Heart transplantation allograft survival: donor atherosclerotic disease risk vs coronary angiography.

BACKGROUND AND AIMS: Guidelines recommend coronary angiography in heart donors at increased risk of coronary artery disease (age >45 years, diabetes, tobacco, or drug use), but the yield is often low. The aim of this study was to evaluate the importance of estimated donor 10-year atherosclerotic cardiovascular disease (ASCVD) risk (≤5% vs >5%) vs coronary angiogram testing for predicting short- to mid-term survival free from graft failure in adult heart transplant recipients. METHODS: Adult heart transplant recipients from the United Network for Organ Sharing database 18 October 2018, to 31 December 2023, who received hearts from donors aged >40 years, or >30 years with diabetes, hypertension, or smoking were included. The risk of a composite outcome (death or graft failure) up to 4 years post-transplant was assessed by multivariable Cox regression. RESULTS: Of 5152 recipients, 86.1% received hearts from donors with ASCVD risk ≤5%. Angiography was performed in 76.1% donors with ASCVD ≤5% and 92.9% of donors with ASCVD >5%. Using donors with ASCVD ≤5% and angiography as the reference group (n = 3378), adjusted hazard ratios for the composite outcome were .91 [95% confidence interval (CI) .74-1.11] for ASCVD ≤5% without angiography (n = 1060); 1.30 (95% CI 1.05-1.60) for ASCVD >5% with angiography (n = 663), and .88 (95% CI .36-2.13) for ASCVD >5% without angiography (n = 51). Findings were consistent when limited to donors meeting current angiography guideline criteria. CONCLUSIONS: Estimated ASCVD risk >5% independently predicts worse transplant outcomes, while routine coronary angiography in low-risk donors (ASCVD ≤5%) does not. These findings suggest that ASCVD-based risk stratification may be more useful than angiography as the initial step in donor heart selection.