Stress Echocardiography as a Gatekeeper to Donation in Aged Marginal Donor Hearts: Anatomic and Pathologic Correlations of Abnormal Stress Echocardiography Results Ornella Leone, MD, a Sonia Gherardi, MD, b Luigi Targa, MD, c Emilio Pasanisi, MD, d Piero Mikus, MD, e Piero Tanganelli, MD, f Massimo Maccherini, MD, g Giorgio Arpesella, MD, e Eugenio Picano, d and Tonino Bombardini, MD, PhD d Background: Owing to the shortage of donor hearts, the criteria for acceptance have been considerably expanded. Pharmacologic stress echocardiography is highly accurate in identifying prognostically significant coronary artery disease, but brain death and catecholamine storm in potential heart donors may substantially alter the cardiovascular response to stress. This study assessed correlates of an abnormal resting/stress echocardiography results in potential donors. Methods: From April 2005 to December 2007, 18 marginal candidate donors (9 men) aged 58  5 years were initially enrolled. After legal declaration of brain death, all marginal donors underwent bedside echocardiography, with baseline and (when resting echocardiography was normal) dipyridamole (0.84 mg/kg in 6 min) or dobutamine (up to 40 g/kg/min) stress echo. Non-eligible hearts (with abnormal rest or stress echo findings) were excluded and underwent cardioautoptic verification. Results: Resting echocardiography showed wall motion abnormalities in 5 patients (excluded from donation). Stress echocardiography was performed in the remaining 13 (dipyridamole in 11; dobutamine in 2). Results were normal in 7, of which 6 were uneventfully transplanted in marginal recipients. Results were abnormal in 6, and autoptic verification performed showed coronary artery disease in 5, and initial cardiomyopathy in 1. Conclusions: Bedside pharmacologic stress echocardiography can safely be performed in candidate heart donors, is able to unmask occult coronary artery disease or cardiomyopathy, and shows potential to extend donor criteria in heart transplantation. Further experience with using marginal donors is needed before exact guidelines can be established. J Heart Lung Transplant 2009;28:1141–9. Copyright © 2009 by the International Society for Heart and Lung Transplantation. Heart transplant is a treatment for heart failure that does not respond to medication, and its efficacy has been established. Unfortunately, organ donation is a limiting factor in this life-saving procedure. Selection of the organs that will be transplanted is based on two factors. The first is a suitable donor, according to standard guidelines. 1 For the heart, an additional criterion is age. This factor is not that important by itself, but it is factor because of the associated age-dependent risk for asymp- tomatic coronary artery disease or latent cardiomyopa- thy. 2 As a result, heart transplant centers have different age limits; generally, the age threshold is between 50 and 60 years. In some centers, the age limit for the donor is 55 years, and older donors are accepted in special cases such as when the recipient’s condition is very poor and represents an emergency. 3 This prudent approach is also dictated by prognostic studies showing a 10% reduc- tion in the 3-year survival rate in patients who receive an allograft from donors aged older than 50 years. 4 The second factor is a suitable organ: the “coronary angiography for all” approach in selecting donor hearts has been abandoned for administrative and logistic reasons. 5,6 We rely on clinical history, lifestyle, resting electrocardiography, echocardiography (echo), hemo- dynamic parameters, and need for inotropic medica- tion. Functional stress testing of the heart would con- ceivably provide more robust risk stratification. Pharmacologic stress echo allows a simultaneous evaluation of inducible ischemia and contractile reserve of the left ventricle (LV); therefore, it is able to unmask From the Departments of a Pathology and e Surgery and Transplants, University of Bologna, Bologna; b Cardiology Division and c Intensive Care Unit, M. Bufalini Hospital, Cesena; d Institute of Clinical Physiol- ogy, National Research Council, Pisa; and Departments of f Pathology and g Surgery and Transplants, University of Siena, Siena, Italy. Submitted Feb 25, 2009; revised May 28, 2009; accepted May 30, 2009. Reprint requests: Tonino Bombardini, MD, PhD, FESC, Associate Researcher, Institute of Clinical Physiology, National Research Coun- cil, Via Moruzzi 1, 56124 Pisa, Italy. Telephone: +39-050-315-2400. Fax: +39-050-315-2374. E-mail: bombardini@ifc.cnr.it Copyright © 2009 by the International Society for Heart and Lung Transplantation. 1053-2498/09/$–see front matter. doi:10.1016/ j.healun.2009.05.029 1141