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Background: Due to the shortage of donor hearts, the criteria for acceptance have been considerably expanded. An abnormal result at pharmacological stress echocardiography is associated with significant coronary artery disease and/or occult cardiomyopathy at verification by cardiac autopsy. The aim of this study is to establish the feasibility of an approach based on pharmacological stress echocardiography as a gatekeeper for extended heart donor criteria.Methods: From April 2005 to December 2010, 51 marginal (>50 years old, n= 41, or <50 years with ≥3 concomitant risk factors, n=10) candidate donors (age 55±8 years, 28 male) were initially enrolled. After legal declaration of brain death, marginal donors underwent rest and, if normal, dipyridamole (0.84 mg/kg in 6', n=30) or dobutamine (up to 40 mcg/kg, n=3) stress echocardiography.Results: We found 23 eligible hearts with normal findings. Of these, 4 were not transplanted due to lack of a matching recipient, and verification by cardiac autopsy showed absence of significant coronary artery disease or cardiomyopathy abnormalities. The remaining 19 eligible hearts were uneventfully transplanted in marginal emergency recipients. All showed normal (n=16) or nearly-normal (minor single- vessel disease, in 3) angiographic, intravascular ultrasound, hemodynamic and ventricolographic findings at 1 month. At follow-up (median 20, interquartile range 10-37 months), 17 patients survived and 2 died, one at 2 months from general sepsis and one at 32 months from allograft vasculopathy in recurrent multiple myeloma.Conclusions: Pharmacological stress echocardiography can safely be performed in candidate heart donors with brain death, and shows potential for extending donor criteria in heart transplantation.