Donor heart selection: Evidence-based guidelines for providers

The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review. The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review. In 1995, Dr J. Copeland noted that “only optimal donors should be accepted for heart transplantation,” implying that extended-criteria donor organs may not be viable.1Copeland JG. Only optimal donors should be accepted for heart transplantation: protagonist.J Heart Lung Transplant. 1995; 14: 1038-1042PubMed Google Scholar Despite this awareness raised from over 25 years ago, this topic has remained much debated. While older donors are more routinely used in Europe, younger donors with short ischemic times are more commonly used in the United States. Mortality rates differ worldwide, and some of these differences are due to donor selection and/or recipient urgency. Seeking a balance between maximizing the number of transplants (by taking greater risk) and minimizing the risk to meet societal needs, while controlling cost, is difficult and frequently related to a lack of reliable data regarding both donors and recipients. The issue is further complicated by the fact that the peri-operative surgical risk is a combination of risk factors that include donor, recipient, and ischemic time. Lastly, meaningful comparisons of transplant outcomes across countries require proper risk-adjustment. The proposed guidelines provide evidence-based as well as expert-consensus recommendations for the selection of donors following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review. Controversial subjects are dealt with one by one and current state-of-the-art information is provided to help define risk. The strength of each recommendation and the corresponding level of available evidence were classified following the International Society for Heart and Lung Transplantation protocol for developing guideline documents.2International Society for Heart Lung Transplantation. Protocol and policies for developing standards statements, guidelines, and consensus documents and for conducting consensus conferences. 2017; https://ishlt.org/ishlt/media/documents/STANDARDS_AND_GUIDELINES_DEVELOPMENT_PROTOCOL_FINAL.pdfGoogle Scholar Task forces were established with an international panel of experts. The task forces reviewed donor characteristics (Task force 1), international donor practices (Task force 2), donor and recipient matched characteristics (Task force 3), extended donor characteristics (Task force 4), and donor risk scores (Task force 5). Factors considered in the clinical stability of the cardiac donor are hemodynamics, hormonal resuscitation,3Dhar R Cotton C Coleman J et al.Comparison of high- and low-dose corticosteroid regimens for organ donor management.J Crit Care. 2013; 28 (111.e111-117)Crossref PubMed Scopus (39) Google Scholar, 4Dupuis S Amiel JA Desgroseilliers M et al.Corticosteroids in the management of brain-dead potential organ donors: a systematic review.Br J Anaesth. 2014; 113: 346-359Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 5Pinsard M Ragot S Mertes PM et al.Interest of low-dose hydrocortisone therapy during brain-dead organ donor resuscitation: the CORTICOME study.Crit Care. 2014; 18: R158Crossref PubMed Scopus (40) Google Scholar, 6Buchanan IA Mehta VA. Thyroid hormone resuscitation after brain death in potential organ donors: a primer for neurocritical care providers and narrative review of the literature.Clin Neurol Neurosurg. 2018; 165: 96-102Crossref PubMed Scopus (9) Google Scholar, 7Cooper LB Milano CA Williams M et al.Thyroid hormone use during cardiac transplant organ procurement.Clin Transplant. 2016; 30: 1578-1583Crossref PubMed Scopus (17) Google Scholar, 8Holndonner-Kirst E Nagy A Czobor NR et al.The impact of l-thyroxine treatment of donors and recipients on postoperative outcomes after heart transplantation.J Cardiothorac Vasc Anesth. 2019; 33: 1629-1635Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 9Mi Z Novitzky D Collins JF Cooper DK. The optimal hormonal replacement modality selection for multiple organ procurement from brain-dead organ donors.Clin Epidemiol. 2015; 7: 17-27PubMed Google Scholar, 10Novitzky D Mi Z Sun Q Collins JF Cooper DK Thyroid hormone therapy in the management of 63,593 brain-dead organ donors: a retrospective analysis.Transplantation. 2014; 98: 1119-1127Crossref PubMed Google Scholar, 11Roels L Spaight C Smits J Cohen B. Critical care staffs' attitudes, confidence levels and educational needs correlate with countries' donation rates: data from the donor action database.Transpl Int. 2010; 23: 842-850Crossref PubMed Scopus (0) Google Scholar and the restoration of intravascular volume and electrolyte imbalance,12Al-Khafaji A Elder M Lebovitz DJ et al.Protocolized fluid therapy in brain-dead donors: the multicenter randomized MOnIToR trial.Intensive Care Med. 2015; 41: 418-426Crossref PubMed Scopus (44) Google Scholar, 13Barklin A. Systemic inflammation in the brain-dead organ donor.Acta Anaesthesiol Scand. 2009; 53: 425-435Crossref PubMed Scopus (129) Google Scholar, 14Kuecuek O Mantouvalou L Klemz R et al.Significant reduction of proinflammatory cytokines by treatment of the brain-dead donor.Transplant Proc. 2005; 37: 387-388Crossref PubMed Scopus (64) Google Scholar, 15McKeown DW Ball J. Treating the donor.Curr Opin Organ Transplant. 2014; 19: 85-91Crossref PubMed Scopus (14) Google Scholar, 16Abdelnour T Rieke S. Relationship of hormonal resuscitation therapy and central venous pressure on increasing organs for transplant.J Heart Lung Transplant. 2009; 28: 480-485Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 17Dimopoulou I Tsagarakis S Anthi A et al.High prevalence of decreased cortisol reserve in brain-dead potential organ donors.Crit Care Med. 2003; 31: 1113-1117Crossref PubMed Scopus (76) Google Scholar, 18Plurad DS Bricker S Neville A Bongard F Putnam B. Arginine vasopressin significantly increases the rate of successful organ procurement in potential donors.Am J Surg. 2012; 204 (discussion 860-851): 856-860Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 19Hadjizacharia P Salim A Brown C et al.Does the use of pulmonary artery catheters increase the number of organs available for transplantation?.Clin Transplant. 2010; 24: 62-66Crossref PubMed Scopus (0) Google Scholar, 20Novitzky D Mi Z Videla LA Collins JF Cooper DK. Hormone resuscitation therapy for brain-dead donors - is insulin beneficial or detrimental?.Clin Transplant. 2016; 30: 754-759Crossref PubMed Scopus (0) Google Scholar, 21Stoica SC Satchithananda DK Charman S et al.Swan-Ganz catheter assessment of donor hearts: outcome of organs with borderline hemodynamics.J Heart Lung Transplant. 2002; 21: 615-622Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 22Saner FH Kavuk I Lang H Radtke A Paul A Broelsch CE. Organ protective management of the brain-dead donor.Eur J Med Res. 2004; 9: 485-490PubMed Google Scholar as well as donor metabolism. 1.Donors receiving low dose norepinephrine (e.g., ≤0.1 µg/kg/min) may be considered suitable for transplantation if (other) inotropes are not required. In general, the higher the dose of norepinephrine in the donor, the poorer the expected outcome after transplant. Level of Evidence: C. 1.If inotropes and/or vasopressors are required to maintain adequate circulatory function in the donor, placement of a Swan-Ganz catheter and goal-directed therapy should be considered to maximize the likelihood of donor heart utilization. Level of Evidence: C.2.Suggested hemodynamic targets for donor hearts include the following:•Mean arterial pressure >60 mm Hg•Cardiac index >2.4 liter/min/m2•Central venous pressure <12 mm Hg•Pulmonary capillary wedge pressure <12 mm Hg•Left ventricular (LV) stroke work index >15 g·min/m2 Level of Evidence: C. 1.Use of hearts from donors with moderately abnormal serum sodium (outside the 135-145 mEq/liter range) may be considered. Level of Evidence: C.2.Hearts from donors with extreme hypo- or hypernatremia (serum sodium <129 or ≥170 mEq/liter, respectively) should not be used. Level of Evidence: C.3.Donor hyperglycemia should not be a contraindication to use for heart transplantation. Level of Evidence: C. The mode of brain death affects clinical outcomes following heart transplantation.23Raichlin E Villarraga HR Chandrasekaran K et al.Cardiac allograft remodeling after heart transplantation is associated with increased graft vasculopathy and mortality.Am J Transplant. 2009; 9: 132-139Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar,35Cantin B Kwok BW Chan MC et al.The impact of brain death on survival after heart transplantation: time is of the essence.Transplantation. 2003; 76: 1275-1279Crossref PubMed Scopus (40) Google Scholar, 36Cohen O De La Zerda DJ Beygui R Hekmat D Laks H. Donor brain death mechanisms and outcomes after heart transplantation.Transplant Proc. 2007; 39: 2964-2969Crossref PubMed Scopus (28) Google Scholar, 37Mehra MR Uber PA Ventura HO Scott RL Park MH. The impact of mode of donor brain death on cardiac allograft vasculopathy: an intravascular ultrasound study.J Am Coll Cardiol. 2004; 43: 806-810Crossref PubMed Scopus (56) Google Scholar Recommendations are provided for donor death by carbon monoxide (CO) poisoning, explosive brain death, and unexplained causes. Furthermore, the pathophysiology of brain death includes neurohormonal and inflammatory changes that may result in donor organ injury. Beneficial effects of corticosteroid administration to brain-dead donors (hormonal resuscitation therapy) in terms of organ recovery, graft survival, and graft function have been reported, but there are many confounding factors that preclude definitive assessment of the utility of steroid administration during donor management.3Dhar R Cotton C Coleman J et al.Comparison of high- and low-dose corticosteroid regimens for organ donor management.J Crit Care. 2013; 28 (111.e111-117)Crossref PubMed Scopus (39) Google Scholar, 4Dupuis S Amiel JA Desgroseilliers M et al.Corticosteroids in the management of brain-dead potential organ donors: a systematic review.Br J Anaesth. 2014; 113: 346-359Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 5Pinsard M Ragot S Mertes PM et al.Interest of low-dose hydrocortisone therapy during brain-dead organ donor resuscitation: the CORTICOME study.Crit Care. 2014; 18: R158Crossref PubMed Scopus (40) Google Scholar 1.Donors with CO poisoning should be carefully screened. Risk factors for early heart allograft dysfunction include ischemic electrocardiogram (ECG) changes, troponin I elevations ≥0.7 ng/ml and left ventricular dysfunction. Level of Evidence: C. 1.Donors with CO poisoning and carboxyhemoglobin levels >40%, ischemic ECG changes, elevated levels of cardiac troponin (≥0.7 ng/ml) or ventricular dysfunction should generally be avoided. Level of Evidence: C. 1.Donors with explosive brain death may be considered for transplantation. There is evidence suggesting reduced long-term survival of recipients of such donors, possibly due to increased cardiac allograft vasculopathy. Level of Evidence: C. Few reports have been published detailing the outcomes of allografts taken from donors with an unexplained cause of death. When faced with such an offer, centers should consider the more common causes of sudden death in young persons. 1.Donors with unexplained cause of sudden death should be carefully screened with ECG and, when appropriate, coronary angiography for cardiac causes of death including hypertrophic cardiomyopathy, long-QT syndrome, Brugada syndrome, and congenital heart disease includes coronary anomalies. Donors with unexplained sudden death can be considered for transplant if the evaluation is negative. Level of Evidence: C. 1.The use of donor hearts <45 years of age is recommended. Level of Evidence: C.2.Donors ≥45 years of age can be used after screening for significant coronary artery disease (e.g., ≤50% narrowing) and if short ischemic times (<4 hours) can be expected. Such screening criteria vary around the world based on risk factors and average population donor characteristics. Considerations should take into account estimated survival benefit, availability of organs, the severity of illness of the recipient, and whether the recipient is on mechanical circulatory support. No established upper age limit currently exists. Level of Evidence: C. 1.Donor selection should account for unique recipient characteristics such as older donors to be used in older or highly sensitized recipients (smaller compatible donor pool) who have a negative crossmatch (either prospective or virtual depending on needs of recipient and/or institution) to the prospective older donor. Level of Evidence: C. Factors considered in developing guidelines on donor size were sex matching,71Khush KK Kubo JT Desai M. Influence of donor and recipient sex mismatch on heart transplant outcomes: analysis of the International Society for Heart and Lung Transplantation Registry.J Heart Lung Transplant. 2012; 31: 459-466Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 72Martinez-Selles M Almenar L Paniagua-Martin MJ et al.Donor/recipient sex mismatch and survival after heart transplantation: only an issue in male recipients? An analysis of the Spanish Heart Transplantation Registry.Transpl Int. 2015; 28: 305-313Crossref PubMed Scopus (31) Google Scholar, 73Kaczmarek I Meiser B Beiras-Fernandez A et al.Gender does matter: gender-specific outcome analysis of 67,855 heart transplants.Thorac Cardiovasc Surg. 2013; 61: 29-36PubMed Google Scholar, 74Reed RM Netzer G Hunsicker L et al.Cardiac size and sex-matching in heart transplantation: size matters in matters of sex and the heart.JACC Heart Fail. 2014; 2: 73-83Crossref PubMed Scopus (148) Google Scholar, 75Bergenfeldt H Stehlik J Hoglund P Andersson B Nilsson J. Donor-recipient size matching and mortality in heart transplantation: influence of body mass index and gender.J Heart Lung Transplant. 2017; 36: 940-947Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar donor weight and height,64Weber DJ Wang IW Gracon AS et al.Impact of donor age on survival after heart transplantation: an analysis of the United Network for Organ Sharing (UNOS) registry.J Card Surg. 2014; 29: 723-728Crossref PubMed Scopus (27) Google Scholar,72Martinez-Selles M Almenar L Paniagua-Martin MJ et al.Donor/recipient sex mismatch and survival after heart transplantation: only an issue in male recipients? An analysis of the Spanish Heart Transplantation Registry.Transpl Int. 2015; 28: 305-313Crossref PubMed Scopus (31) Google Scholar,74Reed RM Netzer G Hunsicker L et al.Cardiac size and sex-matching in heart transplantation: size matters in matters of sex and the heart.JACC Heart Fail. 2014; 2: 73-83Crossref PubMed Scopus (148) Google Scholar,76Correia P Prieto D Batista M Antunes MJ. Gender mismatch between donor and recipient is a factor of morbidity but does not condition survival after cardiac transplantation.Transpl Int. 2014; 27: 1303-1310Crossref PubMed Scopus (0) Google Scholar, 77Fonarow GC. How old is too old for heart transplantation?.Curr Opin Cardiol. 2000; 15: 97-103Crossref PubMed Scopus (20) Google Scholar, 78Everett JE Djalilian AR Kubo SH Kroshus TJ Shumway SJ. Heart transplantation for patients over age 60.Clin Transplant. 1996; 10: 478-481PubMed Google Scholar predicted heart mass (pHM),63Costanzo MR Dipchand A Starling R et al.The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients.J Heart Lung Transplant. 2010; 29: 914-956Abstract Full Text Full Text PDF PubMed Scopus (1176) Google Scholar,69Nagji AS Hranjec T Swenson BR et al.Donor age is associated with chronic allograft vasculopathy after adult heart transplantation: implications for donor allocation.Ann Thorac Surg. 2010; 90: 168-175Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar,79Gong TA Joseph SM Lima B et al.Donor predicted heart mass as predictor of primary graft dysfunction.J Heart Lung Transplant. 2018; 37: 826-835Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar the role of body mass index,75Bergenfeldt H Stehlik J Hoglund P Andersson B Nilsson J. Donor-recipient size matching and mortality in heart transplantation: influence of body mass index and gender.J Heart Lung Transplant. 2017; 36: 940-947Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar,80O'Neill TJ Pisani B. Size matching in heart transplantation donor selection: "Too big to fail"?.J Heart Lung Transplant. 2017; 36: 934-935Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar oversizing for pulmonary hypertension,76Correia P Prieto D Batista M Antunes MJ. Gender mismatch between donor and recipient is a factor of morbidity but does not condition survival after cardiac transplantation.Transpl Int. 2014; 27: 1303-1310Crossref PubMed Scopus (0) Google Scholar,81Jasseron C Legeai C Jacquelinet C et al.Optimization of heart allocation: the transplant risk score.Am J Transplant. 2019; 19: 1507-1517Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar,82Russo MJ Iribarne A Hong KN et al.Factors associated with primary graft failure after heart transplantation.Transplantation. 2010; 90: 444-450Crossref PubMed Scopus (173) Google Scholar and extreme donor-recipient size mismatch.63Costanzo MR Dipchand A Starling R et al.The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients.J Heart Lung Transplant. 2010; 29: 914-956Abstract Full Text Full Text PDF PubMed Scopus (1176) Google Scholar,74Reed RM Netzer G Hunsicker L et al.Cardiac size and sex-matching in heart transplantation: size matters in matters of sex and the heart.JACC Heart Fail. 2014; 2: 73-83Crossref PubMed Scopus (148) Google Scholar,81Jasseron C Legeai C Jacquelinet C et al.Optimization of heart allocation: the transplant risk score.Am J Transplant. 2019; 19: 1507-1517Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar,83Madan S Patel SR Vlismas P et al.Outcomes of early adolescent donor hearts in adult transplant recipients.JACC Heart Fail. 2017; 5: 879-887Crossref PubMed Scopus (6) Google Scholar While there currently is no consensus as to best method of determining size matching, pHM is gaining in popularity. 1.Allocation of female donors to male recipients may be done safely, especially in recipients without pulmonary hypertension and when adequate donor/recipient weight ratio and/or pHM are ensured. A value of pHM within 20% to 30% of recipient is considered acceptable. Level of Evidence: C. 1.Due to the impact on right ventricular dysfunction of the donor allograft, pulmonary hypertension in the intended recipient should be taken into consideration when determining the degree of acceptable size and sex mismatch. Level of Evidence: C. 1.The presence of preformed human leukocyte antigens (HLA) antibodies should be ascertained and compared against the donor HLA, at least virtually, prior to acceptance for organ transplant. Level of Evidence: C.2.There currently is no agreed-upon standard for which HLA antibodies can be crossed and which should be avoided. Center practice varies based on magnitude, strength of antibodies, whether they are C1q positive (e.g., complement-fixing), and the level of experience with managing sensitization and ability to absorb transplant center risk. Level of Evidence: C. (See also Table 1.)Table 1Compatible Blood GroupsRecipient blood typeCompatible donorAA, OBB, OABA, B, AB, OOO Open table in a new tab 1.ABO blood group compatibility should be confirmed. Level of Evidence: C.2.Systems of care should be implemented to assure that blood group compatibility is not violated without a specific reason (ABO-incompatible pediatric transplantation). Level of Evidence: C. 1.Target total organ ischemic time for cardiac transplantation should be ≤4 hours, to reduce the risk of primary graft dysfunction and early death. Level of Evidence: C. 1.A transplant center may allow the total organ ischemic time to exceed 4 hours for donors <45 years of age without compromising early outcomes after heart transplantation. With older donors, it is specifically recommended to avoid long-distance transportation or other factors (e.g., redo sternotomy, ventricular assist device (VAD) explantation, which can cause prolonged operative times) that could result in total donor ischemic times >4 hours. Level of Evidence: C.2.Ex-vivo normothermic heart perfusion platforms can be safely used to decrease ischemic time for distant procurements and potentially to expand the procurement of marginal donors based on metabolic evaluation during ex-vivo perfusion. Level of Evidence: C. (See Table 2 for the gradation of left ventricular hypertrophy (LVH).)Table 2LVH Determined by Measurement of the Interventricular SeptumLevel of LVHIntraventricular septumMild11-13 mmModerate14-16 mmSevere≥17 mm Open table in a new tab 1.LVH should be assessed by measuring the thickness of the interventricular septum or the posterior wall on echocardiography. Level of Evidence: C. 1.Carefully selected donor hearts with LVH >13 mm (measured as outlined above) may be considered, particularly with younger (donors ≤40 years of age) and/or shorter ischemic time (<4 hours). Level of Evidence: C.2.Chronic hypertension (defined by contemporary guidelines) or the use of hearts from donors being treated for hypertension in the absence of LVH do not appear to impact post-transplant outcomes. Level of Evidence: C. (Table 3 illustrates how recommendations have varied over time and across geographic regions.)Table 3Recommended Age Criteria for the Use of Coronary Angiography in Donor Evaluation Across Time and Geographic Region (Class IIa/b; Level of Evidence: C)PublicationRecommended age for menRecommended age for womenRegionYearACCRecommendations125Baldwin JC Anderson JL Boucek MM et al.24th Bethesda conference: cardiac transplantation. Task Force 2: donor guidelines.J Am Coll Cardiol. 1993; 22: 15-20Crossref PubMed Scopus (49) Google Scholar• Age >45 years• Lower by 5-10 years if risk factors present• Age >50 years• Lower by 5-10 years if risk factors presentUS1993Maximizing Use of Organs Recovered From the Cadaver Donor Consensus Conference27Zaroff JG Rosengard BR Armstrong WF et al.Consensus conference report: maximizing use of organs recovered from the cadaver donor: cardiac recommendations, March 28-29, 2001, Crystal City, Va.Circulation. 2002; 106: 836-841Crossref PubMed Scopus (353) Google Scholar• Age >55 years: mandatory• Age >45 years: recommended• Age >35 years if cocaine or 3 risk factors• Age >55 years: mandatory• Age >50 years: recommended• Age >40 years if cocaine or 3 risk factorsUS2002United Network for Organ Sharing126Organ OPTN/UNOS Procurement Organization Committee. Guidance on requested deceased donor information; 2018.https://optn.transplant.hrsa.gov/media/2528/opo_boardreport_201806_guidance.pdfGoogle Scholar• Age >40 years• Younger with risk factors• Age >45 years• Younger with risk factorsUS2018European Committee on Organ Transplantation (Council of Europe)127European Directorate for the Quality of Medicines and HealthcareGuide to the Quality and Qafety of Organs for Transplantation.8th edition. Council of Europe, Strassbourg, France2022https://www.edqm.eu/guide-quality-and-safety-organs-transplantationGoogle Scholar• Age >55 years• Age >45 years if more than 1 risk factor present• Age >55 years• Age >45 years if more than 1 risk factor presentEurope2018 Open table in a new tab 1.Donors with mild luminal irregularities (e.g., ≤50% narrowing) on coronary angiography may be considered for heart transplantation. Level of Evidence: C.2.Coronary angiography should be considered in donors ≥45 years old, depending on geography and other risk factors. See also Table 3. Level of Evidence: C.3.Risk factors suggesting need for coronary angiography include hypertension, diabetes (particularly with longer time of treatment), male sex, obesity, hyperlipidemia, tobacco and/or cocaine/methamphetamine use. Level of Evidence: C.4.Myocardial bridging is rarely a contraindication to transplantation. Level of Evidence: C 1.Donors with single-vessel coronary disease amenable to percutaneous or surgical therapy may be considered after balancing the risk of coronary disease progression and the urgency of the recipient. Level of Evidence: C.2.Donors with left main and/or 2 to 3 vessel obstructive (≥50%) coronary disease are best avoided for transplantation in the absence of extenuating circumstances. Level of Evidence: C. 1.Donors with diabetes mellitus and no other risk factors, particularly without coronary artery disease, can be safely used. Level of Evidence: C.2.Coronary angiography should be considered for diabetic donors, and duration of diabetes and donor age should be carefully weighed. Level of Evidence: C. 1.Donors with cardiopulmonary resuscitation may be used if heart function is normal (by left ventricular ejection fraction (LVEF) and hemodynamics) at the time of procurement, unless the cardiac arrest circumstances raise the suspicion for underlying structural heart disease. Level of Evidence: C.2.The duration of donor cardiopulmonary arrest and of the CPR alone should not be used to exclude donor hearts for transplantation. CPR times >30 minutes in both adult and pediatric donors do not negatively impact post-transplant survival or outcomes if echocardiographic cardiac function and hemodynamics are favorable (e.g., LVEF >50%) after resuscitation. Level of Evidence: C. 1.Tobacco use of significant pack-years increases the risk of donor coronary artery disease (CAD). Depending on donor age (>45 years), obtaining a donor angiogram may be reasonable. Level of Evidence: C. 1.The hearts of donors with a history of alcohol use may be used for transplantation if cardiac function is preserved on echocardiography. Level of Evidence: C. 1.Donors with a history of cocaine use can be considered for heart transplantation if there is no significant LVH (i.e., ≥14 mm; see also the recommendations on donor LVH in this document). Level of Evidence: C.2.Donors with a history of past or active cocaine use should have a coronary angiogram when possible. Level of Evidence: C.3.Donors with toxicology positive for amphetamine or methamphetamine may be utilized for transplant if ventricular function and structure are normal on echocardiogram and imaging. Level of Evidence: C.4.Donors with toxicology positive for multiple substances may be utilized for transplant if ventricular function and structure are normal on echocardiogram and imaging. Level of Evidence: C. This section reviews various potential infections in a donor though it is not comprehensive of all possibilities. Infectious disease thoracic transplant physician specialists should be consulted for unique donor infections as new pathogens are always emerging and treatments are constantly evolving. 1.Transplantation of hearts from bacteremic donors is feasible, provided that the recipient, after being informed of the associated risks, is treated with targeted antimicrobials for an appropriate duration post-transplant. Level of Evidence: C. (See Table 4.)Table 4Fungal InfectionsPathogenRecommendationStrength/level of evidenceAspergillus, activeIf disseminated, do not utilizeIII /CAspergillus, active (lung only)If lung only, consider taking heart with post-transplant prophylaxisIIb /CAspergillus, history of diseaseIf findings, send workup to rule out active disease, possible post-transplant prophylaxisIIa /CCoccidiomycosis, active diseaseDo not utilizeIII /CCoccidiomycosis, history of diseaseIf findings, send workup to rule out active disease, possible post-transplant prophylaxisIIa /CCryptococcus, untreatedDo not utilizeIII /CCryptococcus, actively treatedConsider risks/benefitsIIa /CHistoplasmosis, active diseaseDo not utilizeIII /CHistoplasmosis, history of diseaseIf findings, send workup to rule out active diseaseIIa /C Open table in a new tab (Recommendations concerning donors with hepatitis B,127European Directorate for the Quality of Medicines and HealthcareGuide to the Quality and Qafety of Organs for Transplantation.8th edition. Council of Europe, Strassbourg, France2022https://www.edqm.eu/guide-quality-and-safety-organs-transplantationGoogle Scholar,174Blanes M Gomez D Cordoba J et al.Is there any risk of transmission of hepatitis B from heart donors hepatitis B core antibody positive?.Transplant Proc. 2002; 34: 61-62Crossref PubMed Scopus (16) Google Scholar, 175Chamorro C Aparicio M. Influence of HBcAb positivity in the organ donor in heart transplantation.Med Intensiva. 2012; 36: 563-570Crossref PubMed Scopus (0) Google Scholar, 176Chen YC Chuang MK Chou NK et al.Twenty-four year single-center experience of hepatitis B virus infection in heart transplantation.Transplant Proc. 2012; 44: 910-912Crossref PubMed Google Scholar, 177De Feo TM Poli F Mozzi F Moretti MP Scalamogna M. Risk of transmission of hepatitis B virus from anti-HBC positive cadaveric organ donors: a collabor