Figure 1

The echo-driven destiny of candidate donor heart. To screen aged potential donor hearts for initial cardiomyopathy and functionally significant coronary artery disease, potential donors aged > 55 years will undergo pharmacological stress echo (with either dipyridamole or dobutamine). Hearts with normal regional and global left ventricular function will be recruited. Hearts with stress echo positivity will be excluded. Excluded hearts will undergo cardioautoptic verification to challenge stress echo results versus a pathologic gold standard. Included hearts will be transplanted and the stress echo result will be challenged versus clinical outcome and angiographic verification 1 month after transplant. The Adonhers (Aged Donor Heart Rescue by Stress Echo) Project Additional files (video clips) 1, 2, 3, and 4. A transesophageal pharmacological stress echo test was performed, following the protocol of American Society of Echocardiography [5], using: Dipyridamole (0.84 mg/kg in 6'). The echocardiographic study is divided into two different parts: 1 Segmental wall motion- it is the essential step for the evaluation. The donor with abnormal wall motion at baseline or during stress will be excluded from the donor ship. The donor showed normal regional wall motion at baseline and during stress. (WMSI = 1 at baseline, intermediate and peak stress). Global and regional wall motion is shown in 2 and 4 chambers view at baseline (Additional files 1 and 2) and at peak stress (Additional files 3 and 4). 2 The force-frequency relation (FFR). During the procedure, pressure and ECG were recorded every minute. Brachial blood pressure was measured with cuff sphygmomanometer. In every phase of the stress echo, the projections of the 4 chamber and of the apical 2 chambers were recorded to calculate the left ventricular telesystolic volume. This allowed us to calculate the systolic pressure/left ventricle telesystolic volume ratio in every moment when increasing the cardiac frequency during the stress and building, off-line, the force-frequency relation of the left ventricle. The donor had normal response at rest and with normal regional wall motion during pharmacological stress echo and was considered suitable donor; indeed, this response pattern proved a good coronary and functional reserve of the heart. (Images from Sonia Gherardi, Director Echo lab, Cardiology Division, Cesena Hospital, Italy)