Background: Heart transplantation is the treatment of choice for advanced heart failure, but donor shortage forces increasing reliance on extended criteria. International guidelines state that intoxication is not an absolute contraindication if graft function appears preserved. Carbon monoxide (CO) intoxication, however, is particularly concerning due to systemic hypoxia and mitochondrial injury, which may compromise graft quality. Clinical experience with CO-intoxicated donor hearts remains scarce.
Methods: A 57-year-old male with ischemic cardiomyopathy and refractory cardiogenic shock was supported by an Impella 5.5 device and listed high-urgent for transplantation. A donor heart was offered from a patient rescued after a house fire with carboxyhemoglobin of 25% and prolonged resuscitation. Pre-procurement evaluation showed preserved systolic function and no significant coronary disease. After multidisciplinary discussion and informed consent, the organ was accepted.
Results: The recipient developed primary biventricular graft failure requiring immediate extracorporeal support. Ventricular function subsequently recovered, but secondary left ventricular dysfunction (ejection fraction 40%) occurred on postoperative day 67. Endomyocardial biopsy excluded acute rejection, suggesting CO-related injury. Despite these complications, the patient remained clinically stable, successfully completed rehabilitation, and was discharged home with recovered left ventricular function (ejection fraction 51%) under optimized medical therapy.
Conclusion: This case highlights both the risks and potential feasibility of heart transplantation from a severely CO-intoxicated donor. Although the recipient experienced primary and secondary graft dysfunction, recovery and hospital discharge were achieved, demonstrating that successful outcomes are possible under careful selection and close management. Systematic evaluation of such cases is essential to guide safe expansion of the donor pool.
