Transplant Cardiac Workups — Cardiology Guide

Start

LiverCoronary disease + reserve under clamping, bleeding, vasoplegia and reperfusion.

KidneyCoronary disease + structural function near an achievable dry weight.

Different physiology, different workup

organ-specific priorities

Liver

Baseline ECG + comprehensive TTE for all candidates.
Coronary Important CAD? Treatment feasible within liver urgency, renal reserve and bleeding/DAPT constraints?
Hemodynamics LV/RV reserve, PoPH versus high flow/congestion, oxygenation and HPS.

Kidney

Baseline History, examination and ECG for all. TTE guided by cardiac history, dialysis exposure, PH risk and program pathway.
Coronary Symptoms, prognostic anatomy and whether more testing changes treatment or candidacy.
Hemodynamics Volume, pressure, ischemia or other cardiomyopathy? Interpret near achievable dry weight.

What completes the assessment

beyond a coronary result

Five domains

CAD · LV/RV

Plus valves, pulmonary circulation and rhythm.

Final output

Findings → action

Treatment constraints, anesthesia plan and offer readiness.

Transplant benefit Include harm of waiting. A general surgical score does not settle listing. Separate operative risk from the expected survival benefit of transplantation.
Simultaneous liver–kidney One integrated assessment, shared contrast plan, liver operative demands and residual kidney function.

Shared perioperative decisions

use the companion pathway

General surgery Perioperative guide: timing, antithrombotics, drugs, devices and postoperative events.

Escalate

Active diseaseACS, decompensated HF, sustained ventricular arrhythmia, unstable tachyarrhythmia or symptomatic high-grade block.

Other major flagsSevere symptomatic valve disease, concerning syncope or important RV failure.

Define the consultation

before another test

Context + symptoms

Transplant Organ, donor pathway, listing stage, wait and near-term opportunity.
Reason Initial assessment, abnormal result, reactivation or organ offer?
Function Actual activity and limiting symptom. Chest pain, dyspnea, orthopnea, syncope, palpitations, admissions.

Evidence + risk

Retrieve Dated ECG/TTE, achieved stress and image quality, coronary anatomy, PCI/CABG, valve and device reports.
Risk Diabetes, BP/lipids, tobacco, PAD/CVA, family history, kidney trajectory, dialysis duration, liver severity.

Interpret findings in their measured state

reserve + feasibility

Physiology

Current BP/HR, oxygen, perfusion, congestion, weight, hemoglobin, electrolytes.
Loading Dialysis, diuresis, paracentesis or acute illness around each study.

Treatment constraints

Procedures Bleeding, platelets, contrast and ability to tolerate delay.
Drugs Renal/hepatic handling and current antithrombotic indications.

Question → result → action

complete the decision

OrderName the clinical question and actionable result.

InconclusiveSpecify the next branch and reviewing clinician.

Urgent transplantActive disease → focused stabilization, support and joint timing decision.

Liver assessment: coronary risk and hemodynamic reserve in parallel.

Baseline → abnormal finding → next branch

operational synthesis

ECG + comprehensive TTESymptoms, ischemic ECG or known disease → focused cardiology management.

Define reserveEF/regional motion, GLS when feasible, tissue Doppler/diastology, valves, RV size/function, TR velocity and PA pressure.

Branch the workupCAD risk → advanced coronary pathway. PH probability → specialist/RHC pathway. Hypoxemia/shunt → ABG/pulmonary assessment.

Coronary and pulmonary triggers

do not substitute one for the other

Advanced CAD assessment

AASLD/AST Even one MASLD-associated factor, CKD, LVH, premature family history, tobacco exposure or formal calcium score >0.
Metabolic risk Assess diabetes, hypertension and dyslipidemia. Modality follows the center’s cardiology-approved algorithm.

Pulmonary assessment

ILTS RVSP >40 mm Hg, more than mild RV dilation/dysfunction or intermediate/high PH probability → referral and consideration of RHC.
Oxygenation Assess oxygenation and agitated-saline TTE when available. Intrapulmonary shunt/unexplained hypoxemia → ABG and pulmonary review.

Treatment must fit the transplant window

liver urgency + kidney reserve + bleeding

Readiness Complete / optimize and reassess / team decision pending / currently prohibitive.
Unresolved finding Name the treatment or evidence needed to change that state.

Interpret

Inadequate negative stressUnresolved coronary question.

Normal functional studyDoes not directly establish normal coronary anatomy.

Choose the information needed

center-specific pathway

Test	Best use	Failure mode / next check
Formal calcium	Calcified plaque burden	Not luminal stenosis or noncalcified plaque. Use a numeric Agatston result for thresholds.
CCTA	Epicardial stenosis/anatomy	Calcium, motion/rhythm, hypotension or contrast constraints. Uninterpretable segment = unresolved, especially the left main or proximal major vessels.
Stress echo	Inducible dysfunction/reserve	Blunted chronotropy, beta blockade, limited exercise. Check stress achieved and image quality.
Nuclear / PET / stress CMR	Ischemia and myocardial information	Cirrhotic vasodilation and modality limits. Match expertise and renal/contrast plan.
Angiography	Definitive anatomy that changes care	Bleeding/contrast precautions and feasible treatment plan first.

Before escalating

adequacy → utility → feasibility

Result interpretation

High-risk candidate Does test quality and achieved stress meaningfully lower disease probability?
Before angiography Other candidacy issues assessed? Would acceptable or treatable anatomy permit transplant?

Center-specific plan

Specify Center/version, modality sequence, thresholds and exceptions.
Avoid substitution Incidental liver-CT calcium ≠ formal Agatston score. Age/calcium cutoffs and calcium-to-CMR pathways retain local scope.

Low afterload and high output can hide limited myocardial reserve.

Echo finding → clinical question

read loading conditions

Finding	Action
Reduced EF / new regional dysfunction	Ischemic versus nonischemic cause → optimize, reassess, define support.
Preserved EF + abnormal GLS/diastology	Image quality, loading, competing disease, clinical HF → assess reserve/fluid tolerance.
RV dysfunction / high PA pressure	Flow, filling pressure, vascular disease → PH/RHC pathway.
Important CAD	Symptoms/anatomy/LV function → benefit, procedural harm and transplant timing.

Cirrhotic cardiomyopathy

proposed criteria, not selection thresholds

Systolic

Either LVEF ≤50% or absolute GLS <18%.
Correction Former GLS >22% criterion removed.

Advanced diastolic

At least 3 Septal e′ <7 cm/s, E/e′ ≥15, LAVI >34 mL/m², TR velocity >2.8 m/s.
TR qualifier Use TR velocity only in the absence of primary pulmonary hypertension or PoPH. AASLD/AST considers the transplant-selection role undefined.

CAD treatment feasibility

heart–liver team

Options Medical care, PCI, CABG, selected combined procedures or prohibitive risk.
Constraints Portal bleeding, platelets, kidneys, DAPT, liver deterioration during recovery and transplant opportunity.
Team Hepatology, transplant cardiology/anesthesia and procedural specialists.
Evidence Kidney trials do not establish liver-transplant benefit/futility. Quantified cirrhosis risk.

High PA pressure: separate high flow, congestion and pulmonary vascular disease.

Echo → specialist assessment

source-specific escalation

ILTS

Trigger RVSP >40 mm Hg, more than mild RV enlargement/dysfunction or intermediate/high PH probability.
Action PH referral and consideration of RHC.

AASLD/AST

Trigger RVSP >45 mm Hg or abnormal RV structure/function → RHC.
Pitfall Absent TR jet does not exclude PH.

RHC: verify the wedge and output

document volume, oxygen/ventilation and CO method

Original diagnostic sequence. An elevated mPAP alone cannot distinguish high flow, congestion and pulmonary vascular disease.

Playing

Required context Portal hypertension + mPAP >20 mm Hg, PAWP ≤15 mm Hg and PVR >2 WU, with other important causes excluded. Diagnostic cutoffs differ from allocation criteria.
Measurements RA, systolic/diastolic/mean PA, credible PAWP, CO/CI. PVR = (mPAP − PAWP) / CO.

Worked patterns

synthetic hemodynamics

mPAP/PAWP (mm Hg), CO (L/min)	PVR	Interpretation
32 / 10 / 12 L/min	1.8 WU	High flow, not the PoPH vascular criterion.
35 / 25 / 5 L/min	2.0 WU	High filling pressure → decongest, assess left heart.
40 / 10 / 5 L/min	6.0 WU	Precapillary disease → PH treatment/transplant reassessment.

Before PAH drugs Assess lung, thromboembolic and left-heart causes. Correct material congestion and repeat when decision-changing. Elevated mPAP alone is insufficient.

Separate

Clinical suitabilityRV reserve + hemodynamics + treatment stability.

MELD exceptionAllocation eligibility does not authorize the operation.

Clinical contraindications

retain the source differences

Source	Finding
AASLD/AST	Treated mPAP 45 mm Hg with PVR >3 WU.
ILTS · absolute contraindication	Any mPAP >45–50 mm Hg, PVR >5 WU or severe RV dysfunction.

Interpretation Not interchangeable gates. Below one threshold does not neutralize another dangerous RV/hemodynamic finding.

OPTN standardized exception

policy 9.5.G · verify at submission

Baseline RHCSame-date mPAP ≥35 mm Hg + PVR ≥3 WU. Portal hypertension, other-cause assessment, initial transpulmonary gradient and treatment documented.

Post-treatment RHCWithin 90 days before submission. Paired values from the same test date.

Qualifying branch 1

mPAP <35

mm Hg, with PVR <5 WU

Qualifying branch 2

35 ≤mPAP <45

mm Hg, with PVR <3 WU

Extension RHC since last exception/extension showing sustained qualification. Follow current policy/submission requirements.

Protect the treated RV

PH + transplant anesthesia

Established PoPH ILTS advises avoiding TIPS and beta blockers. Coordinate alternatives with PH/hepatology teams. Do not apply this as an unsupervised stop rule for all portal hypertension.
Perioperative Reassess symptoms, RV, hemodynamics and liver severity. Plan monitoring/rescue. Maintain PAH therapy and uninterrupted parenteral delivery.
After transplant Variable improvement. Withdrawal requires PH follow-up.

Distinguish

HPSIntrapulmonary vascular dilatation + impaired oxygenation.

PoPHPulmonary vascular resistance + RV load. HPS and PoPH can coexist.

Hypoxemia → shunt → oxygenation

HPS workup

Clinical cluesOxygen need, positional symptoms, resting/exertional oxygenation and alternative pulmonary causes.

Contrast TTEAgitated saline when available. If not routine, unexplained symptoms or abnormal oxygenation should trigger testing.

Confirm HPS physiologyBubble timing and the full study must distinguish intracardiac from intrapulmonary shunt. Resolve an uncertain location with imaging expertise. ABG conditions, PaO2/A–a gradient and liver/portal-hypertension context.

Next Pulmonary/transplant review for diagnosis, severity, oxygen and exception request. Bubble positivity alone is insufficient.

OPTN exception

allocation threshold, not diagnostic shorthand

Room-air oxygen

PaO2 <60 mm Hg

Within 30 days before initial submission.

Other requirements

Shunt + portal features

Specified portal-hypertension features, no clinically significant primary pulmonary disease.

Finish the cardiac/pulmonary plan

target the abnormality

Structure + rhythm

Valve Verify severity/symptoms, intervention feasibility and hemodynamic/fluid tolerance.
AF / conduction / QT Triggers, ECG, electrolytes/drugs. Monitor when symptom-directed.

Devices + function

CIED Dependency, interrogation, actual magnet response and restoration.
Low function Cardiac/pulmonary disease, anemia, frailty → feasible prehabilitation.
Pulmonary tests Chest imaging. PFTs for lung disease/significant pulmonary risk.

Kidney evaluation: history, examination, ECG and current dialysis/volume physiology.

Initial pathway

active disease before screening

Symptoms / active diseaseCardiology assessment. Retrieve prior MI/PCI/CABG, ECG and actual activity limits.

Volume + structureDialysis modality/duration, dry weight, residual urine, hypotension/admissions. TTE: EF/regional motion, diastology, valves, RV/PA pressure.

Coronary branchKnown CAD / low-risk proposed branch / functional or anatomic testing. Use prior adequate evidence.

Who needs screening?

guideline and statement differ

KDIGO

CAD Noninvasive screening for asymptomatic high-risk candidates, such as diabetes/prior CAD, or poor functional capacity.
Echo ≥2 years on dialysis or PH risk. Symptoms/structural disease provide additional indications.

AHA proposal

Baseline ECG/TTE for most. Very-low-risk exception: age <40, no CKD-specific coronary risk factor, no dialysis and no previous transplant.
Low-risk CAD branch No known CAD, normal ECG/TTE, age <60, no diabetes/smoking/PAD/CVA, combined dialysis/prior-transplant duration <5 years.
Consequence May list without further coronary testing. A proposal, not a universally validated clearance rule.

Treat findings and define readiness

do not equate poor exercise with ischemia

Optimization CAD prevention, HF/volume, valves, rhythm and PH. Each abnormality needs an action and reassessment.
Activity limits Anemia, dialysis fatigue and orthopedic limitations versus cardiopulmonary symptoms.
Offer plan Antithrombotics, dialysis, monitoring and dated treatment-dependent readiness constraints.

Choose anatomy or ischemia testing for a decision the result can change.

Result → next action

quality before reassurance

Test / result	Interpretation → action
Stress echo / perfusion	Adequacy, burden/location, ventricular response. Moderate/large ischemia → cardiology/anatomic-treatment review.
Normal / small ischemia	Credible stress/modality → prevention and candidacy review. Discordant symptoms/structure → escalate.
CCTA	Interpretable anatomy? Heavy calcium/nondiagnostic segments may require another approach.
Angiography	Symptoms, echo abnormalities or significant ischemia → definitive anatomy only with an actionable downstream plan.

Known CAD versus new screening

avoid repeating answered questions

Prior CAD

Review Anatomy, PCI/CABG, symptoms, EF and medical treatment.
Stable + recent anatomy May avoid another screening study.
New/uncontrolled symptoms May justify angiography. Persistent obstruction requires joint review, not automatic exclusion.

Testing pitfalls

Functional option AHA favors stress echo. Local expertise, calcium and kidney reserve may favor another modality.
Calcium score Plaque burden, not stenosis severity or an automatic PCI indication.
Normal stress Does not directly exclude left-main disease. Resolve discordance rather than sending every normal study to angiography.

Contrast decision

agent + kidney state + volume tolerance

Plan Residual function, AKI, volume, specific iodinated/gadolinium agent and procedural precautions with imaging/nephrology.
Group II gadolinium Advanced CKD is not a blanket ban on necessary MRI. Avoid an unqualified “renal-safe” label.

Do not

Treat the screenAn abnormal result alone does not mandate PCI.

Remove from waitlistInterpret disease significance and treatment feasibility first.

Clinical state → treatment branch

independent coronary indications

Situation	Action
ACS / unstable symptoms	Acute coronary pathway → reassess transplant timing.
Left main / prognostic anatomy suspected	Define anatomy → standard revascularization indications.
Stable asymptomatic ischemia	Medical treatment. Define anatomy if it changes treatment/candidacy.
Persistent symptoms despite feasible therapy	Angiography/revascularization for symptoms or other standard indications.
Intervention mainly to enable transplant	Explicit benefit limits, renal/bleeding harm, recovery/DAPT and delay.

ISCHEMIA-CKD

stable disease, not every transplant question

Main trial · 777

36.4% vs 36.7%

Estimated 3-year death/nonfatal MI, invasive vs conservative.

Post hoc listed · 194

HR 0.91

95% CI 0.54–1.54. No demonstrated benefit. The interval also permits clinically important benefit or harm.

Boundary No universal no-screening rule or immediate-transplant answer. ACS, refractory symptoms, high-risk anatomy and severe LV dysfunction remain separate.
Evidence details Exclusions, harms and listed-subgroup limits.

Feasible prevention

indication and tolerance

Treatment

Priorities Tobacco cessation, achievable activity, BP/diabetes, lipids, indicated antiplatelets and HF therapy.

Constraints

Review Dialysis, hypotension, potassium, tolerance and immunosuppressant interactions. Candidacy alone does not indicate every coronary drug.

Read EF, gradients and PA pressure at a documented BP, weight and dialysis/volume state.

Reduced EF

reassess correctable loading

Find the causeIschemia, pressure/volume load or other cardiomyopathy → optimize dialysis and tolerated HF therapy.

Stable, no other high-risk featureAHA: reassess after about 3 months of maximal therapy. Adapt to urgency.

Persistent LVEF <40%HF specialty referral. This is a management trigger, not a listing prohibition.

Recovery limit Transplantation cannot be assumed to reverse ischemic scar or persistent cardiomyopathy.

Other structural findings

phenotype before candidacy

Valves + rhythm

Valve Confirm severity, symptoms and flow/volume effects → intervention feasibility and timing.
Syncope / rhythm ECG, drug/electrolyte review, device or ambulatory monitoring → treat the actionable problem.

PH + RV

First Optimize volume. Assess left-heart/lung causes.
If decision-changing PH referral/RHC: PAWP, CO, PVR and RV reserve. RVSP alone establishes neither PAH nor prohibition. Record dialysis timing before comparing serial measurements.

KDIGO exclusion

symptoms + correctability + mitigating factors

Scope

Uncorrectable symptomatic NYHA III/IVSevere CAD, LV dysfunction with EF <30%, or severe valve disease.

Isolated kidney transplantGenerally excluded unless mitigating factors exist. Establish benefit and obtain advanced-HF/program adjudication.

Before PCI: establish the antiplatelet course and its cost in transplant opportunity.

2024 AHA/ACC planning anchors

DES surgery requiring antiplatelet interruption

ACS PCI

Ideally ≥12 months

Elective surgery.

Chronic coronary disease

≥6 months

Elective surgery.

Time-sensitive DES

Consider ≥3 months

When waiting is more harmful.

First 30 days Interruption after BMS/DES can be harmful. Within 30 days of BMS or <3 months of DES, continue DAPT unless bleeding outweighs thrombosis protection.
Offer decision Individualize. Record indication, PCI date/anatomy/complexity, drugs/course and harm of declining an organ.

Medication exposure → operating plan

last dose + route + restart

Treatment	Required decision
Aspirin / P2Y12	Indication/last dose, operating on therapy, interruption and restart owner.
Anticoagulant	Agent/indication, kidney/liver function, last dose, surgical/anesthesia pathway and reversal. Tailor DOACs in severe renal failure.
Beta blocker / statin	Perfusion and portal-hypertension indication. Product contraindications/CNI interactions may override generic continuation.
HF drugs / diuretics	Congestion, BP, potassium and renal trajectory → administration/restart.
SGLT2	Planned hold: canagliflozin/dapagliflozin/empagliflozin 3 days, ertugliflozin 4. Short-notice offer → exposure/ketosis assessment.
PAH	Continue through LT. Protect continuous infusion, named team and backup.

Reassess as graft function changes

transplant pharmacy

Clearance Kidney grafts can rapidly change clearance. Liver grafts change metabolism, coagulation and hemodynamics.
Detailed guide Holds/restarts, reversal, statin/CNI and dofetilide/TMP-SMX interactions, insulin/GLP-1, steroid/immunosuppression routes and PAH delivery.

At the offer

Current stateReassess today. Historical clearance does not establish readiness.

New important findingEscalate before acceptance or surgery.

Waitlist triggers

retest the changed question

Cardiac change

Symptoms/events Chest pain, dyspnea, syncope, HF admission, arrhythmia, functional decline, ACS/PCI.
Other changes Valve/RV findings, medication intolerance, liver severity, dialysis or volume control.

Surveillance

PoPH Maintain treatment/hemodynamic follow-up and current exception documentation.
Intervals No universal annual stress-test interval for asymptomatic kidney candidates. Liver intervals require program judgment.

Offer-time checklist

living donor or deceased donor

Confirm	Required information
Stability	Symptoms/admissions, oxygen/rhythm, perfusion/congestion.
Evidence	Dated CAD, LV/RV, valve and PH conclusions, adequacy and remaining uncertainty.
Treatment	Recent PCI, DAPT/OAC last doses, PAH delivery and treatment-dependent conditions.
Kidney / volume	Last dialysis, potassium, achievable volume, residual function and needed treatment.
Operating plan	Anesthesia, monitoring/device plan, hemodynamic concerns, recovery location.
Ownership	Resolve pending issues now. Medication restart and follow-up owner.

Surveillance evidence gap

CARSK

Registry snapshot · 6 October 2026 Active, not recruiting. Estimated primary completion January 2028. No posted results.
Question tested Repeat screening after initial evaluation, not whether initial screening should occur.
Expiration rules Test expiration does not itself establish a benefit from retesting an unchanged patient.

Liver consult: finding → interpretation → action → readiness.

Context and reserve

verified findings

Clinical fields

Context [ ] Liver indication/severity, stage/urgency, donor pathway, simultaneous kidney evaluation.
Status [ ] Symptoms, actual activity/limits, BP/HR, oxygen, perfusion/volume.
ECG [date] Rhythm, ischemia, conduction, QT.

Echo fields

TTE [date/loading] EF/regional motion, GLS, diastology, valves, RV function, PA pressure.
CAD [ ] Risk/prior disease, test/date/adequacy/result, resolved question or uncertainty, action/rationale and result branches/reviewer.

Pulmonary circulation and oxygenation

suitability separate from allocation

PH / PoPH

RHC [date] RA, mPAP, PAWP, CO/CI, PVR WU. Method, volume state, paired same-date measurements and interpretation.
Plan [ ] Echo probability/RV, treatment/response, PH review, clinical readiness and separate exception documentation.

HPS / oxygenation

Evidence [ ] Oxygen need, contrast echo, ABG conditions, PaO2/A–a gradient.
Plan [ ] Diagnosis, pulmonary plan and separate exception documentation.

Decision and next steps

proposed ≠ completed

Assessment [ ] Complete / optimize / team decision pending / prohibitive, with findings/residual risk.
Before listing/surgery [ ] Actions, owners, completion criteria, reassessment interval, PCI/antithrombotic constraints.
Operating plan [ ] Last doses/restarts, interactions/routes, PAH delivery, monitoring and recovery.
Follow-up [ ] Clinical triggers, offer checks and teams involved. Pending studies remain explicit.

Kidney consult: coronary evidence + structure + dialysis physiology.

Current state and structure

record test conditions

Clinical fields

Context [ ] Kidney disease, dialysis modality/duration or preemptive evaluation, donor pathway, listing stage/timing.
Status [ ] Symptoms/activity, BP/HR, admissions, perfusion, weight/congestion.
Dialysis [ ] Dry weight, residual urine, last treatment, hypotension/volume difficulty, electrolytes.

ECG / TTE [dates]

ECG Rhythm, ischemia, conduction.
TTE Weight/dialysis timing, EF/regional motion, diastology, valves, RV/PA pressure.

Coronary decision

select and interpret

Pathway [ ]Known CAD / proposed low-risk branch / screening / symptom evaluation.

Evidence [ ]Test/date/adequacy, result/interpretation and unresolved question.

Treatment [ ]Prevention, symptoms/HF, rationale for medical care, angiography or intervention.

Readiness and offer plan

conditions + responsibility

Assessment [ ] Complete / optimize / team decision pending / prohibitive, with findings/residual risk.
Actions [ ] Owner/completion criterion, volume/HF reassessment, PCI/DAPT/OAC timing.
Offer [ ] Stability, last doses/restarts, graft dosing/interactions/routes, dialysis/electrolytes, monitoring/recovery.
Reassessment [ ] New events, surveillance and teams involved. Prohibitive-risk conclusion needs persistent disease, symptoms, attempted optimization and specialist/program adjudication. A low EF measured during overload is not sufficient.

Synthetic cases: identify the unresolved question, then the next action.

Liver cases

adequacy and hemodynamics

Submaximal “negative” stress

Case 58-year-old, diabetes/metabolic liver disease, preserved EF. No ischemia reported, target stress not achieved.
Next Coronary question unresolved → adequate functional/anatomic study through the advanced CAD pathway.
Pearl Preserved EF does not rescue inadequate stress.

High pressure, high flow

Case mPAP 32, PAWP 10, CO 12 L/min → PVR 1.8 WU.
Next Assess high-flow cause, volume and RV. Confirm wedge/output quality, then complete anesthesia assessment.
Pearl Below the PoPH vascular criterion. Pressure alone does not indicate PAH drugs.

Kidney cases

indication and loading

Stable asymptomatic ischemia

Case Dialysis, preserved LV function, moderate ischemia, no angina.
Next Check adequacy/prevention. Would anatomy change management, particularly suspected high-risk disease?
Pearl ISCHEMIA-CKD does not support routine PCI to normalize a screen.

Overloaded echo

Case EF 35%, high RVSP, edema after missed dialysis, no ACS features.
Next Decongest, assess causes, optimize HF therapy, repeat under documented loading. Persistent dysfunction → HF review.
Pearl First overloaded echo ≠ irreversible dysfunction or automatic exclusion.

Use Teaching examples, not organ-acceptance rules.