BACKGROUND: The decline in the number of suitable donor hearts has led to an increasing interest in the use of previously unacceptable donors. In the United Kingdom, if one centre declines a donor heart on medical grounds it may be offered to other centres. This multi-centre study aimed to evaluate the outcome of recipients of donor hearts considered medically unsuitable for transplantation by one centre that were used in other centres. METHODS: Between April 1998 and March 2003, ninety-three donor hearts (group A) were transplanted, after being considered medically unsuitable for transplantation by another centre. During the same period, 723 hearts (group B) were transplanted in the UK using donors not previously rejected. Data on the donors and recipients was obtained from the UK transplant database. Comparative analysis on the two groups was performed using SPSS 11.5 for Windows. RESULTS: The characteristics of recipients were similar in both groups. The main reasons for refusal of hearts are listed below. In most cases there was more than one reason for refusing the donor heart. We did not find significant differences in the post-operative mortality (up to 30 days), ICU and hospital stay and cardiac cause of death between the two groups. Kaplan-Meier survival curves showed no significant difference in the long-term survival, with Log Rank test = 0.30. CONCLUSION: This study demonstrates that some hearts declined on medical grounds by one centre can safely be transplanted and should be offered out nationally. The use of these hearts was useful to expand the scarce donor pool and there does not seem to be a justification for denying recipients this extra source of organs

A Anyanwu

Ali Machaal

C Blanche

D Wheeldon

EV Potapov

Jim Barnard

M Boucek

M Loebe

N Khasati

Nizar Yonan

Noman H Khasati

S Stoica

T Omoto

V Topkara

English

PubMed

Abstract Background The decline in the number of suitable donor hearts has led to an increasing interest in the use of previously unacceptable donors. In the United Kingdom, if one centre declines a donor heart on medical grounds it may be offered to other centres. This multi-centre study aimed to evaluate the outcome of recipients of donor hearts considered medically unsuitable for transplantation by one centre that were used in other centres. Methods Between April 1998 and March 2003, ninety-three donor hearts (group A) were transplanted, after being considered medically unsuitable for transplantation by another centre. During the same period, 723 hearts (group B) were transplanted in the UK using donors not previously rejected. Data on the donors and recipients was obtained from the UK transplant database. Comparative analysis on the two groups was performed using SPSS 11.5 for Windows. Results The characteristics of recipients were similar in both groups. The main reasons for refusal of hearts are listed below. In most cases there was more than one reason for refusing the donor heart. We did not find significant differences in the post-operative mortality (up to 30 days), ICU and hospital stay and cardiac cause of death between the two groups. Kaplan-Meier survival curves showed no significant difference in the long-term survival, with Log Rank test = 0.30. Conclusion This study demonstrates that some hearts declined on medical grounds by one centre can safely be transplanted and should be offered out nationally. The use of these hearts was useful to expand the scarce donor pool and there does not seem to be a justification for denying recipients this extra source of organs.</p

Barnard Jim

Machaal Ali

Khasati Noman H

Yonan Nizar

Directory of Open Access Journals

Journal of Cardiothoracic Surgery

Donor heart selection: the outcome of "unacceptable" donors

Background: The decline in the number of suitable donor hearts has led to an increasing interest in the use of previously unacceptable donors. In the United Kingdom, if one centre declines a donor heart on medical grounds it may be offered to other centres. This multi-centre study aimed to evaluate the outcome of recipients of donor hearts considered medically unsuitable for transplantation by one centre that were used in other centres. Methods: Between April 1998 and March 2003, ninety-three donor hearts (group A) were transplanted, after being considered medically unsuitable for transplantation by another centre. During the same period, 723 hearts (group B) were transplanted in the UK using donors not previously rejected. Data on the donors and recipients was obtained from the UK transplant database. Comparative analysis on the two groups was performed using SPSS 11.5 for Windows. Results: The characteristics of recipients were similar in both groups. The main reasons for refusal of hearts are listed below. In most cases there was more than one reason for refusing the donor heart. We did not find significant differences in the post-operative mortality (up to 30 days), ICU and hospital stay and cardiac cause of death between the two groups. Kaplan-Meier survival curves showed no significant difference in the long-term survival, with Log Rank test = 0.30. Conclusion: This study demonstrates that some hearts declined on medical grounds by one centre can safely be transplanted and should be offered out nationally. The use of these hearts was useful to expand the scarce donor pool and there does not seem to be a justification for denying recipients this extra source of organs. © 2007 Khasati et al; licensee BioMed Central Ltd

Khasati, Noman H.

Machaal, Ali

Barnard, Jim

Yonan, Nizar

The University of Manchester - Institutional Repository

Donor heart selection: The outcome of "unacceptable" donors

Springer - Publisher Connector

BioMed CentralJournal of Cardiothoracic Surgery
ssOpen AcceResearch article
Donor heart selection: the outcome of "unacceptable" donors
Noman H Khasati*, Ali Machaal, Jim Barnard and Nizar Yonan
Address: Cardiothoracic Surgery Department, Wythenshawe Hospital, Manchester, UK
Email: Noman H Khasati* - nkhasati@yahoo.com; Ali Machaal - alimachaal@msn.com; Jim Barnard - jamesbbarnard@doctors.org.uk; 
Nizar Yonan - nyonan@fs1.with.man.ac.uk
* Corresponding author    
Abstract
Background: The decline in the number of suitable donor hearts has led to an increasing interest
in the use of previously unacceptable donors. In the United Kingdom, if one centre declines a donor
heart on medical grounds it may be offered to other centres. This multi-centre study aimed to
evaluate the outcome of recipients of donor hearts considered medically unsuitable for
transplantation by one centre that were used in other centres.
Methods: Between April 1998 and March 2003, ninety-three donor hearts (group A) were
transplanted, after being considered medically unsuitable for transplantation by another centre.
During the same period, 723 hearts (group B) were transplanted in the UK using donors not
previously rejected. Data on the donors and recipients was obtained from the UK transplant
database. Comparative analysis on the two groups was performed using SPSS 11.5 for Windows.
Results: The characteristics of recipients were similar in both groups. The main reasons for refusal
of hearts are listed below. In most cases there was more than one reason for refusing the donor
heart. We did not find significant differences in the post-operative mortality (up to 30 days), ICU
and hospital stay and cardiac cause of death between the two groups. Kaplan-Meier survival curves
showed no significant difference in the long-term survival, with Log Rank test = 0.30.
Conclusion: This study demonstrates that some hearts declined on medical grounds by one
centre can safely be transplanted and should be offered out nationally. The use of these hearts was
useful to expand the scarce donor pool and there does not seem to be a justification for denying
recipients this extra source of organs.
Background
Using donor hearts outside the conventional selection cri-
teria provides a useful expansion to the donor pool. The
data on the use of borderline hearts was not unequivocal.
Several studies [1-5] have shown that survival with mar-
ginal hearts can be similar to that obtained with standard
donor hearts. Other studies [6-10] however, showed
increased early or late postoperative mortality and mor-
bidity. A study of recipients of donor hearts declined by
our centre on medical grounds and used by another centre
showed that the survival was lower than standard donors
[6]. This retrospective multi-centre study aimed to evalu-
ate the outcome of recipients of donor hearts considered
medically unsuitable for transplantation by one centre,
but then were used by other centres in the United King-
dom.
Published: 17 February 2007
Journal of Cardiothoracic Surgery 2007, 2:13 doi:10.1186/1749-8090-2-13
Received: 27 October 2006
Accepted: 17 February 2007
This article is available from: http://www.cardiothoracicsurgery.org/content/2/1/13
© 2007 Khasati et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5
(page number not for citation purposes)
Journal of Cardiothoracic Surgery 2007, 2:13 http://www.cardiothoracicsurgery.org/content/2/1/13Patients and methods
The selection of the donor heart can sometimes be diffi-
cult and subjective despite the guidelines for acceptance of
cardiothoracic organs (Table 1). If one centre considers a
donor heart medically unsuitable, it may be offered to
other centres through UK Transplant using the relevant
Cardiac or Lung Centre Rota [11], but it is generally
viewed with caution. In this study, adult heart recipients
undergoing heart transplantation between April 1998 to
March 2003 were analyzed. We separated recipients into 2
groups based on the donor profiles. Group A consisted of
recipients of donor hearts considered medically unsuita-
ble for transplantation by one centre, but then accepted
and transplanted in another centre in the UK. Group B
comprised patients, who received donor hearts not previ-
ously rejected. Donor and recipient information was
extracted from the United Kingdom Cardiothoracic Trans-
plant Audit database. The post-operative mortality (up to
30 days), ICU stay, hospital stay and survival, were stud-
ied in both groups. Donor and recipient characteristics
were compared with the X2 test (categorical data) or the
Kruskal-Wallis test (continuous variables). All mean val-
ues are expressed ± the standard deviation from the mean.
Survival curves were estimated using standard Kaplan-
Meier actuarial analysis. We defined significance as p ≤
0.05. We performed statistical analysis using SPSS 11.5 for
Windows.
Results
In the period from April 1998 to March 2003, ninety-three
donor hearts (group A) were transplanted in the UK, after
being considered medically unsuitable for transplantation
by another centre. During the same period, 723 hearts
(group B) were transplanted in the UK using donors not
previously rejected.
The characteristics of recipients were similar in both
groups (Table 2). Recipient age was 49.7 ± 10.5 and 47.14
± 11.9 for groups A and B respectively. Ischemic heart dis-
ease was present in 40% of the patients in group A and 35
% of patients in group B. The severity of the recipient con-
dition (NYHA class, being in hospital, the use of Inotropes
and intraaortic balloon pump) was similar in the two
groups. Only 1% of the recipients in each group had Left
Ventricular Assist Device preoperatively (one patient in
group A and 8 in group B). The percentage of patients with
Donor/Recipient weight ≤ 0.7 was 15% in group A and
38% in group B. Donor hearts refused primarily because
of the size mismatch were not included in group A. The
ischemic time was 217.09 ± 53.1 for group A and 191.43
± 57.7 for group B.
The main reasons for refusal of hearts are listed in Table 3.
In most cases there was more than one reason for refusing
the donor heart. Coronary Angiography and Echocardiog-
raphy was not performed routinely, and we do not have
any data regarding a refusal based on echocardiographic
information. There was no significant difference in the 30-
day mortality (13.6 % in group A versus 12.9 in group B);
ICU and hospital stay (2.3 ± 2.9 and 25.3 ± 15.7 in group
A and 4.1 ± 8.5 and 26.0 ± 17.6 in group B respectively)
between the two groups. 30% of the patients in group A
and 22% in group B recipients died of cardiac causes
(Table 4). Early graft dysfunction was the primary cause of
death in 75% of cardiac deaths in group A and 69% in
group B. Kaplan-Meier survival curves showed no signifi-
cant difference in the long term survival, with Log Rank
test = 0.30 (fig. 1)
Discussion
All cardiothoracic organs donated in the United Kingdom
or Republic of Ireland is offered to the transplant units
according UK Transplant Organ Sharing Scheme Operat-
ing Principles for Cardiothoracic Transplant Units in the
UK and Republic of Ireland. The selection of the donor
hearts can be difficult and subjective. The decline in the
number of suitable donor hearts has led to an increasing
interest in the use of previously unacceptable donors. The
data on the use of borderline hearts was not unequivocal.
Several studies [1-5] have shown the safety of the use of
Table 1: Donor heart suitability criteria
Age Up to 65 years
Size compatibility Height ± 15%, weight ± 25%
Inotropic support: Dopamine 10 mcgs/kg/min or Noradrenalin 10 ml/hr (4 mg in 50 mls)
Filling pressures Normal BP, CVP10, PAWP 15
ECG No LVH, No left axis deviation, ST/T changes can appear following BSD
CXR Normal cardiac size, contour and normal cardiothoracic ratio
Infections Acceptable if treated with the appropriate antibiotics. Viral meningitis is not acceptable. HIV-contraindication, Hepatitis C – 
acceptable for Hep C positive recipients
Past Medical History Angina, Hypertension, Hypercholesterolemia-contraindications
Smoking Acceptable up to 20 pack years
Cardio toxic drugs No intake of amphetamines, cocaine, and tricyclic antidepressants
Tumours Brain tumours may be acceptable according to typePage 2 of 5
(page number not for citation purposes)
Journal of Cardiothoracic Surgery 2007, 2:13 http://www.cardiothoracicsurgery.org/content/2/1/13borderline donor hearts, especially if invasively evaluated
and resuscitated. Other studies [6-10] however showed
increased early or late postoperative mortality and mor-
bidity. A multi centre study by the United Kingdom Car-
diothoracic Transplant Audit steering group showed a
definite effect of suboptimal donor quality with 12%
decrease in 1-year survival[7]. A study by Hetzer group
from Berlin, found a significant increase in long-term car-
diac morbidity due to more focal coronary stenosis in
group of recipients of older donors8. Topkara et al found
that increased donor age is an independent predictor of
reduced long-term survival[9]. A retrospective study of
recipients of donor hearts declined by our centre showed
that the survival was lower than standard donors[6].
The shortage of organs necessitates pushing the bounda-
ries of the guidelines. This has translated into harvesting
of older donor hearts, from more unstable donors as well
as from more distant locations. Of utmost importance is
that when the decision is made to proceed with cardiac
transplantation, the risk/benefit ratio associated with car-
diac transplantation in that particular patient must be
weighed against the mortality and morbidity risk while
remaining on the heart transplant waiting list. Therefore,
decisions need to be made on an individual basis. Despite
the liberation of the criteria for suitability for donation,
many surgeons continue to be conservative in accepting
potentially usable organs. If one centre considers a donor
heart medically unsuitable, it may be offered to other cen-
tres through UKT using the relevant Cardiac or Lung Cen-
tre Rota, but it is generally viewed with caution. Some
surgeons transplant borderline hearts to high-risk recipi-
ents, because they feel high-risk recipients have the greater
marginal benefit from these hearts. Others transplant
these organs to low risk recipients to reduce the overall
risk as the data from United Kingdom Cardiothoracic
Transplant Audit steering show that recipient risk is the
overriding determinant of immediate post-transplant sur-
vival [7]. In our Multi-centre study rejected organs were
transplanted to both high and low risk recipients.
The definition of "unacceptable donors" in this study is
different from conventional "borderline hearts" in other
studies. It does not follow strict criteria and cut-off points
for age, smoking, inotropic support and Haemodynamic
parameters. Decisions to reject or accept these organs were
Table 3: Reasons Why Hearts Were Declined by first centre (n = 93).
Primary Reason Secondary Reason
Inotropic Support * (%) 23.6 4.3
Haemodynamic Instability†(%) 10.7 8.6
ECG Changes‡ (%) 10.7 5.3
Age§(%) 5.3 12.9
Past Medical History (%) 16.1 13.9
Abnormal CXR††(%) 4.3 3.2
Smoking ‡‡(%) 6.5 38.7
Other# (%) 22.8 13.1
* Dopamine >10 μg/kg/min or noradrenalin >0.2 μg/kg/min or adrenaline >0.5 μg/kg/min.
† High filling pressures and low systemic blood pressure.
‡ Abnormal rhythm, bundle branch block, or ST wave changes.
§  Up to a maximum of 65 years.
†† Abnormal cardiac size/cardiothoracic ratio or pulmonary oedema.
‡‡ Up to 20 pack-years (i.e. 1 pack/d for 20 years).
# Cerebral astrocytoma grade IV, brain tumour with unknown histological findings, hypernatremia and hyperkalemia of unknown cause and 
significant history of drug abuse.
Table 2: Recipient Characteristics.
Group A Group B
Recipient age (y) 49.7 ± 10.5 47.14 ± 11.9
Recipient BMI 25.2 ± 4.8 25.7 ± 4.2
Donor/Recipient weight ≤ 0.7 15% of the cases 38 % of the cases
Ischemic time (min) 217.09 ± 53.1 191.43 ± 57.7
IHD recipient (%) 40 35
Recipient in hospital (%) 19 22
Recipient IABP (%) 3.3 4.4
Recipient in NYHA 4 31.4% 30.8%
BMI – Body Mass Index; IHD – Ischemic Heart Disease; IABP-Intra-Aortic Balloon Pump.Page 3 of 5
(page number not for citation purposes)
Journal of Cardiothoracic Surgery 2007, 2:13 http://www.cardiothoracicsurgery.org/content/2/1/13made on a relative basis with some subjectivity. The pres-
ence of multiple centres and organ-sharing scheme pro-
vides a positive backup for the best usage of available
organs. Some organs will be wasted, if not offered to other
centres because of their questionable quality. Our results
showed no significant difference in the 30-day mortality,
ICU and hospital stay and 5-year survival between the two
groups. Although the donors in this study were different
from conventional "borderline hearts", our results con-
firm the findings of the studies, which showed that the
outcome with marginal hearts is similar to that obtained
with standard donor hearts. In conclusion, our study
showed that, hearts declined on medical grounds by one
centre can be safely transplanted and should be offered
out nationally. The use of these hearts was useful to
expand the scarce donor pool and there does not seem to
be a justification for denying recipients this extra source of
organs. Further work should be done to assess the longer-
term results and the quality of life of patients receiving
these hearts.
Kaplan – Meier curvesFigure 1
Kaplan – Meier curves. Group A – recipients of " unacceptable hearts", Group B – recipients of standard donors.
Table 4: Outcome.
Group A Group B P
30 day mortality 13.6 12.9 0.5
ICU stay 2.3 ± 2.9 4.1 ± 8.5 0.07
Hospital stay 25.3 ± 15.7 26.0 ± 17.6 0.2
Cardiac cause of death 30% 22% 0.4Page 4 of 5
(page number not for citation purposes)
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Acknowledgements
We would like to thank Julie Hussey the UK Transplant Statistics Depart-
ment and the transplant coordinators at Wythenshawe Hospital for their 
help in collecting the data for this paper.
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Crossref

A: Should recipient risk be a factor in choosing recipients for suboptimal donor hearts: a multiinstitutional study. Transplant Proc

Donor Heart Selection: Wythenshawe Experience. Transplant Proc

Effect of donor age on longterm survival following cardiac transplantation.

L: Donor shortage: use of the dysfunctional donor heart. J Heart Lung Transplant

Large S: Swan-Ganz catheter assessment of donor hearts: outcome of organs with borderline hemodynamics. J Heart Lung Transplant

Large S: Using &quot;unsuitable&quot; hearts for transplantation.

Medium-term results of heart transplantation using donors over 63 years of age. Transplantation

Medium-term results of heart transplantation using older donor organs. J Heart Lung Transplant

Risk factor analysis of orthotopic heart transplantation. Asian Cardiovasc Thorac Ann

Trento A: Heart transplantation with donors fifty years of age and older. J Thorac Cardiovasc Surg

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Donor heart selection: the outcome of "unacceptable" donors

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