JHLT Open · Jul 27, 2026

Donor coronary artery disease and outcomes after heart transplantation: Effect modification by donor age and allocation era

By Castillo EM, Osorio MF, Del Castillo D et al.

BACKGROUND: The limited availability of donor hearts has led to an increased utilization of organs from donors with pre-existing coronary artery disease (CAD). However, the impact of donor-transmitted CAD (DTCAD) on post-transplant outcomes stratified by donor age remains insufficiently characterized. METHODS: Using the United Network for Organ Sharing database, adults undergoing orthotopic heart transplantation (2000 to 2025) were analyzed. Donors were stratified by age and CAD status on pre-procurement angiography. The primary outcome was all-cause mortality. Effect modification by donor age and allocation era was assessed using multivariable Cox regression. RESULTS: Among 21,805 recipients (median follow-up 3.94 years), 1932 (8.9%) received hearts with CAD. DTCAD was not associated with mortality [hazard ratio (HR) 1.04; 95% confidence interval (CI) 0.95-1.13; p = 0.38]. The CAD × donor age interaction met the prespecified threshold (p = 0.094), with increasing risk among older donors (HR 1.27 at age 60; p = 0.02). Significant effect modification by allocation era was observed (interaction p = 0.018): DTCAD was not associated with higher mortality pre-2018 (HR 0.97) but was associated with a 24% increase in mortality post-2018 (HR 1.24; 95% CI 1.07-1.43; p = 0.005). Secondary outcomes, including graft failure, treated rejection, stroke, dialysis, and pacemaker implantation, did not differ between groups. CONCLUSIONS: DTCAD is not consistently associated with adverse outcomes. However, in the current era characterized by higher-acuity recipients, DTCAD, especially from older donors, is linked to increased mortality. These findings support re-evaluating donor CAD selection criteria in contemporary practice.

doi.org/10.1016/j.jhlto.2026.100646Open accessPubMed 42633214Populations