Fatal early graft failure in a heart transplant recipient with occult multivessel coronary artery disease in a young donor: implications for donor evaluation

Primary graft dysfunction (PGD) represents the leading cause of early mortality following heart transplantation. Among the associated factors, donor characteristics—particularly the presence of undiagnosed coronary artery disease—may play a relevant role. Donor evaluation is typically based on clinical assessment and echocardiographic findings, which may be insufficient to detect subclinical coronary disease, especially in young donors. We report the case of a 52-year-old patient with advanced dilated cardiomyopathy who underwent orthotopic heart transplantation. The donor was a 27-year-old male with no known medical history, evaluated at a secondary-level hospital using electrocardiography and transthoracic echocardiography, both without pathological findings. Following transplantation, the recipient developed severe hemodynamic instability progressing to primary graft dysfunction. Initially, hyperacute rejection was considered in the differential diagnosis given the early and severe graft dysfunction. A postoperative electrocardiogram reportedly showed no ischemic changes; however, a marked elevation in troponin I (80 ng/mL) was documented, suggesting significant myocardial injury. A transesophageal echocardiogram demonstrated global biventricular systolic dysfunction. Mechanical circulatory support with venoarterial extracorporeal membrane oxygenation and intra-aortic balloon pump was required. Despite intensive management, the patient developed multiorgan failure and died within the first 24 h postoperatively. Postmortem histopathological examination of the graft revealed severe multivessel atherosclerotic coronary artery disease that had not been previously diagnosed. This case suggests a possible association between undiagnosed donor coronary artery disease and early graft failure, while highlighting the limitations of conventional donor evaluation, particularly in detecting non-calcified coronary lesions. These findings underscore the need for cautious interpretation of donor assessment, especially in resource-limited settings.