • Younger with risk factors
      US2018
      European Committee on Organ Transplantation (Council of Europe)
      European Directorate for the Quality of Medicines and Healthcare
      Guide to the Quality and Qafety of Organs for Transplantation.
      • Age >55 years

      • Age >45 years if more than 1 risk factor present
      • Age >55 years

      • Age >45 years if more than 1 risk factor present
      Europe2018

      Class IIa

      • 1.
        Donors with mild luminal irregularities (e.g., ≤50% narrowing) on coronary angiography may be considered for heart transplantation. Level of Evidence: C.
      • 2.
        Coronary angiography should be considered in donors ≥45 years old, depending on geography and other risk factors. See also Table 3. Level of Evidence: C.
      • 3.
        Risk factors suggesting need for coronary angiography include hypertension, diabetes (particularly with longer time of treatment), male sex, obesity, hyperlipidemia, tobacco and/or cocaine/methamphetamine use. Level of Evidence: C.
      • 4.
        Myocardial bridging is rarely a contraindication to transplantation. Level of Evidence: C

      Class IIb

      • 1.
        Donors with single-vessel coronary disease amenable to percutaneous or surgical therapy may be considered after balancing the risk of coronary disease progression and the urgency of the recipient. Level of Evidence: C.
      • 2.
        Donors with left main and/or 2 to 3 vessel obstructive (≥50%) coronary disease are best avoided for transplantation in the absence of extenuating circumstances. Level of Evidence: C.

      Recommendations regarding donors with diabetes:
      • Lund LH
      • Edwards LB
      • Kucheryavaya AY
      • et al.
      The registry of the International Society for Heart and Lung Transplantation: thirtieth official adult heart transplant report–2013; focus theme: age.
      ,
      • Smits JM
      • De Pauw M
      • de Vries E
      • et al.
      Donor scoring system for heart transplantation and the impact on patient survival.
      ,
      • Foroutan F
      • Alba AC
      • Guyatt G
      • et al.
      Predictors of 1-year mortality in heart transplant recipients: a systematic review and meta-analysis.
      ,
      • Weiss ES
      • Allen JG
      • Kilic A
      • et al.
      Development of a quantitative donor risk index to predict short-term mortality in orthotopic heart transplantation.
      ,
      • Stehlik J
      • Feldman DS
      • Brown RN
      • et al.
      Interactions among donor characteristics influence post-transplant survival: a multi-institutional analysis.
      ,
      • Nagji AS
      • Hranjec T
      • Swenson BR
      • et al.
      Donor age is associated with chronic allograft vasculopathy after adult heart transplantation: implications for donor allocation.
      ,
      • Jasseron C
      • Legeai C
      • Jacquelinet C
      • et al.
      Optimization of heart allocation: the transplant risk score.
      ,,
      • Khush KK
      • Menza R
      • Nguyen J
      • Zaroff JG
      • Goldstein BA.
      Donor predictors of allograft use and recipient outcomes after heart transplantation.
      ,
      • Taghavi S
      • Jayarajan SN
      • Wilson LM
      • Komaroff E
      • Testani JM
      • Mangi AA.
      Cardiac transplantation can be safely performed using selected diabetic donors.
      • Khush KK
      • Potena L
      • Cherikh WS
      • et al.
      The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: 37th adult heart transplantation report-2020; focus on deceased donor characteristics.
      • Kilic A
      • Weiss ES
      • George TJ
      • et al.
      What predicts long-term survival after heart transplantation? An analysis of 9,400 ten-year survivors.
      • Joseph JT
      • Mulvihill MS
      • Yerokun BA
      • Bell SM
      • Milano CA
      • Hartwig MG.
      Elevated donor hemoglobin A1c does not impair early survival in cardiac transplant recipients [e-pub ahead of print].

      Class IIa

      • 1.
        Donors with diabetes mellitus and no other risk factors, particularly without coronary artery disease, can be safely used. Level of Evidence: C.
      • 2.
        Coronary angiography should be considered for diabetic donors, and duration of diabetes and donor age should be carefully weighed. Level of Evidence: C.

      Recommendations regarding donor experiencing cardiopulmonary arrest and the duration of cardiopulmonary resuscitation (CPR):
      • Cheng A
      • Schumer EM
      • Trivedi JR
      • Van Berkel VH
      • Massey HT
      • Slaughter MS.
      Does donor cardiopulmonary resuscitation time affect heart transplantation outcomes and survival?.
      • Galeone A
      • Lebreton G
      • Leprince P.
      Old Europe carefully looks at a new heart: cardiac arrest-resuscitated donors should not be turned down for heart transplant at first glance.
      • Quader MA
      • Wolfe LG
      • Kasirajan V.
      Heart transplantation outcomes from cardiac arrest-resuscitated donors.
      • Quader M
      • Wolfe L
      • Katlaps G
      • Kasirajan V.
      Donor heart utilization following cardiopulmonary arrest and resuscitation: influence of donor characteristics and wait times in transplant regions.
      • Southerland KW
      • Castleberry AW
      • Williams JB
      • Daneshmand MA
      • Ali AA
      • Milano CA.
      Impact of donor cardiac arrest on heart transplantation.
      • L'Ecuyer T
      • Sloan K
      • Tang L.
      Impact of donor cardiopulmonary resuscitation on pediatric heart transplant outcome.
      • Dark JH
      • Mehew J
      • Venkateswaran R.
      Prolongation of time from brain death to retrieval is beneficial to the donor heart.

      Class IIa

      • 1.
        Donors with cardiopulmonary resuscitation may be used if heart function is normal (by left ventricular ejection fraction (LVEF) and hemodynamics) at the time of procurement, unless the cardiac arrest circumstances raise the suspicion for underlying structural heart disease. Level of Evidence: C.
      • 2.
        The duration of donor cardiopulmonary arrest and of the CPR alone should not be used to exclude donor hearts for transplantation. CPR times >30 minutes in both adult and pediatric donors do not negatively impact post-transplant survival or outcomes if echocardiographic cardiac function and hemodynamics are favorable (e.g., LVEF >50%) after resuscitation. Level of Evidence: C.

      Donor drug use

      Recommendation regarding donor tobacco use:
      • Fagerström K.
      The epidemiology of smoking: health consequences and benefits of cessation.
      • Shea KJ
      • Sopko NA
      • Ludrosky K
      • et al.
      The effect of a donor's history of active substance on outcomes following orthotopic heart transplantation.
      • Kim MS
      • Kang SJ
      • Lee CW
      • et al.
      Prevalence of coronary atherosclerosis in asymptomatic healthy subjects: an intravascular ultrasound study of donor hearts.
      • Tsao CI
      • Chen RJ
      • Chou NK
      • et al.
      The influence of donor characteristics on survival after heart transplantation.
      • Rizzi G
      • Startseva X
      • Wolfrum M
      • et al.
      Unfavorable donor pretransplant APACHE II, SAPS II, and SOFA scores are not associated with outcome: implications for heart transplant donor selection.
      • El Oakley RM
      • Yonan NA
      • Simpson BM
      • Deiraniya AK
      Extended criteria for cardiac allograft donors: a consensus study.

      Class IIa

      • 1.
        Tobacco use of significant pack-years increases the risk of donor coronary artery disease (CAD). Depending on donor age (>45 years), obtaining a donor angiogram may be reasonable. Level of Evidence: C.

      Recommendation regarding donor alcohol use:
      • Bollinger O.
      Über die Häufigkeit und Ursachen der idiopathischen Herzhypertrophie in München.
      • Wang S
      • Ren J.
      Role of autophagy and regulatory mechanisms in alcoholic cardiomyopathy.
      • Houyel L
      • Petit J
      • Nottin R
      • Duffet JP
      • Macé L
      • Neveux JY.
      Adult heart transplantation: Adverse role of chronic alcoholism in donors on early graft function.
      • Freimark D
      • Aleksic I
      • Trento A
      • et al.
      Hearts from donors with chronic alcohol use: a possible risk factor for death after heart transplantation.
      • Taghavi S
      • Jayarajan SN
      • Komaroff E
      • et al.
      Use of heavy drinking donors in heart transplantation is not associated with worse mortality.
      • De La Zerda DJ
      • Cohen O
      • Beygui RE
      • Kobashigawa J
      • Hekmat D
      • Laks H.
      Alcohol use in donors is a protective factor on recipients' outcome after heart transplantation.
      • Newman J
      • Liebo M
      • Lowes BD
      • et al.
      The effect of donor alcohol abuse on outcomes following heart transplantation.
      • Peled Y
      • Varnado S
      • Lowes BD
      • et al.
      Sinus tachycardia is associated with impaired exercise tolerance following heart transplantation [e-pub ahead of print].
      • Wood DM
      • Dargan PI
      • Jones AL.
      Poisoned patients as potential organ donors: postal survey of transplant centres and intensive care units.

      Class IIa

      • 1.
        The hearts of donors with a history of alcohol use may be used for transplantation if cardiac function is preserved on echocardiography. Level of Evidence: C.

      Recommendations regarding donor use of illicit drugs (cocaine, amphetamine, methamphetamine):
      • Shea KJ
      • Sopko NA
      • Ludrosky K
      • et al.
      The effect of a donor's history of active substance on outcomes following orthotopic heart transplantation.
      ,
      • Warraich HJ
      • Lu D
      • Cobb S
      • et al.
      Trends and outcomes of cardiac transplantation from donors dying of drug intoxication.
      • Jayarajan S
      • Taghavi S
      • Komaroff E
      • et al.
      Long-term outcomes in heart transplantation using donors with a history of past and present cocaine use.
      • Brieke A
      • Krishnamani R
      • Rocha MJ
      • et al.
      Influence of donor cocaine use on outcome after cardiac transplantation: analysis of the United Network for Organ Sharing Thoracic Registry.
      • Baran D
      • Long A
      • Lansinger J
      • et al.
      What are you smoking? The impact of donor drug use on long term survival post-transplant [Abstract].
      • Lansinger JT
      • Long A
      • Barreiro C
      • et al.
      Donors and Drugs: How Often Do They Mix? Utilization of Donors Based on Toxicology Findings [e-pub ahead of print].
      • Vieira JL
      • Cherikh WS
      • Lindblad K
      • Stehlik J
      • Mehra MR.
      Cocaine use in organ donors and long-term outcome after heart transplantation: an International Society for Heart and Lung Transplantation registry analysis.
      • Baran DA
      • Lansinger J
      • Long A
      • et al.
      Intoxicated donors and heart transplant outcomes: long-term safety.

      Class IIa

      • 1.
        Donors with a history of cocaine use can be considered for heart transplantation if there is no significant LVH (i.e., ≥14 mm; see also the recommendations on donor LVH in this document). Level of Evidence: C.
      • 2.
        Donors with a history of past or active cocaine use should have a coronary angiogram when possible. Level of Evidence: C.
      • 3.
        Donors with toxicology positive for amphetamine or methamphetamine may be utilized for transplant if ventricular function and structure are normal on echocardiogram and imaging. Level of Evidence: C.
      • 4.
        Donors with toxicology positive for multiple substances may be utilized for transplant if ventricular function and structure are normal on echocardiogram and imaging. Level of Evidence: C.

      Infections in the donor

      This section reviews various potential infections in a donor though it is not comprehensive of all possibilities. Infectious disease thoracic transplant physician specialists should be consulted for unique donor infections as new pathogens are always emerging and treatments are constantly evolving.

      Recommendation regarding bacterial infections in the donor:
      • Costanzo MR
      • Dipchand A
      • Starling R
      • et al.
      The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients.
      ,
      • Fishman JA
      • Greenwald MA
      • Grossi PA.
      Transmission of infection with human allografts: essential considerations in donor screening.
      • Len O
      • Los-Arcos I
      • Aguado JM
      • et al.
      Selection criteria of solid organ donors in relation to infectious diseases: a Spanish consensus.
      • Ison MG
      • Nalesnik MA.
      An update on donor-derived disease transmission in organ transplantation.
      • Wolfe CR
      • Ison MG.
      Donor-derived infections: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice.
      • Kubak BM
      • Gregson AL
      • Pegues DA
      • et al.
      Use of hearts transplanted from donors with severe sepsis and infectious deaths.

      Class IIa

      • 1.
        Transplantation of hearts from bacteremic donors is feasible, provided that the recipient, after being informed of the associated risks, is treated with targeted antimicrobials for an appropriate duration post-transplant. Level of Evidence: C.

      Recommendations regarding fungal infections:
      • Singh N
      • Huprikar S
      • Burdette SD
      • Morris MI
      • Blair JE
      • Wheat LJ.
      Donor-derived fungal infections in organ transplant recipients: guidelines of the American Society of Transplantation, Infectious Diseases Community of Practice.
      • Sun HY
      • Alexander BD
      • Lortholary O
      • et al.
      Unrecognized pretransplant and donor-derived cryptococcal disease in organ transplant recipients.
      • Gomez CA
      • Singh N.
      Donor-derived filamentous fungal infections in solid organ transplant recipients.
      • Gajurel K
      • Dhakal R
      • Deresinski S.
      Histoplasmosis in transplant recipients [e-pub ahead of print].
      • Nelson JK
      • Giraldeau G
      • Montoya JG
      • Deresinski S
      • Ho DY
      • Pham M.
      Donor-Derived Coccidioides immitis Endocarditis and Disseminated Infection in the Setting of Solid Organ Transplantation [e-pub ahead of print].
      • Cuellar-Rodriguez J
      • Avery RK
      • Lard M
      • et al.
      Histoplasmosis in solid organ transplant recipients: 10 years of experience at a large transplant center in an endemic area.
      • Kusne S
      • Taranto S
      • Covington S
      • et al.
      Coccidioidomycosis transmission through organ transplantation: a report of the OPTN Ad Hoc disease transmission advisory committee.
      • Kovacs CS
      • Koval CE
      • van Duin D
      • et al.
      Selecting suitable solid organ transplant donors: reducing the risk of donor-transmitted infections.

      (See Table 4.)
      Table 4Fungal Infections
      PathogenRecommendationStrength/level of evidence
      Aspergillus, activeIf disseminated, do not utilizeIII /C
      Aspergillus, active (lung only)If lung only, consider taking heart with post-transplant prophylaxisIIb /C
      Aspergillus, history of diseaseIf findings, send workup to rule out active disease, possible post-transplant prophylaxisIIa /C
      Coccidiomycosis, active diseaseDo not utilizeIII /C
      Coccidiomycosis, history of diseaseIf findings, send workup to rule out active disease, possible post-transplant prophylaxisIIa /C
      Cryptococcus, untreatedDo not utilizeIII /C
      Cryptococcus, actively treatedConsider risks/benefitsIIa /C
      Histoplasmosis, active diseaseDo not utilizeIII /C
      Histoplasmosis, history of diseaseIf findings, send workup to rule out active diseaseIIa /C

      Recommendations regarding bloodborne viral infections in the donor

      (Recommendations concerning donors with hepatitis B,
      European Directorate for the Quality of Medicines and Healthcare
      Guide to the Quality and Qafety of Organs for Transplantation.
      ,
      • Blanes M
      • Gomez D
      • Cordoba J
      • et al.
      Is there any risk of transmission of hepatitis B from heart donors hepatitis B core antibody positive?.
      • Chamorro C
      • Aparicio M.
      Influence of HBcAb positivity in the organ donor in heart transplantation.
      • Chen YC
      • Chuang MK
      • Chou NK
      • et al.
      Twenty-four year single-center experience of hepatitis B virus infection in heart transplantation.
      • De Feo TM
      • Poli F
      • Mozzi F
      • Moretti MP
      • Scalamogna M.
      Risk of transmission of hepatitis B virus from anti-HBC positive cadaveric organ donors: a collaborative study.
      • Dhillon GS
      • Levitt J
      • Mallidi H
      • et al.
      Impact of hepatitis B core antibody positive donors in lung and heart-lung transplantation: an analysis of the United Network for organ sharing database.
      • Horan JL
      • Stout JE
      • BD Alexander
      Hepatitis B core antibody-positive donors in cardiac transplantation: a single-center experience.
      • Huprikar S
      • Danziger-Isakov L
      • Ahn J
      • et al.
      Solid organ transplantation from hepatitis B virus-positive donors: consensus guidelines for recipient management.
      • Krassilnikova M
      • Deschenes M
      • Tchevenkov J
      • Giannetti N
      • Cecere R
      • Cantarovich M.
      Effectiveness of post-transplant prophylaxis with anti-hepatitis B virus immunoglobulin in recipients of heart transplant from hepatitis B virus core antibody positive donors.
      • Large SR.
      Impact of hepatitis B core antibody positive donors in lung and heart-lung transplantation: an analysis of the UNOS database.

      Organ Procurement and Transplantation Network. Policy 1: Administrative rules and definitions. 2021; https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf.

      • Pinney SP
      • Cheema FH
      • Hammond K
      • Chen JM
      • Edwards NM
      • Mancini D.
      Acceptable recipient outcomes with the use of hearts from donors with hepatitis-B core antibodies.
      • Salvadori M
      • Rosso G
      • Carta P
      • Larti A
      • di Maria L
      • Bertoni E.
      Donors positive for hepatitis B core antibodies in nonliver transplantations.
      • Shin HS
      • Cho HJ
      • Jeon ES
      • et al.
      The impact of hepatitis B on heart transplantation: 19 years of national experience in Korea.
      • Tenderich G
      • Zittermann A
      • Prohaska W
      • et al.
      Frequent detection of hepatitis B core antibodies in heart transplant recipients without preceding hepatitis B infection.
      • Wachs ME
      • Amend WJ
      • Ascher NL
      • et al.
      The risk of transmission of hepatitis B from HBsAg(-), HBcAb(+), HBIgM(-) organ donors.
      hepatitis C,
      • Aslam S
      • Grossi P
      • Schlendorf KH
      • et al.
      Utilization of hepatitis C virus-infected organ donors in cardiothoracic transplantation: an ISHLT expert consensus statement.
      • Blumberg EA.
      Organs from hepatitis C virus-positive donors.
      • Gasink LB
      • Blumberg EA
      • Localio AR
      • Desai SS
      • Israni AK
      • Lautenbach E.
      Hepatitis C virus seropositivity in organ donors and survival in heart transplant recipients.
      • Gidea CG
      • Narula N
      • Reyentovich A
      • et al.
      Increased early acute cellular rejection events in hepatitis C-positive heart transplantation.
      • Gottlieb RL
      • Hall SA.
      The new direct antiviral agents and hepatitis C in thoracic transplantation: impact on donors and recipients.
      • McLean RC
      • Reese PP
      • Acker M
      • et al.
      Transplanting hepatitis C virus-infected hearts into uninfected recipients: a single-arm trial.
      • Patel SR
      • Madan S
      • Saeed O
      • et al.
      Cardiac transplantation from non-viremic hepatitis C donors.
      • Schlendorf KH
      • Zalawadiya S
      • Shah AS
      • et al.
      Early outcomes using hepatitis c-positive donors for cardiac transplantation in the era of effective direct-acting antiviral therapies.
      • Woolley AE
      • Singh SK.
      The curious phenomenon of early cardiac allograft rejection with hepatitis C‒infected donor heart transplants.
      • Woolley AE
      • Singh SK
      • Goldberg HJ
      • et al.
      Heart and lung transplants from HCV-infected donors to uninfected recipients.
      and human immunodeficiency virus (HIV)
      • Boyarsky BJ
      • Durand CM
      • Palella FJ
      • Segev DL
      Challenges and clinical decision-making in HIV-to-HIV transplantation: insights from the HIV literature.
      • Chen C
      • Wen X
      • Yadav A
      • Belviso N
      • Kogut S
      • McCauley J.
      Outcomes in human immunodeficiency virus-infected recipients of heart transplants.
      • Madan S
      • Patel SR
      • Saeed O
      • et al.
      Outcomes of heart transplantation in patients with human immunodeficiency virus.
      • Miro JM
      • Grossi PA
      • Durand CM.
      Challenges in solid organ transplantation in people living with HIV.
      • Muller E
      • Barday Z
      • Mendelson M
      • Kahn D.
      HIV-positive-to-HIV-positive kidney transplantation–results at 3 to 5 years.
      National Institutes of Health
      Final Human Immunodeficiency Virus (HIV) Organ Policy Equity (HOPE) Act Safeguards and Research Criteria for Transplantation of Organs Infected With HIV.
      Organ Procurement and Transplantation Network. Modify HOPE Act Variance to Include Other.
      • Selhorst P
      • Combrinck CE
      • Manning K
      • et al.
      Longer-term outcomes of HIV-positive-to-HIV-positive renal transplantation.
      • Uriel N
      • Jorde UP
      • Cotarlan V
      • et al.
      Heart transplantation in human immunodeficiency virus-positive patients.
      are summarized in Table 5.)
      Table 5Bloodborne Infections
      PathogenRecommendationStrength/level of evidence
      Hepatitis B Ag+Should be limited to carefully selected, consented recipients.IIa /C
      Hepatitis B cAb+With appropriate post-transplant monitoring and prophylaxis, HBcAb+ donor organs may be used for transplantation.IIa /C
      Hepatitis C (anti-HCV+, HCV-RNA-)Generally safe for transplantation but requires post-transplant HCV-RNA monitoring.IIa /C
      Hepatitis C (anti-HCV+, HCV RNA+)Should be limited to consented recipients with appropriate post-transplant treatment and monitoring.IIa /C
      HIVTransplantation of HIV seropositive hearts into HIV seropositive recipients is reasonable with full informed consent and involvement of local infectious disease experts in advance.IIa /C

      Recommendation regarding donors with tuberculosis:
      • Malinis M
      • Koff A.
      Mycobacterium tuberculosis in solid organ transplant donors and recipients.

      (See Table 6.)
      Table 6Recommendation Regarding Donors with Tuberculosis
      PathogenRecommendationStrength/level of evidence
      Mycobacterium tuberculosis, active diseaseConsider taking organ, consult infectious disease specialist for follow up and isonicotinic acid hydrazide (INH) for 6 monthsIIb /C
      Mycobacterium tuberculosis, history of diseaseAccept organ, consult infectious disease specialist for follow up and consider INH 3-6 monthsIIa /C

      Recommendation regarding donors with increased infection risk:
      European Directorate for the Quality of Medicines and Healthcare
      Guide to the Quality and Qafety of Organs for Transplantation.
      ,
      • Gottlieb RL
      • Hall SA.
      The new direct antiviral agents and hepatitis C in thoracic transplantation: impact on donors and recipients.
      ,
      • Bixler D
      • Annambholta P
      • Abara WE
      • et al.
      Hepatitis B and C virus infections transmitted through organ transplantation investigated by CDC, United States, 2014-2017.
      • Gaffey AC
      • Doll SL
      • Thomasson AM
      • et al.
      Transplantation of "high-risk" donor hearts: implications for infection.
      • Green M
      • Covington S
      • Taranto S
      • et al.
      Donor-derived transmission events in 2013: a report of the organ procurement transplant network ad hoc disease transmission advisory committee.
      • Grossi PA
      • Dalla Gasperina D
      • Lombardi D
      • Ricci A
      • Piccolo G
      • Nanni Costa A
      Organ transplantation from "increased infectious risk donors": the experience of the Nord Italia Transplant program - a retrospective study.
      • Humar A
      • Morris M
      • Blumberg E
      • et al.
      Nucleic acid testing (NAT) of organ donors: is the 'best' test the right test? A consensus conference report.
      • Irwin L
      • Kotton CN
      • Elias N
      • et al.
      Utilization of increased risk for transmission of infectious disease donor organs in solid organ transplantation: retrospective analysis of disease transmission and safety.
      • Ison MG
      • Llata E
      • Conover CS
      • et al.
      Transmission of human immunodeficiency virus and hepatitis C virus from an organ donor to four transplant recipients.
      • Jones JM
      • Gurbaxani BM
      • Asher A
      • et al.
      Quantifying the risk of undetected HIV, hepatitis B virus, or hepatitis C virus infection in public health service increased risk donors.
      • Jones JM
      • Kracalik I
      • Levi ME
      • et al.
      Assessing solid organ donors and monitoring transplant recipients for human immunodeficiency virus, hepatitis B virus, and hepatitis C virus infection - U.S. public health service guideline, 2020.
      • Kaul DR
      • Tlusty SM
      • Michaels MG
      • Limaye AP
      • Wolfe CR.
      Donor-derived hepatitis C in the era of increasing intravenous drug use: a report of the disease transmission advisory committee.
      • Kucirka LM
      • Sarathy H
      • Govindan P
      • et al.
      Risk of window period hepatitis-C infection in high infectious risk donors: systematic review and meta-analysis.
      • Kucirka LM
      • Sarathy H
      • Govindan P
      • et al.
      Risk of window period HIV infection in high infectious risk donors: systematic review and meta-analysis.

      Organ Procurement and Transplantation Network. Policy 15: Identification of transmissible diseases. 2021; https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf. .

      Organ Procurement and Transplantation Network. Policy 2.9: Required deceased donor infectious disease testing.
      • Sahulee R
      • Lytrivi ID
      • Savla JJ
      • Rossano JW.
      Centers for disease control "high-risk" donor status does not significantly affect recipient outcome after heart transplantation in children.
      • Shudo Y
      • Cohen JE
      • Lingala B
      • He H
      • Zhu Y
      • Woo YJ.
      Impact of "increased-risk" donor hearts on transplant outcomes: a propensity-matched analysis.
      • Suryaprasad A
      • Basavaraju SV
      • Hocevar SN
      • et al.
      Transmission of hepatitis C virus from organ donors despite nucleic acid test screening.
      • White SL
      • Rawlinson W
      • Boan P
      • et al.
      Infectious disease transmission in solid organ transplantation: donor evaluation, recipient risk, and outcomes of transmission.

      (See also Table 7.)
      Table 7Behavioral, Social, Medical, and Other Factors that Increase Risk for Recent Hepatitis B, Hepatitis C, or HIV Infection in Organ Donors Per US Guidelines
      • Jones JM
      • Kracalik I
      • Levi ME
      • et al.
      Assessing solid organ donors and monitoring transplant recipients for human immunodeficiency virus, hepatitis B virus, and hepatitis C virus infection - U.S. public health service guideline, 2020.
      Risk criteria (in the preceding 30 days):
      • Sex
      The term sex refers to vaginal, anal or oral sexual contact.
      with a person known or suspected to have HIV, HBV, HCV infection
      • Man who has had sex with another man
      • Sex in exchange for money or drugs
      • Sex with a person who had sex in exchange for money or drugs
      • Drug injection for non-medical reasons
      • Sex with a person who injected drugs for non-medical reasons
      • Incarceration (confinement in jail, prison, or a juvenile correctional facility) for ≥72 consecutive hours
      • Child breastfed by a mother with HIV infection
      • Child born to a mother with HIV, HBV, or HCV infection
      • People in whom medical and social histories cannot be obtained or is unknown
      a The term sex refers to vaginal, anal or oral sexual contact.

      Class I

      • 1.
        Carefully selected donors at increased risk for unrecognized/recent hepatitis B, hepatitis C, and HIV may be selected for transplantation with surveillance post-transplant for disease transmission. Level of Evidence: B.

      Recommendations regarding emerging viral pathogens:
      • Aslam S
      • Goldstein DR
      • Vos R
      • et al.
      COVID-19 vaccination in our transplant recipients: the time is now.
      • Aslam S
      • Mehra MR.
      COVID-19: yet another coronavirus challenge in transplantation.
      • Bragin-Sánchez D
      • Chang PP.
      West Nile virus encephalitis infection in a heart transplant recipient: a case report.
      • Holm AM
      • Mehra MR
      • Courtwright A
      • et al.
      Ethical considerations regarding heart and lung transplantation and mechanical circulatory support during the COVID-19 pandemic: an ISHLT COVID-19 Task Force statement.
      • Iacovoni A
      • Boffini M
      • Pidello S
      • et al.
      A case series of novel coronavirus infection in heart transplantation from 2 centers in the pandemic area in the North of Italy.
      • Iwamoto M
      • Jernigan DB
      • Guasch A
      • et al.
      Transmission of West Nile virus from an organ donor to four transplant recipients.
      • Kates OS
      • Haydel BM
      • Florman SS
      • et al.
      COVID-19 in solid organ transplant: a multi-center cohort study.
      • Kaul DR
      • Valesano AL
      • Petrie JG
      • et al.
      Donor to recipient transmission of SARS-CoV-2 by lung transplantation despite negative donor upper respiratory tract testing.
      • Kotton CN.
      Zika virus and solid organ transplantation: significant pathogen or harbinger of things to come?.
      • Levi ME.
      Zika virus: a cause of concern in transplantation?.
      • Li F
      • Cai J
      • Dong N.
      First cases of COVID-19 in heart transplantation from China.
      • Nogueira ML
      • Estofolete CF
      • Terzian AC
      • et al.
      Zika virus infection and solid organ transplantation: a new challenge.
      • Pereira MR
      • Mohan S
      • Cohen DJ
      • et al.
      COVID-19 in solid organ transplant recipients: initial report from the US epicenter.
      • Rosen A
      • Ison MG.
      Screening of living organ donors for endemic infections: understanding the challenges and benefits of enhanced screening.
      • Schwartzmann PV
      • Ramalho LN
      • Neder L
      • et al.
      Zika virus meningoencephalitis in an immunocompromised patient.
      • Silveira FP
      • Campos SV.
      The Zika epidemics and transplantation.
      • Winston DJ
      • Vikram HR
      • Rabe IB
      • et al.
      Donor-derived West Nile virus infection in solid organ transplant recipients: report of four additional cases and review of clinical, diagnostic, and therapeutic features.

      (See Table 8.)
      Table 8Emerging Viruses
      VirusRecommendationStrength /level of evidence
      SARS-CoV-2, active confirmedShould be limited to informed recipients. Ideally should be offered to immunized recipients or with perioperative prophylaxis.
      As COVID-19 therapies are rapidly evolving, so is the utilization of these donors.
      IIb /C
      SARS-CoV-2, recoveredCan be utilized for informed recipients. Ideally should be offered to immunized recipients or with perioperative therapies.
      As COVID-19 therapies are rapidly evolving, so is the utilization of these donors.
      IIb /C
      West Nile virus, IgM+, NAT+, active confirmedDo not utilize.III /C
      West Nile virus, IgG+, history of diseaseConsider utilizationIIa/C
      Zika virus, IgM+, active confirmedDo not utilize.III /C
      Zika virus, IgG+, history of diseaseConsider utilizationIIb/C
      a As COVID-19 therapies are rapidly evolving, so is the utilization of these donors.

      Recommendations regarding parasitic infections in the donor:
      • Huprikar S
      • Danziger-Isakov L
      • Ahn J
      • et al.
      Solid organ transplantation from hepatitis B virus-positive donors: consensus guidelines for recipient management.
      ,
      • Benvenuti LA
      • Roggério A
      • Cavalcanti MM
      • Nishiya AS
      • Levi JE.
      An autopsy-based study of Trypanosoma cruzi persistence in organs of chronic chagasic patients and its relevance for transplantation.
      • Casadei D.
      Chagas' disease and solid organ transplantation.
      • Chin-Hong PV
      • Schwartz BS
      • Bern C
      • et al.
      Screening and treatment of chagas disease in organ transplant recipients in the United States: recommendations from the chagas in transplant working group.
      • Kim JH
      • Kim DS
      • Yoon YK
      • Sohn JW
      • Kim MJ.
      Donor-derived Strongyloidiasis infection in solid organ transplant recipients: a review and pooled analysis.
      • Kun H
      • Moore A
      • Mascola L
      • et al.
      Transmission of Trypanosoma cruzi by heart transplantation.
      • Le M
      • Ravin K
      • Hasan A
      • et al.
      Single donor-derived strongyloidiasis in three solid organ transplant recipients: case series and review of the literature.
      • Pinazo MJ
      • Miranda B
      • Rodríguez-Villar C
      • et al.
      Recommendations for management of Chagas disease in organ and hematopoietic tissue transplantation programs in nonendemic areas.
      • Sadjadi SA
      • Damodaran C
      • Sharif M.
      Strongyloides stercoralis infection in transplanted patients.
      • Schwartz BS
      • Mawhorter SD.
      Parasitic infections in solid organ transplantation.

      (See Table 9.)
      Table 9Parasitic Infections
      InfectionRecommendationStrength /level of evidence
      Trypanosoma cruzii (Chagas disease) confirmedDo not utilize.III /C
      Strongyloides stercoralisMay be used with prophylaxis and surveillance post-transplant.IIa /C

      Recommendations regarding central nervous system infections in the donor:
      • Kaul DR
      • Covington S
      • Taranto S
      • et al.
      Solid organ transplant donors with central nervous system infection.
      ,

      Organ Procurement and Transplantation Network. Guidance for Recognizing Central Nervous System Infections in Potential Deceased Organ Donors. 2014; https://optn.transplant.hrsa.gov/resources/guidance/guidance-for-recognizing-central-nervous-system-infections-in-potential-deceased-organ-donors/.

      (See Table 10.)
      Table 10CNS Infections
      InfectionRecommendationStrength /level of evidence
      Viral meningoencephalitisDo not utilize.III /C
      Fungal meningoencephalitisDo not utilize.III /C
      Amebic meningoencephalitisDo not utilize.III /C
      Bacterial meningitisDonors with treated bacterial meningitis are suitable for heart transplantation.IIa /C

      Malignancies in the donor

      Recommendations regarding malignancy in donors:
      • Buell JF
      • Trofe J
      • Hanaway MJ
      • et al.
      Transmission of donor cancer into cardiothoracic transplant recipients.
      • Desai R
      • Collett D
      • Watson CJ
      • Johnson P
      • Evans T
      • Neuberger J.
      Cancer transmission from organ donors-unavoidable but low risk.
      • Garrido G
      • Matesanz R.
      The Spanish National Transplant Organization (ONT) tumor registry.
      • Hornik L
      • Tenderich G
      • Wlost S
      • Zittermann A
      • Minami K
      • Koerfer R.
      Organs from donors with primary brain malignancy: the fate of cardiac allograft recipients.
      • Huang S
      • Tang Y
      • Zhu Z
      • et al.
      Outcomes of organ transplantation from donors with a cancer history.
      • Kauffman HM
      • McBride MA
      • Cherikh WS
      • Spain PC
      • Marks WH
      • Roza AM.
      Transplant tumor registry: donor related malignancies.
      • Zucchini N
      • Fiorentino M
      • D'Errico Grigioni A
      • et al.
      The Italian multiorgan donor cancer screening protocol: 2002-2005 experience.

      (See also Table 11.)
      Table 11Risks and Recommendations Regarding Malignancy (By Risk and Tumor Type) for the Utilization of Donor Hearts
      • Nalesnik MA
      • Woodle ES
      • Dimaio JM
      • et al.
      Donor-transmitted malignancies in organ transplantation: assessment of clinical risk.
      Risk categoryTumor characteristicsRecommended clinical useStrength/level of evidence
      No significant riskBenign tumors in which malignancy is excludedStandard donorIIa /C
      Minimal risk (<0.1% transmission)• Basal cell carcinoma, skin

      • Squamous cell carcinoma, skin without metastases

      • Carcinoma in situ, skin (non-melanoma)

      In situ cervical carcinoma

      In situ vocal cord carcinoma

      • Superficial (noninvasive) papillary carcinoma of bladder (T0N0M0 by the TNM staging system) (nonrenal transplant only)

      • Solitary papillary thyroid carcinoma, ≤0.5 cm

      • Minimally invasive follicular carcinoma, thyroid, ≤ 1.0 cm

      • (Resected) solitary renal cell carcinoma, ≤1.0 cm, well differentiated (Fuhrman 1-2)
      Clinical judgment with informed consentIIa /C
      Low risk (0.1-1% transmission)• (Resected) solitary renal cell carcinoma, >1.0 cm ≤2.5 cm, well differentiated (Fuhrman 1-2)

      • Low grade CNS tumor (WHO grade I or II)

      • Primary CNS mature teratoma

      • Solitary papillary thyroid carcinoma, 0.5-2.0 cm

      • Minimally invasive follicular carcinoma, thyroid, 1.0-2.0 cm

      • History of treated non-CNS malignancy (≥5 years prior) with >99% probability of cure
      Use in recipients at significant risk without transplant. Informed consent requiredIIa /C
      Intermediate risk (1-10% transmission)• Breast carcinoma (stage 0, i.e., carcinoma in situ)

      • Colon carcinoma (stage 0, i.e., carcinoma in situ)

      • (Resected) solitary renal cell carcinoma T1b (4-7 cm) well differentiated (Fuhrman 1-2) stage I

      • History of treated non-CNS malignancy (≥5 years prior) with probability of cure between 90% and 99%
      Use of these donors is generally not recommended. Lifesaving transplant may be acceptable in circumstances where recipient expected survival without transplantation is short (e.g., a few days or less). Informed consent required.IIb /C
      High Risk (>10% transmission)• Malignant melanoma

      • Breast carcinoma >stage 0 (active)

      • Colon carcinoma >stage 0 (active)

      • Choriocarcinoma

      • CNS tumor (any) with ventriculoperitoneal or ventriculoatrial shunt, surgery (other than uncomplicated biopsy), irradiation or extra-CNS metastasis

      • CNS Tumor WHO grade III or IV

      • Leukemia or lymphoma

      • History of melanoma, leukemia or lymphoma, small cell lung/neuroendocrine carcinoma

      • Any other history of treated non-CNS malignancy either (a) insufficient follow-up to predict behavior, (b) considered incurable or (c) with probability of cure <90%

      • Metastatic carcinoma

      • Sarcoma

      • Lung cancer (stages I-IV)

      • Renal cell carcinoma >7cm or stage II-IV

      • Small cell/neuroendocrine carcinoma, any site of origin

      • Active cancer not listed elsewhere
      Use of these donors is discouraged except in rare and extreme circumstances. Informed consent required and consult with oncology may be desired.III /C

      Class IIa

      • 1.
        Donors with non-melanoma skin cancers and low-grade primary central nervous system tumors should be considered favorably as potential donors because the risk of cancer transmission is low. Level of Evidence: C.
      • 2.
        The tumor type, histology, disease stage, disease-free interval, and the recipient's risk of dying on the waiting list should be considered when making decisions regarding the suitability of organs for transplantation. Level of Evidence: C.

      Class IIb

      • 1.
        Donors with a history of melanoma, choriocarcinoma, breast or colon adenocarcinoma, lymphoma, or leukemia are considered at high risk for transmission. Level of Evidence: C.
      • 2.
        There should be high level of suspicion for a metastatic tumor in potential donors with a past history of malignancy who experience a nontraumatic cerebral hemorrhage. In such cases, a thorough thoracic and abdominal exploration is recommended before recovering organs for transplantation, with possible biopsy and pathologic evaluation. Level of Evidence: C.

      Diagnostic studies

      Cardiac biomarkers

      The measurement of biomarkers is an established method of predicting risk for many cardiovascular conditions, including myocardial injury and heart failure, and has drawn considerable interest in the assessment of organ donors. B-type Natriuretic Peptide (BNP), NT-proBNP, and troponin are elevated after brain death, particularly subarachnoid hemorrhage, likely due to increased sympathetic activity and release of catecholamines with associated elevated wall stress and myocardial injury.
      • Tomida M
      • Muraki M
      • Uemura K
      • Yamasaki K.
      Plasma concentrations of brain natriuretic peptide in patients with subarachnoid hemorrhage.
      ,
      • Tung PP
      • Olmsted E
      • Kopelnik A
      • et al.
      Plasma B-type natriuretic peptide levels are associated with early cardiac dysfunction after subarachnoid hemorrhage.

      Recommendations regarding troponin:
      • Anderson JR
      • Hossein-Nia M
      • Brown P
      • Holt DW
      • Murday A.
      Donor cardiac troponin-T predicts subsequent inotrope requirements following cardiac transplantation.
      • Potapov EV
      • Ivanitskaia EA
      • Loebe M
      • et al.
      Value of cardiac troponin I and T for selection of heart donors and as predictors of early graft failure.
      • Freundt M
      • Philipp A
      • Kolat P
      • et al.
      Impact of elevated donor troponin I as predictor of adverse outcome in adult heart transplantation: a single-center experience.
      • Madan S
      • Saeed O
      • Shin J
      • et al.
      Donor troponin and survival after cardiac transplantation: an analysis of the united network of organ sharing registry.

      Class IIb

      • 1.
        Coronary angiography should be considered for potential donors with significantly increased troponin concentrations (with quantitative limits being institution-dependent) depending on clinical context of donor cause of death and risk factors for CAD. Level of Evidence: C.
      • 2.
        Troponin levels may be elevated (with quantitative limits being institution-dependent) following brain death but are not independent reasons to decline a donor. Correlation with echocardiography and clinical scenario is necessary. Level of Evidence: C.

      Recommendation regarding B-type natriuretic peptide (BNP) and NT-proBNP:
      • Dronavalli VB
      • Banner NR
      • Bonser RS.
      Assessment of the potential heart donor: a role for biomarkers?.
      ,
      • Vorlat A
      • Conraads VM
      • Jorens PG
      • et al.
      Donor B-type natriuretic peptide predicts early cardiac performance after heart transplantation.

      Class IIa

      • 1.
        BNP levels may be elevated following brain death but are not independent reasons to decline a donor. Correlation with echocardiography and clinical scenario is necessary. Level of Evidence: C.

      Recommendation for cardiac imaging:
      • Bombardini T
      • Arpesella G
      • Maccherini M
      • et al.
      Medium-term outcome of recipients of marginal donor hearts selected with new stress-echocardiographic techniques over standard criteria.
      • Bombardini T
      • Gherardi S
      • Arpesella G
      • et al.
      Favorable short-term outcome of transplanted hearts selected from marginal donors by pharmacological stress echocardiography.
      • Bombardini T
      • Gherardi S
      • Leone O
      • Sicari R
      • Picano E.
      Transplant of stunned donor hearts rescued by pharmacological stress echocardiography: a "proof of concept" report.
      • Borbely XI
      • Krishnamoorthy V
      • Modi S
      • et al.
      Temporal changes in left ventricular systolic function and use of echocardiography in adult heart donors.
      • Casartelli M
      • Bombardini T
      • Simion D
      • Gaspari MG
      • Procaccio F.
      Wait, treat and see: echocardiographic monitoring of brain-dead potential donors with stunned heart.
      • Dorosz JL
      • Lezotte DC
      • Weitzenkamp DA
      • Allen LA
      • Salcedo EE.
      Performance of 3-dimensional echocardiography in measuring left ventricular volumes and ejection fraction: a systematic review and meta-analysis.
      • Khush KK
      • Nguyen J
      • Goldstein BA
      • McGlothlin DP
      • Zaroff JG.
      Reliability of transthoracic echocardiogram interpretation in potential adult heart transplant donors.
      • Lang RM
      • Badano LP
      • Mor-Avi V
      • et al.
      Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
      • Nair N
      • Gongora E.
      Role of cardiovascular imaging in selection of donor hearts.
      • Picano E
      • Pellikka PA.
      Stress echo applications beyond coronary artery disease.
      • Venkateswaran RV
      • Townend JN
      • Wilson IC
      • Mascaro JG
      • Bonser RS
      • Steeds RP.
      Echocardiography in the potential heart donor.

      Class I

      • 1.
        Echocardiography should be conducted and imaging available for review as part of donor evaluation. Level of Evidence: C.
      • 2.
        Serial echocardiography in donors with initial LV dysfunction after brain death may be useful to identify donors with reversible LV dysfunction. Level of Evidence: C.
      • 3.
        Computed tomography (CT) angiography for coronary artery disease is a reasonable alternative to traditional angiography in some centers. Level of Evidence: C.

      Recommendation for pharmacological stress echocardiography:
      • Bombardini T
      • Gherardi S
      • Arpesella G
      • et al.
      Favorable short-term outcome of transplanted hearts selected from marginal donors by pharmacological stress echocardiography.
      ,
      • Khush KK
      • Nguyen J
      • Goldstein BA
      • McGlothlin DP
      • Zaroff JG.
      Reliability of transthoracic echocardiogram interpretation in potential adult heart transplant donors.
      ,
      • Picano E
      • Pellikka PA.
      Stress echo applications beyond coronary artery disease.

      Class IIa

      • 1.
        Pharmacologic stress echo may be used in the assessment of dysfunctional donor hearts to distinguish between CAD or subclinical cardiomyopathy and reversible left ventricular dysfunction. Level of Evidence: C.

      Recommendation for strain rate imaging:
      • Dandel M
      • Lehmkuhl H
      • Knosalla C
      • Suramelashvili N
      • Hetzer R.
      Strain and strain rate imaging by echocardiography - basic concepts and clinical applicability.
      • Ingul CB
      • Torp H
      • Aase SA
      • Berg S
      • Stoylen A
      • Slordahl SA.
      Automated analysis of strain rate and strain: feasibility and clinical implications.
      • Marwick TH.
      Measurement of strain and strain rate by echocardiography: ready for prime time?.
      • Uematsu M
      • Miyatake K
      • Tanaka N
      • et al.
      Myocardial velocity gradient as a new indicator of regional left ventricular contraction: detection by a two-dimensional tissue Doppler imaging technique.
      • D'Hooge J
      • Heimdal A
      • Jamal F
      • et al.
      Regional strain and strain rate measurements by cardiac ultrasound: principles, implementation and limitations.
      • Edvardsen T
      • Gerber BL
      • Garot J
      • Bluemke DA
      • Lima JA
      • Smiseth OA.
      Quantitative assessment of intrinsic regional myocardial deformation by Doppler strain rate echocardiography in humans: validation against three-dimensional tagged magnetic resonance imaging.
      • Cullen MW
      • Pellikka PA.
      Recent advances in stress echocardiography.

      Class IIa

      • 1.
        Myocardial strain echo may assist to distinguishing between ischemic and stunned myocardium. Level of Evidence: C.

      Recommendation for contrast-enhanced 3D echocardiography:
      • Dorosz JL
      • Lezotte DC
      • Weitzenkamp DA
      • Allen LA
      • Salcedo EE.
      Performance of 3-dimensional echocardiography in measuring left ventricular volumes and ejection fraction: a systematic review and meta-analysis.
      ,
      • Lang RM
      • Badano LP
      • Mor-Avi V
      • et al.
      Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
      ,
      • Nair N
      • Gongora E.
      Role of cardiovascular imaging in selection of donor hearts.
      ,
      • Venkateswaran RV
      • Townend JN
      • Wilson IC
      • Mascaro JG
      • Bonser RS
      • Steeds RP.
      Echocardiography in the potential heart donor.

      Class IIa

      • 1.
        Use of echo contrast agents should be considered to improve myocardial visualization when images are suboptimal. Level of Evidence: C.

      Recommendation for cardiac magnetic resonance imaging (MRI):
      • Jenkins C
      • Moir S
      • Chan J
      • Rakhit D
      • Haluska B
      • Marwick TH.
      Left ventricular volume measurement with echocardiography: a comparison of left ventricular opacification, three-dimensional echocardiography, or both with magnetic resonance imaging.
      • Chaves AH
      • Cava JR
      • Simpson P
      • Hoffman GM
      • Samyn MM.
      Infant cardiac magnetic resonance imaging using oscillatory ventilation: safe and effective.
      • Camarda J
      • Saudek D
      • Tweddell J
      • et al.
      MRI validated echocardiographic technique to measure total cardiac volume: a tool for donor-recipient size matching in pediatric heart transplantation.

      Class IIb

      • 1.
        Cardiac MRI is a useful option for visualization of structure and function of donor hearts, but availability and ease of performance limit its use. Level of Evidence: C.

      Coronary angiography

      While there are no evidence-based findings with respect to coronary angiography, it is reasonable to consider performing this test in donors who are considered to have high risk for coronary artery disease.

      Recommendation for coronary angiography

      Class IIb

      • 1.
        A coronary angiogram should be obtained in donors at high risk of CAD, such as age >45 years and those with diabetes or tobacco use or illicit drug use (e.g., cocaine, amphetamine, methamphetamine). Level of Evidence: C.

      The rational use of donor hearts meeting extended criteria

      Utilization of extended-criteria donor hearts has the aim to expand use while mitigating recipient risk. Considerable debate exists on how to define “extended criteria” with the greatest emphasis on traditional risk factors such as increased donor age, left ventricular dysfunction, left ventricular hypertrophy, and prolonged ischemic time.
      • Tomida M
      • Muraki M
      • Uemura K
      • Yamasaki K.
      Plasma concentrations of brain natriuretic peptide in patients with subarachnoid hemorrhage.
      ,
      • Messer S
      • Lannon J
      • Wong E
      • et al.
      The potential of transplanting hearts from donation after circulatory determined death (DCD) donors within the United Kingdom.
      ,
      • Noterdaeme T
      • Detry O
      • Hans MF
      • et al.
      What is the potential increase in the heart graft pool by cardiac donation after circulatory death?.
      These risk factors, as well as others (diabetes, hypertension, death due to stroke), have been evaluated in single-center studies and in analyses of large databases such as the UNOS registry.
      • Weiss ES
      • Allen JG
      • Kilic A
      • et al.
      Development of a quantitative donor risk index to predict short-term mortality in orthotopic heart transplantation.
      ,
      • Khush KK.
      Donor selection in the modern era.
      However, careful evaluation of the data would suggest that a closer look is warranted.

      Recommendation for the utilization of extended-criteria donor hearts:
      • Weiss ES
      • Allen JG
      • Kilic A
      • et al.
      Development of a quantitative donor risk index to predict short-term mortality in orthotopic heart transplantation.
      ,
      European Directorate for the Quality of Medicines and Healthcare
      Guide to the Quality and Qafety of Organs for Transplantation.
      ,
      • Khush KK.
      Donor selection in the modern era.
      • Dorent R
      • Gandjbakhch E
      • Goéminne C
      • et al.
      Assessment of potential heart donors: a statement from the French heart transplant community.
      • Miranda B
      • Segovia C
      • Sanchez M
      • Felipe C
      • Naya MT
      • Matesanz R.
      Evolution of organ procurement and donor characteristics in Spain.

      Class IIa

      • 1.
        For recipients who are challenging to match (e.g., highly sensitized patients, patients on temporary circulatory support, VAD complications) consideration of an extended-criteria donor may be lifesaving. Acceptance of such donors should be considered in the context of concurrent risk factors. Level of Evidence: C.

      Recommendation regarding the use of donor hearts with low ejection fraction:
      • Lund LH
      • Khush KK
      • Cherikh WS
      • et al.
      The registry of the International Society for Heart and Lung Transplantation: thirty-fourth adult heart transplantation report-2017; focus theme: allograft ischemic time.
      ,
      • Roig E
      • Almenar L
      • Crespo-Leiro M
      • et al.
      Heart transplantation using allografts from older donors: multicenter study results.
      ,
      • Reed RM
      • Netzer G
      • Hunsicker L
      • et al.
      Cardiac size and sex-matching in heart transplantation: size matters in matters of sex and the heart.
      ,
      • Bergenfeldt H
      • Stehlik J
      • Hoglund P
      • Andersson B
      • Nilsson J.
      Donor-recipient size matching and mortality in heart transplantation: influence of body mass index and gender.
      ,
      • Wever Pinzon O
      • Stoddard G
      • Drakos SG
      • et al.
      Impact of donor left ventricular hypertrophy on survival after heart transplant.
      ,
      • Kuppahally SS
      • Valantine HA
      • Weisshaar D
      • et al.
      Outcome in cardiac recipients of donor hearts with increased left ventricular wall thickness.
      ,
      • Khush KK
      • Menza R
      • Nguyen J
      • Zaroff JG
      • Goldstein BA.
      Donor predictors of allograft use and recipient outcomes after heart transplantation.
      ,
      • Grauhan O
      • Siniawski H
      • Dandel M
      • et al.
      Coronary atherosclerosis of the donor heart–impact on early graft failure.
      ,
      • Bombardini T
      • Arpesella G
      • Maccherini M
      • et al.
      Medium-term outcome of recipients of marginal donor hearts selected with new stress-echocardiographic techniques over standard criteria.
      ,
      • Bombardini T
      • Gherardi S
      • Leone O
      • Sicari R
      • Picano E.
      Transplant of stunned donor hearts rescued by pharmacological stress echocardiography: a "proof of concept" report.
      ,
      • Borbely XI
      • Krishnamoorthy V
      • Modi S
      • et al.
      Temporal changes in left ventricular systolic function and use of echocardiography in adult heart donors.
      ,
      • Khush KK.
      Donor selection in the modern era.
      ,
      • Zaroff JG
      • Babcock WD
      • Shiboski SC.
      The impact of left ventricular dysfunction on cardiac donor transplant rates.
      • Dujardin KS
      • McCully RB
      • Wijdicks EF
      • et al.
      Myocardial dysfunction associated with brain death: clinical, echocardiographic, and pathologic features.
      • Madan S
      • Saeed O
      • Vlismas P
      • et al.
      Outcomes after transplantation of donor hearts with improving left ventricular systolic dysfunction.
      • Kono T
      • Nishina T
      • Morita H
      • Hirota Y
      • Kawamura K
      • Fujiwara A.
      Usefulness of low-dose dobutamine stress echocardiography for evaluating reversibility of brain death-induced myocardial dysfunction.
      • Garcia-Dorado D
      • Andres-Villarreal M
      • Ruiz-Meana M
      • Inserte J
      • Barba I
      Myocardial edema: a translational view.
      • Kobashigawa J
      • Khush K
      • Colvin M
      • et al.
      Report from the American Society of Transplantation Conference on donor heart selection in adult cardiac transplantation in the United States.
      • Kransdorf EP
      • Kittleson MM
      • Benck LR
      • et al.
      Predicted heart mass is the optimal metric for size match in heart transplantation.
      • Mehra MR
      • Canter CE
      • Hannan MM
      • et al.
      The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: a 10-year update.
      • Ziaziaris W
      • Chew HC
      • Dhital K
      • Hayward C
      • Pleass H
      • Macdonald P.
      Size and gender matching in heart transplantation – optimizing donor utilization in an era of changing donor and recipient characteristics.
      Organ Procurement and Transplantation Network. Deceased Donors Recovered in the U.S. by Donor Age; 2018.
      • Estevez-Loureiro R
      • Paniagua-Martin MJ
      • Calviño-Santos R
      • et al.
      Prevalence of donor-transmitted coronary artery disease and its influence on heart transplant outcomes.
      • Pinto CS
      • Prieto D
      • Antunes MJ.
      Coronary artery bypass graft surgery during heart transplantation.
      • Abid Q
      • Parry G
      • Forty J
      • Dark JH.
      Concurrent coronary grafting of the donor heart with left internal mammary artery: 10-year experience.
      • Marelli D
      • Laks H
      • Bresson S
      • et al.
      Results after transplantation using donor hearts with preexisting coronary artery disease.
      • Pawale A
      • Tang GH
      • Milla F
      • Pinney S
      • Adams DH
      • Anyanwu AC.
      Bench mitral valve repair of donor hearts before orthotopic heart transplantation.
      • Floerchinger B
      • Oberhuber R
      • Tullius SG.
      Effects of brain death on organ quality and transplant outcome.
      • Mohamedali B
      • Bhat G
      • Zelinger A.
      Frequency and pattern of left ventricular dysfunction in potential heart donors: Implications regarding use of dysfunctional hearts for successful transplantation.
      • Sztark F
      • Thicoïpé M
      • Lassié P
      • Petitjean ME
      • Dabadie P.
      Mitochondrial energy metabolism in brain-dead organ donors.
      • Khush KK
      • Zaroff JG
      • Nguyen J
      • Menza R
      • Goldstein BA.
      National decline in donor heart utilization with regional variability: 1995-2010.
      • Chen CW
      • Sprys MH
      • Gaffey AC
      • et al.
      Low ejection fraction in donor hearts is not directly associated with increased recipient mortality.

      (See also Table 12).
      Table 12Recommendations for the Use of Donor Hearts with Ventricular Abnormalities
      Donor concernRecommended interventionOutcomesStrength/level of evidence
      LVEF <45%Dobutamine stress echocardiography, repeat transthoracic echocardiography (TTE)Ventricular wall augmentation predicts improvement in LVEFIIa /C
      LVH >1.4 cmNonePoor outcomes if concurrent donor age >55 years and ischemic time 4 hours
      • Wever Pinzon O
      • Stoddard G
      • Drakos SG
      • et al.
      Impact of donor left ventricular hypertrophy on survival after heart transplant.
      IIa /B
      Donor/recipient size mismatchCalculate predicted heart mass (pHM)Lower survival with pHM difference >10%-15%
      • Reed RM
      • Netzer G
      • Hunsicker L
      • et al.
      Cardiac size and sex-matching in heart transplantation: size matters in matters of sex and the heart.
      IIa /B
      Donor CADPercutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG)Slightly lower survival in 1 vessel disease, worse survival in multivessel disease
      • Grauhan O
      • Siniawski H
      • Dandel M
      • et al.
      Coronary atherosclerosis of the donor heart–impact on early graft failure.
      IIa/C

      Class IIa

      • 1.
        Hearts with an initially low LVEF, especially from young brain-dead donors, should be aggressively pursued. It is reasonable to repeat echocardiographic assessments to determine improvement of such donors. Level of Evidence: C.
      • 2.
        It is reasonable to consider a heart with reduced but improved LVEF in the setting of a young donor especially for recipients with an urgent clinical need (e.g., INTERMACS Class 1 or 2), balancing risks and benefits. Level of Evidence: C.

      Recommendation regarding the use of donor hearts with valvular abnormalities
      • Zaroff JG
      • Rosengard BR
      • Armstrong WF
      • et al.
      Consensus conference report: maximizing use of organs recovered from the cadaver donor: cardiac recommendations, M