1
|
Gregory V, Okumura K, Isath A, Levine A, De La Pena C, Shimamura J, Spielvogel D, Kai M, Ohira S. Impact of Left Ventricular Unloading on Outcome of Heart Transplant Bridging With Extracorporeal Membrane Oxygenation Support in New Allocation Policy. J Am Heart Assoc 2024; 13:e033590. [PMID: 38742529 PMCID: PMC11179799 DOI: 10.1161/jaha.123.033590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/01/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND The new heart allocation policy places veno-arterial extracorporeal membrane oxygenation (VA-ECMO)-supported heart transplant (HT) candidates at the highest priority status. Despite increasing evidence supporting left ventricular (LV) unloading during VA-ECMO, the effect of LV unloading on transplant outcomes following bridging to HT with VA-ECMO remains unknown. METHODS AND RESULTS From October 18, 2018 to March 21, 2023, 624 patients on VA-ECMO at the time of HT were identified in the United Network for Organ Sharing database and were divided into 2 groups: VA-ECMO alone (N=384) versus VA-ECMO with LV unloading (N=240). Subanalysis was performed in the LV unloading group: Impella (N=106) versus intra-aortic balloon pump (N=134). Recipient age was younger in the VA-ECMO alone group (48 versus 53 years, P=0.018), as was donor age (VA-ECMO alone, 29 years versus LV unloading, 32 years, P=0.041). One-year survival was comparable between groups (VA-ECMO alone, 88.0±1.8% versus LV unloading, 90.4±2.1%; P=0.92). Multivariable Cox hazard model showed LV unloading was not associated with posttransplant mortality after HT (hazard ratio, 0.92; P=0.70). Different LV unloading methods had similar 1-year survival (intra-aortic balloon pump, 89.2±3.0% versus Impella, 92.4±2.8%; P=0.65). Posttransplant survival was comparable between different Impella versions (Impella 2.5, versus Impella CP, versus Impella 5.0, versus Impella 5.5). CONCLUSIONS Under the current allocation policy, LV unloading did not impact waitlist outcome and posttransplant survival in patients bridged to HT with VA-ECMO, nor did mode of LV unloading. This highlights the importance of a tailored approach in HT candidates on VA-ECMO, where routine LV unloading may not be universally necessary.
Collapse
Affiliation(s)
| | - Kenji Okumura
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
| | - Ameesh Isath
- Department of Cardiology Westchester Medical Center Valhalla NY USA
| | - Avi Levine
- New York Medical College Valhalla NY USA
- Department of Cardiology Westchester Medical Center Valhalla NY USA
| | - Corazon De La Pena
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
| | - Junichi Shimamura
- New York Medical College Valhalla NY USA
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
| | - David Spielvogel
- New York Medical College Valhalla NY USA
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
| | - Masashi Kai
- Division of Cardiac Surgery Beth Israel Deaconess Medical Center Boston MA USA
| | - Suguru Ohira
- New York Medical College Valhalla NY USA
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
| |
Collapse
|
2
|
Mardini MT, Bai C, Bledsoe M, Shickel B, Al-Ani MA. An explainable machine learning approach using contemporary UNOS data to identify patients who fail to bridge to heart transplantation. Front Cardiovasc Med 2024; 11:1383800. [PMID: 38832313 PMCID: PMC11144884 DOI: 10.3389/fcvm.2024.1383800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/30/2024] [Indexed: 06/05/2024] Open
Abstract
Background The use of Intra-aortic Balloon Pump (IABP) and Impella devices as a bridge to heart transplantation (HTx) has increased significantly in recent times. This study aimed to create and validate an explainable machine learning (ML) model that can predict the failure of status two listings and identify the clinical features that significantly impact this outcome. Methods We used the UNOS registry database to identify HTx candidates listed as UNOS Status 2 between 2018 and 2022 and supported with either Impella (5.0 or 5.5) or IABP. We used the eXtreme Gradient Boosting (XGBoost) algorithm to build and validate ML models. We developed two models: (1) a comprehensive model that included all patients in our cohort and (2) separate models designed for each of the 11 UNOS regions. Results We analyzed data from 4,178 patients listed as Status 2. Out of them, 12% had primary outcomes indicating Status 2 failure. Our ML models were based on 19 variables from the UNOS data. The comprehensive model had an area under the curve (AUC) of 0.71 (±0.03), with a range between 0.44 (±0.08) and 0.74 (±0.01) across different regions. The models' specificity ranged from 0.75 to 0.96. The top five most important predictors were the number of inotropes, creatinine, sodium, BMI, and blood group. Conclusion Using ML is clinically valuable for highlighting patients at risk, enabling healthcare providers to offer intensified monitoring, optimization, and care escalation selectively.
Collapse
Affiliation(s)
- Mamoun T. Mardini
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Chen Bai
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Maisara Bledsoe
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States
| | - Benjamin Shickel
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Mohammad A. Al-Ani
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States
| |
Collapse
|
3
|
Eapen S, Nordan T, Critsinelis AC, Li B, Chen FY, Couper GS, Kawabori M. Blood type O heart transplant candidates have longer waitlist time and higher delisting under the new allocation system. J Thorac Cardiovasc Surg 2024; 167:231-240.e7. [PMID: 36100474 DOI: 10.1016/j.jtcvs.2022.07.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/02/2022] [Accepted: 07/22/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Prior studies have examined the effect of blood type on heart transplantation (HTx) waitlist outcomes in cohorts through 2015. We aim to analyze the effect of blood type on contemporary waitlist outcomes with a new allocation system focus. METHODS Adults listed for HTx between April 2015 and December 2020 were included. Survival to HTx and waitlist death/deterioration was compared between type O and non-type O candidates using competing risks regression. Donor/recipient ABO compatibility trends were further investigated. RESULTS Candidates with blood type O (n = 7509) underwent HTx less frequently than candidates with blood type other than type O (n = 9699) (subhazard ratio [sHR], 0.56; 95% CI, 0.53-0.58) with higher rates of waitlist death/deterioration (sHR, 1.18; 95% CI, 1.04-1.34). Subgroup analyses demonstrated persistence of this trend under the new donor heart allocation system (HTx: sHR, 0.58; 95% CI, 0.54-0.62; death/clinical deterioration: sHR, 1.27; 95% CI, 1.02-1.60), especially among those listed at high status (1, 2, or 3) (HTx: sHR, 0.69; 95% CI, 0.63-0.75; death/deterioration: sHR, 1.61; 95% CI, 1.16-2.22). Among those listed at status 3, waitlist death/deterioration was modified by presence of a durable left ventricular assist device (left ventricular assist device: sHR, 1.57; 95% CI, 0.58-4.29; no left ventricular assist device: sHR, 3.79; 95% CI, 1.28-11.2). Type O donor heart allocation to secondary ABO candidates increased in the new system (14.5% vs 12.0%; P < .01); post-HTx survival remained comparable between recipients with blood type O and non-type O (log-rank P = .07). CONCLUSIONS Further logistical considerations are warranted to minimize allocation inequity regarding blood type under the new allocation system.
Collapse
Affiliation(s)
- Sarah Eapen
- Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, Boston, Mass
| | - Taylor Nordan
- Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, Boston, Mass
| | | | - Borui Li
- Division of Cardiology, CardioVascular Center, Tufts Medical Center, Boston, Mass
| | - Frederick Y Chen
- Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, Boston, Mass
| | - Gregory S Couper
- Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, Boston, Mass
| | - Masashi Kawabori
- Division of Cardiac Surgery, CardioVascular Center, Tufts Medical Center, Boston, Mass.
| |
Collapse
|
4
|
Loardi CM, Zanobini M, Ricciardi G, Vermes E. Current and future options for adult biventricular assistance: a review of literature. Front Cardiovasc Med 2023; 10:1234516. [PMID: 38028456 PMCID: PMC10657899 DOI: 10.3389/fcvm.2023.1234516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
In cardiogenic shock various short-term mechanical assistances may be employed, including an Extra Corporeal Membrane Oxygenator and other non-dischargeable devices. Once hemodynamic stabilization is achieved and the patient evolves towards a persisting biventricular dysfunction or an underlying long-standing end-stage disease is present, aside from Orthotopic Heart Transplantation, a limited number of long-term therapeutic options may be offered. So far, only the Syncardia Total Artificial Heart and the Berlin Heart EXCOR (which is not approved for adult use in the United States unlike in Europe) are available for extensive implantation. In addition to this, the strategy providing two continuous-flow Left Ventricular Assist Devices is still off-label despite its widespread use. Nevertheless, every solution ensures at best a 70% survival rate (reflecting both the severity of the condition and the limits of mechanical support) with patients suffering from heavy complications and a poor quality of life. The aim of the present paper is to summarize the features, implantation techniques, and results of current devices used for adult Biventricular Mechanical Circulatory Support, as well as a glance to future options.
Collapse
Affiliation(s)
| | - Marco Zanobini
- Department of Cardiac Surgery, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | | | - Emmanuelle Vermes
- Department of Cardiology, Amiens University Hospital, Amiens, France
| |
Collapse
|
5
|
Al-Ani MA, Bai C, Bledsoe M, Ahmed MM, Vilaro JR, Parker AM, Aranda JM, Jeng E, Shickel B, Bihorac A, Peek GJ, Bleiweis MS, Jacobs JP, Mardini MT. Utilization of the percutaneous left ventricular support as bridge to heart transplantation across the United States: In-depth UNOS database analysis. J Heart Lung Transplant 2023; 42:1597-1607. [PMID: 37307906 DOI: 10.1016/j.healun.2023.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/12/2023] [Accepted: 06/06/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Intra-aortic balloon pump (IABP) and Impella device utilization as a bridge to heart transplantation (HTx) have risen exponentially. We aimed to explore the influence of device selection on HTx outcomes, considering regional practice variation. METHODS A retrospective longitudinal study was performed on a United Network for Organ Sharing (UNOS) registry dataset. We included adult patients listed for HTx between October 2018 and April 2022 as status 2, as justified by requiring IABP or Impella support. The primary end-point was successful bridging to HTx as status 2. RESULTS Of 32,806 HTx during the study period, 4178 met inclusion criteria (Impella n = 650, IABP n = 3528). Waitlist mortality increased from a nadir of 16 (in 2019) to a peak of 36 (in 2022) per thousand status 2 listed patients. Impella annual use increased from 8% in 2019 to 19% in 2021. Compared to IABP, Impella patients demonstrated higher medical acuity and lower success rate of transplantation as status 2 (92.1% vs 88.9%, p < 0.001). The IABP:Impella utilization ratio varied widely between regions, ranging from 1.77 to 21.31, with high Impella use in Southern and Western states. However, this difference was not justified by medical acuity, regional transplant volume, or waitlist time and did not correlate with waitlist mortality. CONCLUSIONS The shift in utilizing Impella as opposed to IABP did not improve waitlist outcomes. Our results suggest that clinical practice patterns beyond mere device selection determine successful bridging to HTx. There is a critical need for objective evidence to guide tMCS utilization and a paradigm shift in the UNOS allocation system to achieve equitable HTx practice across the United States.
Collapse
Affiliation(s)
- Mohammad A Al-Ani
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida.
| | - Chen Bai
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida
| | - Maisara Bledsoe
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Mustafa M Ahmed
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Juan R Vilaro
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Alex M Parker
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Juan M Aranda
- From the Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Eric Jeng
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Benjamin Shickel
- Department of Medicine, University of Florida, Gainesville, Florida; and the Intelligent Critical Care Center (IC3), University of Florida, Gainesville, Florida
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, Florida; and the Intelligent Critical Care Center (IC3), University of Florida, Gainesville, Florida
| | - Giles J Peek
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Mark S Bleiweis
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Mamoun T Mardini
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida
| |
Collapse
|
6
|
Fox DK, Waken RJ, Wang F, Wolfe JD, Robbins K, Fanous E, Vader JM, Schilling JD, Joynt Maddox KE. The Association of the UNOS Heart Allocation Policy Change With Transplant and Left Ventricular Assist Device Access and Outcomes. Am J Cardiol 2023; 204:392-400. [PMID: 37586314 PMCID: PMC10950424 DOI: 10.1016/j.amjcard.2023.07.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/14/2023] [Indexed: 08/18/2023]
Abstract
In October 2018, the allocation policy for adult orthotopic heart transplant (OHTx) in the United States was changed, with the goal of reducing waitlist mortality and providing broader sharing of donor organs within the United States. This study aimed to assess the association of this policy change with changes in access to OHTx versus left ventricular assist devices (LVADs), overall and in key sociodemographic subgroups, in the United States from 2016 to 2019. We identified all patients receiving OHTx or LVAD between 2016 and 2019 using the National Inpatient Sample. Controlling for medical co-morbidities, prepolicy trends, and within-hospital-year effects, we fit a dynamic logistic regression model to evaluate patient and hospital factors associated with receiving OHTx versus LVAD before versus after policy change. We also examined the frequency of temporary mechanical circulatory support in the same fashion. We identified 2,264 patients who received OHTx and 3,157 who received LVADs during the study period. In its first year of implementation, the United Network for Organ Sharing policy change of 2018 was associated with no overall change utilization of OHTx versus LVAD. In OHTx recipients, the frequency of use of temporary mechanical circulatory support changed from 15.6% in the before period to 42.6% in the after period (p <0.001). Although the policy change was associated with differences in the odds of receiving an OHTx versus LVAD between different regions of the country, there were no significant changes based on age, gender, race/ethnicity, insurance status, or rurality. In conclusion, the United Network for Organ Sharing policy change on access to OHTx was associated with no overall change in OHTx versus LVAD use in its first year of implementation although we observed small changes in relative odds of transplant based on rurality. Shifts in regional allocation were not significant overall, although certain regions appeared to have a relative increase in their use of OHTx.
Collapse
Affiliation(s)
- Daniel K Fox
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - R J Waken
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; Center for Advancing Health Services, Policy & Economics Research, Institute for Public Health, Washington University in St. Louis
| | - Fengxian Wang
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; Center for Advancing Health Services, Policy & Economics Research, Institute for Public Health, Washington University in St. Louis
| | - Jonathan D Wolfe
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Keenan Robbins
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Erika Fanous
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Justin M Vader
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Joel D Schilling
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, Missouri
| | - Karen E Joynt Maddox
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri; Center for Advancing Health Services, Policy & Economics Research, Institute for Public Health, Washington University in St. Louis.
| |
Collapse
|
7
|
Gong TA, Hall SA. Challenges with the current United Network for Organ Sharing heart allocation system. Curr Opin Organ Transplant 2023; 28:355-361. [PMID: 37595099 DOI: 10.1097/mot.0000000000001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
PURPOSE OF REVIEW The revised United States heart organ allocation system was launched in October 2018. In this review, we summarize this United Network for Organ Sharing (UNOS) policy and describe intended and unintended consequences. RECENT FINDINGS Although early studies published after the change suggested postheart transplant survival declined at 6 months and 1 year, recent publications with longer follow-up time have confirmed comparable posttransplant survival in adjusted models and several patient cohorts. Moreover, the new allocation decreased overall waitlist time from 112 to 39 days ( P < 0.001). Mean ischemic time increased because of greater distances traveled to acquire donor hearts under broader sharing. Despite the intention to decrease exception requests by expanding the number of priority tiers to provide more granular risk stratification, ∼30% of patients remain waitlisted under exception status. Left-ventricular assist device (LVAD) implants are declining and the number of LVAD patients on the transplant list has decreased dramatically after the allocation system change. SUMMARY As the next allocation system is developed, it is imperative to curtail the use of temporary mechanical support as a strategy solely for listing purposes, identify attributes that more clearly stratify the severity of illness, provide greater oversight of exception requests, and address concerns regarding patients with durable LVADs.
Collapse
Affiliation(s)
- Timothy A Gong
- Center for Advanced Heart and Lung Disease, Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
- Division of Cardiology, Department of Advanced Heart Failure, Mechanical Support, and Transplant, Baylor Heart and Vascular Hospital, Dallas
- Texas A&M University College of Medicine, Bryan, Texas
| | - Shelley A Hall
- Center for Advanced Heart and Lung Disease, Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
- Division of Cardiology, Department of Advanced Heart Failure, Mechanical Support, and Transplant, Baylor Heart and Vascular Hospital, Dallas
- Texas A&M University College of Medicine, Bryan, Texas
| |
Collapse
|
8
|
Cohen WG, Rekhtman D, Iyengar A, Shin M, Ibrahim M, Bermudez C, Cevasco M, Wald J. Extended Support With the Impella 5.5: Transplant, ECMO, and Complications. ASAIO J 2023; 69:642-648. [PMID: 37039780 DOI: 10.1097/mat.0000000000001931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
We report midterm results of Impella 5.5 use with focus placed on bridge-outcomes, venoarterial extracorporeal membrane oxygenation (VA-ECMO) transition, complications, and risk factors for mortality. A retrospective review of patients implanted with the Impella 5.5 at our medical center was conducted. Forty patients were included with varying bridge strategies. Sixteen (40%) patients were supported for <14 days, 13 (32.5%) for 14-30 days, and 11 (27.5%) for >30 days. Thirty day mortality was 22.5% (9/40). Twenty-five (62.5%) were successfully bridged to transplant or durable left ventricular assist device (LVAD), while four (10.0%) recovered without the need for any further cardiac support. Five of 11 (60%) patients initially supported with VA-ECMO were either transitioned to durable left ventricular assist device (dLVAD; n = 3, 27.3%), transplanted (n = 1, 9.1%), or recovered (n = 1, 9.1%). Of nine patients with >moderate right ventricle (RV) dysfunction, five (55.6%) were successfully bridged to transplant or LVAD. Five (12.5%) patients required interval cannulation to VA-ECMO, often in the setting of RV dysfunction, and all (100%) were successfully transplanted. Lower pulmonary artery (PA) systolic pressure ( P = 0.029), among other factors, was associated with mortality. In summary, the Impella 5.5 may be able to effectively stabilize patients in refractory left ventricular predominant cardiogenic shock for extended durations, allowing time for mechanical circulatory support (MCS) and transplant evaluations.
Collapse
Affiliation(s)
- William G Cohen
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Rekhtman
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Max Shin
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Ibrahim
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce Wald
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
9
|
Salter BS, Gross CR, Weiner MM, Dukkipati SR, Serrao GW, Moss N, Anyanwu AC, Burkhoff D, Lala A. Temporary mechanical circulatory support devices: practical considerations for all stakeholders. Nat Rev Cardiol 2023; 20:263-277. [PMID: 36357709 PMCID: PMC9649020 DOI: 10.1038/s41569-022-00796-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 11/12/2022]
Abstract
Originally intended for life-saving salvage therapy, the use of temporary mechanical circulatory support (MCS) devices has become increasingly widespread in a variety of clinical settings in the contemporary era. Their use as a short-term, prophylactic support vehicle has expanded to include procedures in the catheterization laboratory, electrophysiology suite, operating room and intensive care unit. Accordingly, MCS device design and technology continue to develop at a rapid pace. In this Review, we describe the functionality, indications, management and complications associated with temporary MCS, together with scenario-specific utilization, goal-directed development and bioengineering of future devices. We address various considerations for the use of temporary MCS devices in both prophylactic and rescue scenarios, with input from stakeholders from various cardiovascular specialties, including interventional and heart failure cardiology, electrophysiology, cardiothoracic anaesthesiology, critical care and cardiac surgery.
Collapse
Affiliation(s)
- Benjamin S Salter
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Caroline R Gross
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Menachem M Weiner
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregory W Serrao
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
| | - Noah Moss
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
| | - Anelechi C Anyanwu
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Mount Sinai, New York, NY, USA
| |
Collapse
|
10
|
Sawinski D, Lai JC, Pinney S, Gray AL, Jackson AM, Stewart D, Levine DJ, Locke JE, Pomposelli JJ, Hartwig MG, Hall SA, Dadhania DM, Cogswell R, Perez RV, Schold JD, Turgeon NA, Kobashigawa J, Kukreja J, Magee JC, Friedewald J, Gill JS, Loor G, Heimbach JK, Verna EC, Walsh MN, Terrault N, Testa G, Diamond JM, Reese PP, Brown K, Orloff S, Farr MA, Olthoff KM, Siegler M, Ascher N, Feng S, Kaplan B, Pomfret E. Addressing sex-based disparities in solid organ transplantation in the United States - a conference report. Am J Transplant 2023; 23:316-325. [PMID: 36906294 DOI: 10.1016/j.ajt.2022.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/17/2022] [Accepted: 11/04/2022] [Indexed: 01/15/2023]
Abstract
Solid organ transplantation provides the best treatment for end-stage organ failure, but significant sex-based disparities in transplant access exist. On June 25, 2021, a virtual multidisciplinary conference was convened to address sex-based disparities in transplantation. Common themes contributing to sex-based disparities were noted across kidney, liver, heart, and lung transplantation, specifically the existence of barriers to referral and wait listing for women, the pitfalls of using serum creatinine, the issue of donor/recipient size mismatch, approaches to frailty and a higher prevalence of allosensitization among women. In addition, actionable solutions to improve access to transplantation were identified, including alterations to the current allocation system, surgical interventions on donor organs, and the incorporation of objective frailty metrics into the evaluation process. Key knowledge gaps and high-priority areas for future investigation were also discussed.
Collapse
Affiliation(s)
- Deirdre Sawinski
- Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York, USA.
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, University of California, San Francisco, California, USA
| | - Sean Pinney
- University of Chicago Medicine, Chicago, Illinois, USA
| | - Alice L Gray
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Annette M Jackson
- Department of Surgery, Duke University, Department of Surgery, Durham, Carolina, USA
| | - Darren Stewart
- United Network for Organ Sharing, Richmond, Virginia, USA
| | | | - Jayme E Locke
- University of Alabama at Birmingham, Heersink School of Medicine, Birmingham, Alabama, USA
| | - James J Pomposelli
- Department of Surgery University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | | | | | - Darshana M Dadhania
- Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York, USA
| | - Rebecca Cogswell
- University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Richard V Perez
- Department of Surgery, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Jon Kobashigawa
- Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, California, USA
| | - John C Magee
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - John Friedewald
- Northwestern University Feinberg School of Medicine, Chicago, Illinois USA
| | - John S Gill
- Division of Nephrology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Gabriel Loor
- Baylor College of Medicine Lung Institute, Houston, Texas, USA
| | | | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University, Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Mary Norine Walsh
- Ascension St Vincent Heart Center, Indianapolis, Indianapolis, Indiana, USA
| | - Norah Terrault
- Keck Medicine of University of Southern California, Los Angeles, California, USA
| | - Guiliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter P Reese
- Division of Renal, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Susan Orloff
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Portland, Oregon, USA
| | - Maryjane A Farr
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kim M Olthoff
- Department of Surgery, Penn Transplant Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark Siegler
- University of Chicago Medicine, Chicago, Illinois, USA; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - Nancy Ascher
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Sandy Feng
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Bruce Kaplan
- Department of Surgery University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| | - Elizabeth Pomfret
- Department of Surgery University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado, USA
| |
Collapse
|
11
|
Anticoagulation Strategies in Temporary Mechanical Circulatory Support. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023. [DOI: 10.1007/s11936-023-00978-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
|
12
|
Cohen WG, Han J, Shin M, Iyengar A, Wang X, Helmers MR, Cevasco M. Lack of volume-outcome association in ECMO bridge to heart transplantation. J Card Surg 2022; 37:4883-4890. [PMID: 36352776 DOI: 10.1111/jocs.17157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a bridge to cardiac transplantation. As the 2018 United Network for Organ Sharing (UNOS) heart allocation policy change elevated waitlist status for patients receiving mechanical circulatory support (MCS), we aimed to determine if a center's annual heart transplant volume was associated with ECMO-support duration and posttransplant outcomes. METHODS Adults heart transplant candidates between January 1, 2011, and December 31, 2021, were isolated in the UNOS database. VA-ECMO use was identified at the time of listing for transplant. Average annual transplant volume was calculated by the center, with stratification as high (≥20 cardiac transplants, high volume center [HVC]) or low (<20 cardiac transplants, low volume center [LVC]) volume centers. Results are reported as mean (interquartile range) or n (%). RESULTS In total, 543 patients at HVCs and 275 at LVCs were listed for transplant supported with VA-ECMO. Those listed at HVCs were more likely to be supported by intra-aortic balloon pump (103 [19%] vs. 32 [11.6%], p = .008) and inotropes (267 [49.2%] vs. 106 [38.5%], p = .004) at time of listing. Patients at HVCs received ECMO support for 6 [4-9] days, compared to 8 [4-15] days at low-volume centers (p = .030), and but were cannulated a similar time before listing (2 [1-5] vs. 3 [1-7] days, p = .517). There were no differences in rates of transplant (p = .2126), waitlist mortality (p = .8645), delisting due to clinical deterioration (p = .8419), or recovery (p = .1773) between groups. Among transplanted patients, there were no differences in support duration (6 [4-8] vs. 6 [4-10], p = .187), or time from registration to transplant (5 [2-20] vs. 7 [3-22] days, p = .560). Posttransplant survival did not vary (p = .293). CONCLUSIONS LVCs can successfully bridge patients to transplant with VA-ECMO and achieve comparable outcomes to HVCs.
Collapse
Affiliation(s)
- William G Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason Han
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Xingmei Wang
- Perelman School of Medicine at the University of Pennsylvania, Biostatistics Analysis Center, Philadelphia, Pennsylvania, USA
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marisa Cevasco
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
13
|
Hwang NC, Sivathasan C. Preoperative Evaluation and Care of Heart Transplant Candidates. J Cardiothorac Vasc Anesth 2022; 36:4161-4172. [PMID: 36028377 DOI: 10.1053/j.jvca.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 06/20/2022] [Accepted: 07/08/2022] [Indexed: 11/11/2022]
Abstract
Heart transplantation is recommended for patients with advanced heart failure refractory to medical and device therapy, and who do not have absolute contraindications. When patients become eligible for heart transplantation, they undergo comprehensive evaluation and preparation to optimize their posttransplantation outcomes. This review provides an overview of the processes that are employed to enable the candidates to be transplant-ready when donor hearts are available.
Collapse
Affiliation(s)
- Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore.
| | - Cumaraswamy Sivathasan
- Mechanical Cardiac Support and Heart Transplant Program, Department of Cardiothoracic Surgery, National Heart Centre, Singapore
| |
Collapse
|
14
|
A Holistic View of Advanced Heart Failure. Life (Basel) 2022; 12:life12091298. [PMID: 36143336 PMCID: PMC9501910 DOI: 10.3390/life12091298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/08/2022] [Accepted: 08/21/2022] [Indexed: 01/12/2023] Open
Abstract
Advanced heart failure (HF) may occur at any level of left ventricular (LV) ejection fraction (LVEF). The latter, which is widely utilized for the evaluation of LV systolic performance and treatment guidance of HF patients, is heavily influenced by LV size and geometry. As the accurate evaluation of ventricular systolic function and size is crucial in patients with advanced HF, the LVEF should be supplemented or even replaced by more specific indices of LV function such as the systolic strain and cardiac power output and size such as the LV diastolic diameters and volumes. Conventional treatment (cause eradication, medications, devices) is often poorly tolerated and fails and advanced treatment (mechanical circulatory support [MCS], heart transplantation [HTx]) is required. The effectiveness of MCS is heavily dependent on heart size, whereas HTx which is effective in the vast majority of the cases is limited by the small donor pool. Expanding the MCS indications to include patients with small ventricles as well as the HTx donor pool are major challenges in the management of advanced HF.
Collapse
|
15
|
Siddiqi U, Lirette S, Hoang R, Cruz J, Mohammed A, Copeland J, Baran DA, Copeland H. Ischemic time and patient outcomes after the 2018 UNOS donor heart allocation system change. J Card Surg 2022; 37:2685-2690. [PMID: 35678362 DOI: 10.1111/jocs.16668] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/03/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The allocation system for heart donors in the United States changed on October 18, 2018. The typical distance from donor hospitals to recipient hospitals has increased as has the ischemic time. We investigated patient outcomes with the new allocation system and the differential effects of ischemic time under both the old and new allocation schemas. METHODS The United Network for Organ Sharing Registry (UNOS) was queried for data regarding heart transplants occurring from October 1, 1987 to March 1, 2021. In total, 62,301 adult heart transplants were examined. Survival outcomes at 30 days and 1 year and ischemic times were compared via adjusted logistic and Cox models (overall survival and time until post-transplant rejection). RESULTS Mean ischemic time was slightly increased in the new system (3.43 h vs. 3.03 h, p < .001). Survival differences between old versus new systems were not observed in adjusted models (p = .818). However, there was evidence to suggest longer ischemic times are more detrimental to long-term survival under the new system (hazard ratio [HR] = 1.15 per hour increase; p = .001) versus the old system (HR = 1.08 per hour increase; p < .001), although this relationship did not reach statistical significance (p = .150). CONCLUSIONS Although travel distances have significantly increased under the new allocation system, survival outcomes remain largely unchanged. Ischemic time is an influential factor in recipient survival that should be limited during organ transport. Further studies on the impact of travel distances and ischemic time under the new allocation system are needed.
Collapse
Affiliation(s)
- Umar Siddiqi
- Department of Surgery, Section of Cardiac Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | | | - Ryan Hoang
- Department of Surgery, Section of Cardiac Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Jennifer Cruz
- Department of Surgery, Section of Cardiac Surgery, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Asim Mohammed
- Lutheran Hospital Department of Cardiovascular Surgery, Heart Transplant, Mechanical Circulatory Support and ECMO - Fort Wayne, Indiana University School of Medicine - Fort Wayne (IUSM-FW), Fort Wayne, Indiana, USA
| | - Jack Copeland
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - David A Baran
- Clevelad Clinic Heart and Vascular Institute Division of Cardiology, Norfolk, Virginia, USA
| | - Hannah Copeland
- Lutheran Hospital Department of Cardiovascular Surgery, Heart Transplant, Mechanical Circulatory Support and ECMO - Fort Wayne, Indiana University School of Medicine - Fort Wayne (IUSM-FW), Fort Wayne, Indiana, USA
| |
Collapse
|
16
|
Yazji JH, Garg P, Wadiwala I, Alomari M, Alamouti-Fard E, Hussain MWA, Jacob S. Expanding Selection Criteria to Repairable Diseased Hearts to Meet the Demand of Shortage of Donors in Heart Transplantation. Cureus 2022; 14:e25485. [PMID: 35663679 PMCID: PMC9150717 DOI: 10.7759/cureus.25485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2022] [Indexed: 11/05/2022] Open
Abstract
Heart transplant surgery is considered the destination therapy for end-stage heart disease. Unfortunately, many patients in the United States of America who are eligible candidates for transplants cannot undergo surgery due to donor shortage. In addition, some donors' hearts are being labeled as unacceptable for transplant surgery because of the rigorous and restricted rules placed on the approval process of using a donor's heart. Over the last few decades, the rising discrepancy between the scarcity of donor hearts and the demand for such organs has led to the discussion of expanding the donor heart selection criteria. A softer view on using marginal hearts for transplants would help those on the waitlist to receive a heart transplant. Marginal hearts that contain the hepatitis c virus (HCV), COVID-19, older age, or repairable heart defects have become viable options to use for a heart transplant. Also, the prioritization based on the new heart allocation system would help efficiently decide which recipients would be the first to get a donor's heart. Recently there has been a consensus to broaden the eligibility of donor's hearts by accepting valvular abnormalities, coronary artery disease, and congenital abnormalities. This review highlights some of those expansions in selection criteria in particular using repairable hearts, which could be fixed in the operating room on the back table before transplantation.
Collapse
|
17
|
Wang TS, Cevasco M, Birati EY, Mazurek JA. Predicting, Recognizing, and Treating Right Heart Failure in Patients Undergoing Durable LVAD Therapy. J Clin Med 2022; 11:jcm11112984. [PMID: 35683372 PMCID: PMC9181012 DOI: 10.3390/jcm11112984] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 12/04/2022] Open
Abstract
Despite advancing technology, right heart failure after left ventricular assist device implantation remains a significant source of morbidity and mortality. With the UNOS allocation policy change, a larger proportion of patients proceeding to LVAD are destination therapy and consist of an overall sicker population. Thus, a comprehensive understanding of right heart failure is critical for ensuring the ongoing success of durable LVADs. The purpose of this review is to describe the effect of LVAD implantation on right heart function, review the diagnostic and predictive criteria related to right heart failure, and discuss the current evidence for management and treatment of post-LVAD right heart failure.
Collapse
Affiliation(s)
- Teresa S. Wang
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Correspondence: ; Tel.: +1-267-624-7276
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Edo Y. Birati
- Division of Cardiovascular Medicine, Padeh-Poriya Medical Center, Bar-Ilan University, Ramat Gan 5290002, Israel;
| | - Jeremy A. Mazurek
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| |
Collapse
|
18
|
Abramov D, Minhas AMK, Fudim M, Chung JS, Patel JN, Rabkin DG. Impact of the heart transplant allocation policy change on inpatient cost of index hospitalization. Clin Transplant 2022; 36:e14692. [PMID: 35499219 PMCID: PMC9541533 DOI: 10.1111/ctr.14692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/01/2022] [Accepted: 04/25/2022] [Indexed: 11/30/2022]
Abstract
Background We sought to determine the financial impact of the United Network for Organ Sharing heart transplant (HT) allocation policy change of October 2018. Methods Using the Nationwide Inpatient Sample we retrospectively analyzed hospital discharge data between January 1, 2016 and December 31, 2019. ICD‐10‐CM procedure codes were used to identify hospitalizations of patients undergoing HT as well as the use of temporary mechanical circulatory support (MCS) during the HT hospitalization. Patients < 18 years old and those with missing data on costs were excluded. The primary outcome was inflation‐adjusted costs. Total costs were inflated to 2019 US dollars. Results During the course of the study, temporary MCS increased significantly among 11 380 weighted patients transplanted while mean length of stay (LOS) did not. Mean inflation‐adjusted costs rose about $40k per HT. On univariate analysis, transplantation year, use of temporary MCS and LOS were all significantly associated with increased cost while on multivariate analysis only temporary MCS and LOS were. Conclusions The 2018 allocation change has resulted in more expensive inpatient costs for HT correlating with an increase in temporary MCS.
Collapse
Affiliation(s)
- Dmitry Abramov
- Department of Medicine, Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | | | - Marat Fudim
- Department of Medicine, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Josh S Chung
- Department of Cardiothoracic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Jay N Patel
- Division of Cardiology, Loma Linda Veterans Administration Healthcare System, Loma Linda, CA, USA
| | - David G Rabkin
- Department of Cardiothoracic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| |
Collapse
|
19
|
Shah P, Yuzefpolskaya M, Hickey GW, Breathett K, Wever-Pinzon O, Ton VK, Hiesinger W, Koehl D, Kirklin JK, Cantor RS, Jacobs JP, Habib RH, Pagani FD, Goldstein DJ. Twelfth Interagency Registry for Mechanically Assisted Circulatory Support Report: Readmissions After Left Ventricular Assist Device. Ann Thorac Surg 2022; 113:722-737. [PMID: 35007505 PMCID: PMC8854346 DOI: 10.1016/j.athoracsur.2021.12.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 02/07/2023]
Abstract
The twelfth annual report from The Society of Thoracic Surgeons (STS) Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) highlights outcomes for 26 688 continuous-flow left ventricular assist device (LVAD) patients over the past decade (2011-2020). In 2020, we observed the largest drop in yearly LVAD implant volumes since the registry's inception, which reflects the effects of the COVID-19 pandemic on cardiac surgical volumes in the United States. The 2018 heart transplant allocation policy change in the United States continues to affect LVAD implantation volumes and device strategy, with 78.1% of patients now receiving LVAD implants as destination therapy. Despite an older and sicker patient cohort, survival in the recent era (2016-2020) at 1 and 2 years continues to improve at 82.8% and 74.1%. Patient adverse event profile has also improved in the recent era, with significant reductions in stroke, gastrointestinal bleeding, infection, and device malfunction/pump thrombosis. Finally, we review the burden of readmissions after LVAD implant and highlight an opportunity to improve patient outcomes by reducing this frequent and vexing problem.
Collapse
Affiliation(s)
- Palak Shah
- Heart Failure, Mechanical Circulatory Support and Transplant, Inova Heart and Vascular Institute, Falls Church, Virginia.
| | - Melana Yuzefpolskaya
- Division of Cardiovascular Medicine, Columbia University Irving Medical Center, New York City, New York
| | - Gavin W Hickey
- Division of Cardiovascular Medicine, UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
| | - Van-Khue Ton
- Advanced Heart Failure, Mechanical Circulatory Support and Heart Transplant, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James K Kirklin
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey P Jacobs
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | | | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Daniel J Goldstein
- Department of Cardiothoracic Surgery, Montefiore Medical Center, Bronx, New York
| |
Collapse
|
20
|
Patel JN, Abramov D, Fudim M, Okwuosa IS, Rabkin DG, Chung JS. The heart transplant allocation change attenuates but does not eliminate blood group O waitlist outcome disadvantage. Clin Transplant 2022; 36:e14620. [PMID: 35213753 PMCID: PMC9285771 DOI: 10.1111/ctr.14620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/08/2022] [Accepted: 02/12/2022] [Indexed: 11/28/2022]
Abstract
Background Patients with blood group O have historically been disadvantaged in the United Network for Organ Sharing (UNOS) heart transplant allocation system. We sought to determine whether the new UNOS allocation system implemented in 2018 had an impact on waitlist and post‐transplant outcomes among blood groups. Methods Using the UNOS database we included all adult patients listed and transplanted with first‐time single‐organ heart transplant between 10/17/15 and 10/1/21. For post‐transplant outcomes, we separately evaluated all adult patients transplanted with the same time‐frame. We used exclusion criteria and censoring to limit biases from changing clinical practices around the allocation change (10/18/2018), and from unequal or inadequate follow‐up. We compared clinical characteristics and outcomes before and after the allocation change among each blood group. Fine‐Gray and Cox regression models were used to estimate the effect of the new allocation system on competing waitlist outcomes‐ transplantation, death‐or‐removal from waitlist‐ and post‐transplant survival, respectively. Results Of the 21,565 patients listed for transplantation 14,000 met criteria for waitlist analysis (7,035 in the old system vs. 6,965 in the new), and 7,657 met criteria for post‐transplant analysis (3,519 in the old system vs. 4,138 in the new). Among each blood group, new allocation change was associated with higher transplantation rates lower waitlist days and lower waitlist mortality (except Group AB). However, despite improvements, Group O was still associated with worse waitlist outcomes for each metric compared to non‐O Groups. The new allocation system did not have a significant impact on post‐transplant survival among any blood groups. Conclusion Changes in heart transplant allocation have attenuated but not eliminated blood group O disadvantage in access to donor hearts.
Collapse
Affiliation(s)
- Jay N Patel
- Division of Cardiology, Loma Linda Veterans Administration Healthcare System, Loma Linda, CA, USA
| | - Dmitry Abramov
- Department of Medicine, Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Marat Fudim
- Department of Medicine, Duke University Medical Center, Durham, NC and Duke Clinical Research Institute, Durham, NC, USA
| | - Ike S Okwuosa
- Bluhm Cardiovascular Institute, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - David G Rabkin
- Department of Cardiothoracic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Joshua S Chung
- Department of Cardiothoracic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| |
Collapse
|
21
|
Abstract
Cardiac transplantation is considered the gold-standard treatment option for patients suffering from end-stage heart failure refractory to maximum medical therapy. A major determinant of graft function and recipient survival is a comprehensive evaluation of the donor allograft. Challenges arise when designing and implementing an evidence-based donor evaluation protocol due to the number of influential donor-specific characteristics and the complex interactions that occur between them. Here, we present our systematic approach to donor evaluation by examining the impact that relevant donor variables have on graft function and recipient outcomes.
Collapse
Affiliation(s)
- Robert Tatum
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, 1025 Walnut St, Suite 607, Philadelphia, PA 19107 USA
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, 20 Hawkins Drive E318, Iowa City, IA 52242 USA
| | - Vakhtang Tchantchaleishvili
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, 1025 Walnut St, Suite 607, Philadelphia, PA 19107 USA
| | - H. Todd Massey
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, 1025 Walnut St, Suite 607, Philadelphia, PA 19107 USA
| |
Collapse
|
22
|
Hickner B, Anand A, Godfrey EL, Dunson J, Reul RM, Cotton R, Galvan NTN, O'Mahony C, Goss JA, Rana A. Trends in Survival for Pediatric Transplantation. Pediatrics 2022; 149:184553. [PMID: 35079811 DOI: 10.1542/peds.2020-049632] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Progress in pediatric transplantation measured in the context of waitlist and posttransplant survival is well documented but falls short of providing a complete perspective for children and their families. An intent-to-treat analysis, in which we measure survival from listing to death regardless of whether a transplant is received, provides a more comprehensive perspective through which progress can be examined. METHODS Univariable and multivariable Cox regression was used to analyze factors impacting intent-to-treat survival in 12 984 children listed for heart transplant, 17 519 children listed for liver transplant, and 16 699 children listed for kidney transplant. The Kaplan-Meier method and log-rank test were used to assess change in waitlist, posttransplant, and intent-to-treat survival. Wait times and transplant rates were compared by using χ2 tests. RESULTS Intent-to-treat survival steadily improved from 1987 to 2017 in children listed for heart (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.96-0.97), liver (HR 0.95, 95% CI 0.94-0.97), and kidney (HR 0.97, 95% CI 0.95-0.99) transplant. Waitlist and posttransplant survival also improved steadily for all 3 organs. For heart transplant, the percentage of patients transplanted within 1 year significantly increased from 1987 to 2017 (60.8% vs 68.7%); however, no significant increase was observed in liver (68.9% vs 72.5%) or kidney (59.2% vs 62.7%) transplant. CONCLUSIONS Intent-to-treat survival, which is more representative of the patient perspective than individual metrics alone, steadily improved for heart, liver, and kidney transplant over the study period. Further efforts to maximize the donor pool, improve posttransplant outcomes, and optimize patient care while on the waitlist may contribute to future progress.
Collapse
Affiliation(s)
| | | | - Elizabeth L Godfrey
- Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut
| | | | | | - Ronald Cotton
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Nhu Thao Nguyen Galvan
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Christine O'Mahony
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Abbas Rana
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
23
|
Patient selection for heart transplant: balancing risk. Curr Opin Organ Transplant 2022; 27:36-44. [PMID: 34939963 DOI: 10.1097/mot.0000000000000943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Heart failure incidence continues to rise despite a relatively static number of available donor hearts. Selecting an appropriate heart transplant candidate requires evaluation of numerous factors to balance patient benefit while maximizing the utility of scarce donor hearts. Recent research has provided new insights into refining recipient risk assessment, providing additional tools to further define and balance risk when considering heart transplantation. RECENT FINDINGS Recent publications have developed models to assist in risk stratifying potential heart transplant recipients based on cardiac and noncardiac factors. These studies provide additional tools to assist clinicians in balancing individual risk and benefit of heart transplantation in the context of a limited donor organ supply. SUMMARY The primary goal of heart transplantation is to improve survival and maximize quality of life. To meet this goal, a careful assessment of patient-specific risks is essential. The optimal approach to patient selection relies on integrating recent prognostication models with a multifactorial assessment of established clinical characteristics, comorbidities and psychosocial factors.
Collapse
|
24
|
Alvarez P, Kitai T, Okamoto T, Niikawa H, McCurry KR, Papamichail A, Doulamis I, Briasoulis A. Trends, risk factors, and outcomes of post-operative stroke after heart transplantation: an analysis of the UNOS database. ESC Heart Fail 2021; 8:4211-4217. [PMID: 34431235 PMCID: PMC8497374 DOI: 10.1002/ehf2.13562] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/14/2021] [Accepted: 08/04/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Post-operative stroke increases morbidity and mortality after cardiac surgery. Data on characteristics and outcomes of stroke after heart transplantation (HTx) are limited. METHODS AND RESULTS We conducted a retrospective analysis of the United Network for Organ Sharing (UNOS) database from 2009 to 2020 to identify adults who developed stroke after orthotropic HTx. Heart transplant recipients were divided according to the presence or absence of post-operative stroke. The primary endpoint was all-cause mortality. A total of 25 015 HT recipients were analysed, including 719 (2.9%) patients who suffered a post-operative stroke. The stroke rates increased from 2.1% in 2009 to 3.7% in 2019, and the risk of stroke was higher after the implantation of the new allocation system [odds ratio 1.29, 95% confidence intervals (CI) 1.06-1.56, P = 0.01]. HTx recipients with post-operative stroke were older (P = 0.008), with higher rates of prior cerebrovascular accident (CVA) (P = 0.004), prior cardiac surgery (P < 0.001), longer waitlist time (P = 0.04), higher rates of extracorporeal membrane oxygenation (ECMO) support (P < 0.001), left ventricular assist devices (LVADs) (P < 0.001), mechanical ventilation (P = 0.003), and longer ischaemic time (P < 0.001). After multivariable adjustment for recipient and donor characteristics, age, prior cardiac surgery, CVA, support with LVAD, ECMO, ischaemic time, and mechanical ventilation at the time of HTx were independent predictors of post-operative stroke. Stroke was associated with increased risk of 30 day and all-cause mortality (hazard ratio 1.49, 95% CI 1.12-1.99, P = 0.007). CONCLUSIONS Post-operative stroke after HTx is infrequent but associated with higher mortality. Redo sternotomy, LVAD, and ECMO support at HTx are among the risk factors identified.
Collapse
Affiliation(s)
- Paulino Alvarez
- Division of Cardiology, Heart and Vascular InstituteCleveland ClinicClevelandOHUSA
| | - Takeshi Kitai
- Department of Cardiovascular MedicineKobe City Medical Center General HospitalKobeJapan
| | - Toshihiro Okamoto
- Department of Thoracic and Cardiovascular SurgeryCleveland ClinicClevelandOHUSA
| | - Hiromichi Niikawa
- Department of Thoracic and Cardiovascular SurgeryTohoku UniversitySendaiJapan
| | - Kenneth R. McCurry
- Department of Thoracic and Cardiovascular SurgeryCleveland ClinicClevelandOHUSA
| | | | - Ilias Doulamis
- Department of Cardiac Surgery, Boston's Children HospitalHarvard Medical SchoolBostonMAUSA
| | - Alexandros Briasoulis
- National Kapodistrian University of Athens Medical SchoolAthensGreece
- Division of Cardiovascular Medicine, Section of Heart Failure and TransplantationUniversity of Iowa200 Hawkins DrIowa CityIA52242USA
| |
Collapse
|
25
|
Pagani FD, Cantor R, Cowger J, Goldstein DJ, Teuteberg JJ, Mahr CW, Atluri P, Kilic A, Maozami N, Habib RH, Naftel D, Kirklin JK. Concordance of Treatment Effect: An Analysis of The Society of Thoracic Surgeons Intermacs Database. Ann Thorac Surg 2021; 113:1172-1182. [PMID: 34087236 DOI: 10.1016/j.athoracsur.2021.05.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/28/2021] [Accepted: 05/02/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Society of Thoracic Surgeons (STS) Intermacs Registry represents a real-world data source of durable, left ventricular assist devices that can address knowledge gaps not informed through randomized clinical trials. We sought to compare survival with contemporary left ventricular assist device technologies using multiple analytic approaches to assess concordance of treatment effects and to validate prior STS Intermacs observations. METHODS Patients (aged > 19 years) enrolled into STS Intermacs between August 2017 - June 2019 were stratified by device type (centrifugal device with hybrid levitation [CF-HL] or full magnetic levitation [CF-FML]). The primary outcome was 1-year survival assessed by three statistical methodologies (multivariable regression, propensity score matching, and instrumental variable analysis). RESULTS Of 4,448 patients, 2,012 (45.2%) received CF-HL and 2,436 (54.8%) received CF-FML. One-year survival for CF-FML was 88% vs. 79% for CF-HL (overall p < .001), with a hazard ratio for mortality of 3.18 for CF-HL (p<0.0001) after risk adjustment. With propensity score matching (n=1400 each cohort), 1-year survival was 87% for CF-FML vs. 80% for CF-HL, with a hazard ratio of 3.20 for mortality with CF-HL (p<0.0001) after risk adjustment. With an instrumental variable analysis, the probability of receiving CF-HL was associated with a hazard ratio of 3.11 (p<0.0001). CONCLUSIONS Statistical methodology using propensity score matching and instrumental variable analysis increased the robustness of observations derived from real-world data and demonstrates the feasibility of performing comparative effectiveness research using STS Intermacs. These analyses provide additional evidence supporting a survival benefit of CF-FML versus CF-HL.
Collapse
Affiliation(s)
- Francis D Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
| | - Ryan Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Daniel J Goldstein
- Department of Cardiothoracic & Vascular Surgery, Montefiore Einstein Center for Heart and Vascular Care, New York, New York
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, California
| | - Claudius W Mahr
- Department of Medicine, University of Washington Medical Center, Seattle, Washington
| | - Pavan Atluri
- Division of Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arman Kilic
- Division of Cardiac Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Nader Maozami
- Department of Cardiothoracic Surgery, Langone Medical Center, New York University, New York, New York
| | - Robert H Habib
- The Society of Thoracic Surgeons Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - David Naftel
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| |
Collapse
|
26
|
Atluri P, Balsam LB. Invited Expert Opinion papers on mechanical circulatory support. J Thorac Cardiovasc Surg 2021; 162:140-142. [PMID: 33994001 DOI: 10.1016/j.jtcvs.2021.03.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 03/19/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Leora B Balsam
- Division of Cardiac Surgery, UMass Memorial Medical Center, Worcester, Mass.
| |
Collapse
|
27
|
Rao V. Commentary: The ethics of donor allocation. J Thorac Cardiovasc Surg 2020; 161:1849-1851. [PMID: 33220969 DOI: 10.1016/j.jtcvs.2020.09.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Vivek Rao
- Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada.
| |
Collapse
|
28
|
Knoper RC, John R. Commentary: The only constant is change: Understanding the changes in the new heart allocation system. J Thorac Cardiovasc Surg 2020; 161:1851-1852. [PMID: 33288240 DOI: 10.1016/j.jtcvs.2020.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/01/2020] [Accepted: 10/02/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Ryan C Knoper
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn.
| | - Ranjit John
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn
| |
Collapse
|