Coronary angiography in heart transplants from donors older than 40: a Eurotransplant study

BACKGROUND AND AIMS: The increasing age of heart donors in Europe raises concerns about undetected coronary artery disease (CAD), a contributor to early graft dysfunction and long-term complications. This study examined the association between donor coronary angiography (CA) and heart transplant utilization, particularly in donors aged >40 years. METHODS: A total of 20 681 donor heart offers reported to Eurotransplant between 2004 and 2020 were analysed. The use of CA, donor characteristics, and acceptance rates were assessed. CAD status was imputed for donors without angiography using logistic regression based on clinical risk factors. Transplantation probabilities were modelled using observed and imputed CAD severity to explore potential differences under a scenario of broader CA availability. RESULTS: CA was performed in 23.5% of cases, predominantly in older donors and those with cardiovascular risk factors. Among donors with CA, 37.5% had CAD, which was significantly associated with age, male sex, hypertension, and smoking. Donors with normal CA findings had lower odds of rejection compared with those without CA (odds ratio 0.36, P < .0001). In a counterfactual model, broader CA availability in donors aged >40 years was associated with a higher estimated transplant utilization (56.4%-67.1%), corresponding to a model-based increase of ∼535 transplants. CONCLUSIONS: In this observational cohort, CA availability was associated with differences in donor heart utilization, particularly when findings were normal or showed non-significant CAD. These findings suggest that angiographic information may reduce diagnostic uncertainty and support clinical decision-making in older donors. A risk-adapted, resource-sensitive approach to CA use is warranted.