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Colvin MM, Smith JM, Ahn YS, Handarova DK, Martinez AC, Lindblad KA, Israni AK, Snyder JJ. OPTN/SRTR 2022 Annual Data Report: Heart. Am J Transplant 2024; 24:S305-S393. [PMID: 38431362 DOI: 10.1016/j.ajt.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
The number of heart transplants in the United States has continued to increase. Since 2011, pediatric heart transplants have increased 31.7% to 494 and adult heart transplants have increased 85.8% to 3,668 in 2022. The numbers of new candidates for pediatric and adult heart transplants have also increased, with 703 new pediatric candidates and 4,446 new adult candidates in 2022. Adult heart transplant rates continue to rise, peaking at 122.5 transplants per 100 patient-years in 2022; however, the pediatric heart transplant rate decreased to its lowest rate in the past decade, 104.2 transplants per 100 patient-years, a decrease of 13.9% from 121 transplants per 100 patient-years in 2011. Despite this, pretransplant mortality among pediatric candidates has decreased by 52.2%, from 20.8 deaths per 100 patient-years in 2011 to 10.0 deaths per 100 patient-years in 2022, but remains excessive for candidates younger than 1 year at 25.7 deaths per 100 patient-years. Among adult candidates, pretransplant mortality declined from 15 deaths per 100 patient-years in 2011 to 8.7 deaths per 100 patient-years in 2022. Since 2011, posttransplant mortality has been stable to slightly better; among recipients who underwent transplant in 2015-2017, the 1-, 3-, and 5-year pediatric survival rates were 93.7%, 89.2%, and 85.0%, respectively, and the adult survival rates were 91.3%, 85.7%, and 80.4%. Donor trends have been favorable, with an increase in the numbers of hearts recovered and growing numbers of hearts procured after circulatory death.
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Affiliation(s)
- Monica M Colvin
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN; Department of Cardiology, University of Michigan, Ann Arbor, MI
| | - Jodi M Smith
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN; Department of Pediatrics, University of Washington, Seattle, WA
| | - Yoon Son Ahn
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Dzhuliyana K Handarova
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - Alina C Martinez
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - Kelsi A Lindblad
- Organ Procurement and Transplantation Network, United Network for Organ Sharing, Richmond, VA
| | - Ajay K Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN; Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN
| | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN; Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN; Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, MN
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Kelty CE, Dickinson MG, Leacche M, Jani M, Shrestha NK, Lee S, Acharya D, Rajapreyar I, Sadler RC, McNeely E, Loyaga-Rendon RY. Increased disparities in waitlist and post-heart transplantation outcomes according to socioeconomic status with the new heart transplant allocation system. J Heart Lung Transplant 2024; 43:134-147. [PMID: 37643656 PMCID: PMC11152116 DOI: 10.1016/j.healun.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 07/31/2023] [Accepted: 08/20/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The study objective was to assess disparities in outcomes in the waitlist and post-heart transplantation (HT) according to socioeconomic status (SES) in the old and new U.S. HT allocation systems. METHODS Adult HT candidates in the United Network for Organ Sharing database from 2014 through 2021 were included. Old or new system classification was according to listing before or after October 18, 2018. SES was stratified by patient ZIP code and median household income via U.S. Census Bureau and classified into terciles. Competing waitlist outcomes and post-transplantation survival were compared between systems. RESULTS In total, 26,450 patients were included. Waitlisted candidates with low SES were more frequently younger, female, African American, and with higher body mass index. Reduced cumulative incidence (CI) of HT in the old system occurred in low SES (53.5%) compared to middle (55.7%, p = 0.046), and high (57.9%, p < 0.001). In the new system, the CI of HT was 65.3% in the low SES vs middle (67.6%, p = 0.002) and high (70.2%, p < 0.001), and SES remained significant in the adjusted analysis. In the old system, CI of death/delisting was similar across SES. In the new system, low SES had increased CI of death/delisting (7.4%) vs middle (6%, p = 0.012) and high (5.4%, p = 0.002). The old system showed similar 1-year survival across SES. In the new system, recipients with low SES had decreased 1-year survival (p = 0.041). CONCLUSIONS SES affects waitlist and post-transplant outcomes. In the new system, all SES had increased access to HT; however, low SES had increased death/delisting due to worsening clinical status and decreased post-transplant survival.
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Cascino TM, Cogswell R, Shah P, Cowger JA, Molina EJ, Shah KB, Grinstein J, Wood KL, Gosev I, Kanwar MK. Equitable Access to Advanced Heart Failure Therapies in the United States: A Call to Action. J Card Fail 2024; 30:78-84. [PMID: 37884168 DOI: 10.1016/j.cardfail.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/17/2023] [Accepted: 09/19/2023] [Indexed: 10/28/2023]
Affiliation(s)
- Thomas M Cascino
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI
| | - Rebecca Cogswell
- Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Palak Shah
- Cardiovascular Medicine, Inova Heart and Vascular Institute, Falls Church, VA
| | | | | | - Keyur B Shah
- The Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | | | - Katherine L Wood
- Division of Cardiothoracic Surgery, University of Rochester, Rochester, NY
| | - Igor Gosev
- Division of Cardiothoracic Surgery, University of Rochester, Rochester, NY
| | - Manreet K Kanwar
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI; Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA.
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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.
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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
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5
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Alam A, Hall S. Navigating the rough seas of heart allocation. J Heart Lung Transplant 2023; 42:1183-1184. [PMID: 37301244 DOI: 10.1016/j.healun.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Affiliation(s)
- Amit Alam
- Baylor University Medical Center, Dallas, Texas; Texas A&M University College of Medicine, Bryan, Texas
| | - Shelley Hall
- Baylor University Medical Center, Dallas, Texas; Texas A&M University College of Medicine, Bryan, Texas.
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Johnson DY, Ahn D, Lazenby K, Zeng S, Zhang K, Narang N, Khush K, Parker WF. Association of high-priority exceptions with waitlist mortality among heart transplant candidates. J Heart Lung Transplant 2023; 42:1175-1182. [PMID: 37225029 PMCID: PMC10524782 DOI: 10.1016/j.healun.2023.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/06/2023] [Accepted: 05/14/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND The US heart allocation system ranks candidates using six categorical status levels. Transplant programs can request exceptions to increase a candidate's status level if they believe their candidate has the same medical urgency as candidates who meet the standard criteria for that level. We aimed to determine if exception candidates have the same medical urgency as standard candidates. METHODS Using the Scientific Registry of Transplant Recipients, we constructed a longitudinal waitlist history dataset of adult heart-only transplant candidates listed between October 18, 2018 and December 1, 2021. We estimated the association between exceptions and waitlist mortality with a mixed-effects Cox proportional hazards model that treated status and exceptions as time-dependent covariates. RESULTS Out of 12,458 candidates listed during the study period, 2273 (18.2%) received an exception at listing and 1957 (15.7%) received an exception after listing. After controlling for status, exception candidates had approximately half the risk of waitlist mortality as standard candidates (hazard ratio [HR] 0.55, 95% confidence interval [CI] [0.41, 0.73], p < .001). Exceptions were associated with a 51% lower risk of waitlist mortality among Status 1 candidates (HR 0.49, 95% CI [0.27, 0.91], p = .023) and a 61% lower risk among Status 2 candidates (HR 0.39, 95% CI [0.24, 0.62], p < .001). CONCLUSIONS Under the new heart allocation policy, exception candidates had significantly lower waitlist mortality than standard candidates, including exceptions for the highest priority statuses. These results suggest that candidates with exceptions, on average, have a lower level of medical urgency than candidates who meet standard criteria.
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Affiliation(s)
- Daniel Y Johnson
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Daniel Ahn
- Department of Surgery, Stanford University, Stanford, California
| | - Kevin Lazenby
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Sharon Zeng
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Kevin Zhang
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois; Department of Medicine, University of Illinois-Chicago, Chicago, Illinois
| | - Kiran Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - William F Parker
- Department of Medicine, University of Chicago, Chicago, Illinois; Department of Public Health Sciences, University of Chicago, Chicago, Illinois; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois.
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Golbus JR, Li J, Cascino TM, Tang W, Zhu J, Colvin M, Walsh MN, Nallamothu BK. Greater geographic sharing and heart transplantation waitlist outcomes following the 2018 heart allocation policy. J Heart Lung Transplant 2023; 42:936-942. [PMID: 36931987 PMCID: PMC10551820 DOI: 10.1016/j.healun.2023.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/12/2023] [Accepted: 02/10/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND In 2018, a new heart allocation policy was introduced to reduce variability in access to and outcomes after transplantation, in part, through attempts at broader geographic sharing of donor hearts. We evaluated how this policy affected geographic sharing and waitlist outcomes by donation service area (DSA). METHODS This retrospective study of the Scientific Registry of Transplant Recipients database included adult patients waitlisted between October 2016 and October 2020, stratified by policy period. Our primary outcomes were mean proportion of imported and exported hearts aggregated by DSA as well as time to transplant. RESULTS Following the policy change, there was substantial evidence of sharing across DSAs. The mean proportion of imported hearts transplanted by a DSA increased from 32% (95% CI: 27%-36%) to 74% (95% CI: 71%-78%; p < 0.001), and the mean proportion of exported hearts increased from 37% (95% CI: 33%-42%) to 75% (95% CI: 71%-79%; p < 0.001). The mean sharing ratio, defined as the log-transformed ratio of imported to exported hearts per DSA, shifted from 1.15 (95% CI: 0.88-1.42) to 1.02 (95% CI: 0.96-1.07), with a 76% decline in the variance across DSAs. As sharing increased, time to transplant per DSA declined from 153.9 days (95% CI, 143.4-164.4 days) pre-policy to 89.6 days (95% CI, 83.1-96.1 days) post-policy (p < 0.001). A larger decrease in waitlist time was associated with a higher proportion of exported hearts. CONCLUSIONS The 2018 heart allocation policy was associated with more uniform access to heart transplantation and improved waitlist outcomes.
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Affiliation(s)
- Jessica R Golbus
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP) and Division of Cardiovascular Diseases, University of Michigan, Ann Arbor, Michigan.
| | - Jinming Li
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Thomas M Cascino
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Weijing Tang
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Ji Zhu
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Monica Colvin
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Mary Norine Walsh
- Department of Internal Medicine, Ascension St Vincent Heart Center, Indianapolis, Indiana
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP) and Division of Cardiovascular Diseases, University of Michigan, Ann Arbor, Michigan; The Center for Clinical Management and Research, Ann Arbor VA Medical Center, Ann Arbor, Michigan
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Daniel L, Desiré E, Lescroart M, Jehl C, Leprince P, Varnous S, Coutance G. Practical application of the French two-score heart allocation scheme: Insights from a high-volume heart transplantation centre. Arch Cardiovasc Dis 2023; 116:210-218. [PMID: 37003914 DOI: 10.1016/j.acvd.2023.02.004] [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: 12/13/2022] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND In 2018, a cardiac allocation scheme based on an individual score considering the risk of death both on the waitlist and after heart transplantation was implemented in France. AIMS To analyse the practical application of the pre- and post-transplant risk score in a French high-volume heart transplantation centre. METHODS All consecutive adult patients listed for a first non-combined heart transplantation between 02 January 2018 and 30 June 2022 at our centre were included. Baseline characteristics of candidates and recipients were retrieved from the national CRISTAL registry. Both scores were calculated at listing and at transplant. RESULTS Overall, 364 patients were included. During follow-up, 257 patients (70.6%) were transplanted, and 57 (15.6%) died or were removed from the waitlist. Post-transplant 3-month survival was 84.8%. Total bilirubin and natriuretic peptides had the most important weight in the pretransplant risk score. This score had a major impact on waitlist outcomes: quartile 1 was characterized by low access to heart transplantation (58.2%) and risk of death on the waitlist (9.9%) compared with quartile 4 (heart transplantation rate 74.1%, mortality on the waiting list>20%). According to the post-transplant risk score, a minimal number of candidates were considered ineligible for heart transplantation (<1%), but 12.4% were contraindicated to at least one donor category. The number of contraindicated donor categories had a significant impact on waitlist outcomes. Although adequately calibrated, the post-transplant score had a limited discrimination (area under the curve 0.65, 95% confidence interval 0.59-0.71). CONCLUSION Our results highlight the major impact of pre- and post-transplantation risk scores on waitlist outcomes following the allocation scheme update.
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Affiliation(s)
- Lucie Daniel
- Department of cardiac and thoracic surgery, cardiology Institute, Pitié-Salpêtrière hospital, Sorbonne university medical school, AP-HP, 75013 Paris, France
| | - Eva Desiré
- Department of cardiac and thoracic surgery, cardiology Institute, Pitié-Salpêtrière hospital, Sorbonne university medical school, AP-HP, 75013 Paris, France; Inserm, UMRS 1166-ICAN, Institute of cardiometabolism and nutrition, 75013 Paris, France
| | - Mickaël Lescroart
- Department of cardiac and thoracic surgery, cardiology Institute, Pitié-Salpêtrière hospital, Sorbonne university medical school, AP-HP, 75013 Paris, France
| | - Clément Jehl
- Department of cardiac and thoracic surgery, cardiology Institute, Pitié-Salpêtrière hospital, Sorbonne university medical school, AP-HP, 75013 Paris, France
| | - Pascal Leprince
- Department of cardiac and thoracic surgery, cardiology Institute, Pitié-Salpêtrière hospital, Sorbonne university medical school, AP-HP, 75013 Paris, France; Inserm, UMRS 1166-ICAN, Institute of cardiometabolism and nutrition, 75013 Paris, France
| | - Shaida Varnous
- Department of cardiac and thoracic surgery, cardiology Institute, Pitié-Salpêtrière hospital, Sorbonne university medical school, AP-HP, 75013 Paris, France
| | - Guillaume Coutance
- Department of cardiac and thoracic surgery, cardiology Institute, Pitié-Salpêtrière hospital, Sorbonne university medical school, AP-HP, 75013 Paris, France; Inserm, UMRS-970, Paris translational research centre for organ transplantation, 75015 Paris, France.
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Maitra NS, Dugger SJ, Balachandran IC, Civitello AB, Khazanie P, Rogers JG. Impact of the 2018 UNOS Heart Transplant Policy Changes on Patient Outcomes. JACC. HEART FAILURE 2023; 11:491-503. [PMID: 36892486 DOI: 10.1016/j.jchf.2023.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 12/19/2022] [Accepted: 01/04/2023] [Indexed: 03/05/2023]
Abstract
In 2018, the United Network for Organ Sharing implemented a 6-tier allocation policy to replace the prior 3-tier system. Given increasing listings of critically ill candidates for heart transplantation and lengthening waitlist times, the new policy aimed to better stratify candidates by waitlist mortality, shorten waiting times for high priority candidates, add objective criteria for common cardiac conditions, and further broaden sharing of donor hearts. There have been significant shifts in cardiac transplantation practices and patient outcomes following the implementation of the new policy, including changes in listing practices, waitlist time and mortality, transplant donor characteristics, post-transplantation outcomes, and mechanical circulatory support use. This review aims to highlight emerging trends in United States heart transplantation practice and outcomes following the implementation of the 2018 United Network for Organ Sharing heart allocation policy and to address areas for future modification.
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Affiliation(s)
- Neil S Maitra
- Baylor College of Medicine, Department of Medicine, Houston, Texas, USA
| | - Samuel J Dugger
- Baylor College of Medicine, Department of Medicine, Houston, Texas, USA
| | - Isabel C Balachandran
- Baylor College of Medicine, Department of Medicine, Houston, Texas, USA; Texas Heart Institute, Houston, Texas, USA
| | - Andrew B Civitello
- Baylor College of Medicine, Department of Medicine, Houston, Texas, USA; Texas Heart Institute, Houston, Texas, USA
| | - Prateeti Khazanie
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Joseph G Rogers
- Baylor College of Medicine, Department of Medicine, Houston, Texas, USA; Texas Heart Institute, Houston, Texas, USA.
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Impact of the 2018 French two-score allocation scheme on the profile of heart transplantation candidates and recipients: Insights from a high-volume centre. Arch Cardiovasc Dis 2023; 116:54-61. [PMID: 36624026 DOI: 10.1016/j.acvd.2022.11.003] [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: 07/19/2022] [Revised: 10/28/2022] [Accepted: 11/02/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND In 2018, a new cardiac allograft allocation scheme, based on an individual scoring system, considering the risk of death both on the waiting list and after heart transplantation, was implemented in France. AIM To assess the impact of this new scheme on the profile of transplantation candidates and recipients. METHODS In this single-centre retrospective study, we included consecutive patients listed and/or transplanted between 01 January 2012 and 30 September 2021 at La Pitié-Salpêtrière Hospital. Baseline characteristics of patients were retrieved from the national CRISTAL registry and were compared according to the type of allocation scheme (before or after 2018). RESULTS A total of 1098 newly listed transplantation candidates and 855 transplant recipients were included. One-year mortality rates after listing and after transplantation were 12.4% and 20%, respectively. At listing, the proportion of candidates on inotropes significantly declined following the scheme update (26.3 versus 20.9%; P=0.038), reflecting a change in medical practice. At transplantation, recipients had worse kidney function (estimated glomerular filtration rate<60mL/min/1.73 m2: old scheme, 29.7%; new scheme, 46.4%; P<0.001) and were more likely to be on extracorporeal membrane oxygenation support (33.5% versus 28.1%; P=0.080) under the new scheme, reflecting the prioritization of more severe patients. Outcomes after transplantation were not significantly influenced by the allocation system. CONCLUSIONS The implementation of the 2018 French allocation scheme had a limited impact on the profile of transplantation candidates, but selected more severe patients for transplantation without significant impact on outcomes after transplantation.
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Hess NR, Hickey GW, Keebler ME, Huston JH, McNamara DM, Mathier MA, Wang Y, Kaczorowski DJ. Left ventricular assist device bridging to heart transplantation: Comparison of temporary versus durable support. J Heart Lung Transplant 2023; 42:76-86. [PMID: 36182653 DOI: 10.1016/j.healun.2022.08.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/25/2022] [Accepted: 08/28/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Since the revision of the United States heart allocation system, increasing use of mechanical circulatory support has been observed as a means to support acutely ill patients. We sought to compare outcomes between patients bridged to orthotopic heart transplantation (OHT) with either temporary (t-LVAD) or durable left ventricular assist devises (d-LVAD) under the revised system. METHODS The United States Organ Network database was queried to identify all adult OHT recipients who were bridged to transplant with either an isolated t-LVAD or d-LVAD from 10/18/2018 to 9/30/2020. The primary outcome was 1-year post-transplant survival. Predictors of mortality were also modeled, and national trends of LVAD bridging were examined across the study period. RESULTS About 1,734 OHT recipients were analyzed, 1,580 (91.1%) bridged with d-LVAD and 154 (8.9%) bridged with t-LVAD. At transplant, the t-LVAD cohort had higher total bilirubin levels and greater prevalence of pre-transplant intravenous inotrope usage and mechanical ventilation. Median waitlist time was also shorter for t-LVAD. At 1 year, there was a non-significant trend of increased survival in the t-LVAD cohort (94.8% vs 90.1%; p = 0.06). After risk adjustment, d-LVAD was associated with a 4-fold hazards for 1-year mortality (hazard ratio 3.96, 95% confidence interval 1.42-11.03; p = 0.009). From 2018 to 2021, t-LVAD bridging increased, though d-LVAD remained a more common bridging strategy. CONCLUSIONS Since the 2018 allocation change, there has been a steady increase in t-LVAD usage as a bridge to OHT. Overall, patients bridged with these devices appear to have least equivalent 1-year survival compared to those bridged with d-LVAD.
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Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gavin W Hickey
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Mary E Keebler
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Jessica H Huston
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Dennis M McNamara
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Michael A Mathier
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Yisi Wang
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - David J Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania.
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Chung K, Parker WF. A bridge to nowhere: The durable left ventricular assist device dilemma in the new heart allocation system. J Heart Lung Transplant 2023; 42:87-88. [PMID: 36437169 PMCID: PMC10792764 DOI: 10.1016/j.healun.2022.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/12/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- Kevin Chung
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - William F Parker
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois; Department of Public Health Sciences, University of Chicago, Chicago, Illinois; Department of Medicine, University of Chicago, Chicago, Illinois.
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13
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Cao L, Kim SK, Schwartz B, Cole R, Patel J, Czer L, Esmailian F, Kobashigawa JA, Hamilton MA, Kittleson MM. The impact of the United Network of Organ Sharing allocation change on waitlist trajectories of inpatients listed with inotropic support: A single-center analysis. Clin Transplant 2023; 37:e14834. [PMID: 36259510 DOI: 10.1111/ctr.14834] [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: 06/06/2022] [Revised: 07/24/2022] [Accepted: 10/03/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND In the United Network of Organ Sharing (UNOS) allocation scheme prior to October 18, 2018, heart transplant (HTx) candidates with extracorporeal membrane oxygenation (ECMO), temporary mechanical circulatory support (MCS), or pulmonary artery (PA) catheter inotropic support all received Status 1A priority. In revised scheme, patients with PA catheter and inotropic support are Status 3 after those on ECMO (Status 1) or temporary MCS (Status 2). We examined the impact of the allocation change on HTx candidates listed Status 1A versus Status 3 at a high-volume transplant center. METHODS Between January 2017 and January 2021, 75 patients were listed with a PA catheter and inotropic support prior to the allocation change (Era 1) and 48 were listed after (Era 2). Clinical characteristics and outcomes were compared for these 123 patients. RESULTS Heart transplant (HTx) candidates in Era 2 had higher median inotrope doses at listing. There was no significant difference in inpatient wait list days (12 vs. 20 days, P = .15), transition to temporary MCS (33.3% vs. 22.7%, P = .15), or wait list mortality (6.3% vs. 4.0%, P = .68). There was also no significant difference in survival to transplantation (91.7% vs. 94.7%, P = .71). There were no differences in post-transplant outcomes including 1-year survival (88.6% vs. 93.0%, P = .38). CONCLUSION At a high-volume transplant center, the UNOS allocation change did not result in increased wait list time, use of temporary MCS, or mortality on the waitlist or post-transplant for candidates on inotropic support with continuous hemodynamic monitoring.
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Affiliation(s)
- Louie Cao
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Seong Kyu Kim
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Brandon Schwartz
- Department of Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Robert Cole
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jignesh Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lawrence Czer
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Fardad Esmailian
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jon A Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michele A Hamilton
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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14
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Narang N, Thibodeau JT, Parker WF, Grodin JL, Garg S, Tedford RJ, Levine BD, McGuire DK, Drazner MH. Comparison of Accuracy of Estimation of Cardiac Output by Thermodilution Versus the Fick Method Using Measured Oxygen Uptake. Am J Cardiol 2022; 176:58-65. [PMID: 35613956 PMCID: PMC9648100 DOI: 10.1016/j.amjcard.2022.04.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/24/2022] [Accepted: 04/08/2022] [Indexed: 11/18/2022]
Abstract
The thermodilution (TD) method is routinely used for the estimation of cardiac output (Q̇C). However, its accuracy, compared with the gold-standard Fick method, where systemic oxygen uptake (V̇O2) is directly measured, and Q̇C calculated from V̇O2 and the arterio-venous oxygen difference ("direct" Fick), has not been well validated. The present study determined the agreement between TD and Fick methods in consecutive patients who underwent pulmonary artery catheterization for a broad range of clinical conditions. This is a subanalysis of a previous study comparing the indirect versus Fick method based on a prospective, consecutive patient registry of 253 patients who underwent pulmonary artery catheterization for clinical indications at a single center between 1999 and 2005. We included patients that had an estimation of Q̇C both by the Fick method using measured V̇O2 by exhaled gas analyses from timed Douglas bag collections and by TD. Cardiac index was classified as low when ≤2.2 L/min/m2 or normal when >2.2 L/min/m2. The median (25th, 75th percentile) age of the cohort was 59 (50,67) years, and 50% were female. A total of 43.5% had normal left ventricular function by ventriculography, and 25.7% had ischemic heart disease. Median overall Fick and TD Q̇C were 4.4 (3.5, 5.5) and 4.3 (3.7, 5.2) L/min, respectively (p = 0.04). The median absolute percent error between Fick and TD Q̇C was 17.5 (7.7, 28.4)%, with a typical error of 0.88 L/min (95% confidence interval [CI] 0.82 to 0.95). Median absolute percent error was comparable in the low (n = 118) and normal Q̇CI (n = 135) groups (16.9% vs 18.9%, respectively, p = 0.88). typical error was 0.3 (95% CI 0.27 to 0.33) and 0.49 (95% CI 0.45 to 0.55) L/min/m2 in that comparison. Percent error >25% between Fick and TD Q̇C was observed in over 30% of patients. Overall, Fick and TD Q̇C modestly correlated (Rs = 0.64, p <0.001), with a nondirectional error introduced by TD Q̇C [mean bias of 0.21 (-2.2, 2.7) L/min]. There was poor agreement between TD and the gold-standard Fick method, highlighting the limitations of making clinical decisions based on TD.
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Affiliation(s)
- Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois; Division of Cardiology, Department of Medicine, University of Illinois-Chicago, Chicago, Illinois.
| | - Jennifer T Thibodeau
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - William F Parker
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Justin L Grodin
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sonia Garg
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Benjamin D Levine
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas
| | - Darren K McGuire
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas
| | - Mark H Drazner
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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15
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Lazenby KA, Narang N, Pelzer KM, Ran G, Parker WF. An updated estimate of posttransplant survival after implementation of the new donor heart allocation policy. Am J Transplant 2022; 22:1683-1690. [PMID: 34951528 PMCID: PMC9177535 DOI: 10.1111/ajt.16931] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/24/2021] [Accepted: 12/16/2021] [Indexed: 01/25/2023]
Abstract
The Organ Procurement and Transplant Network (OPTN) implemented a new heart allocation policy on October 18, 2018. Published estimates of lower posttransplant survival under the new policy in cohorts with limited follow-up may be biased by informative censoring. Using the Scientific Registry of Transplant Recipients, we used the Kaplan-Meier method to estimate 1-year posttransplant survival for pre-policy (November 1, 2016, to October 31, 2017) and post-policy cohorts (November 1, 2018, to October 31, 2019) with follow-up through March 2, 2021. We adjusted for changes in recipient population over time with a multivariable Cox proportional hazards model. To demonstrate the effect of inadequate follow-up on post-policy survival estimates, we repeated the analysis but only included follow-up through October 31, 2019. Transplant programs transplanted 2594 patients in the pre-policy cohort and 2761 patients in the post-policy cohort. With follow-up through March 2, 2021, unadjusted 1-year posttransplant survival was 90.6% (89.5%-91.8%) in the pre-policy cohort and 90.8% (89.7%-91.9%) in the post-policy cohort (adjusted HR = 0.93 [0.77-1.12]). Ignoring follow-up after October 31, 2019, the post-policy estimate was biased downward (1-year: 82.2%). When estimated with adequate follow-up, 1-year posttransplant survival under the new heart allocation policy was not significantly different.
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Affiliation(s)
- Kevin A. Lazenby
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Nikhil Narang
- Department of Medicine, University of Illinois-Chicago, Chicago, Illinois,Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois
| | - Kenley M. Pelzer
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Gege Ran
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - William F. Parker
- Department of Medicine, University of Chicago, Chicago, Illinois,MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
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16
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Kim ST, Tran Z, Xia Y, Mabeza R, Hernandez R, Benharash P. Association of center-level temporary mechanical circulatory support use and waitlist outcomes after the 2018 adult heart allocation policy. Surgery 2022; 172:844-850. [PMID: 35489977 DOI: 10.1016/j.surg.2022.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/23/2022] [Accepted: 03/27/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The present study characterizes the association of center-level temporary mechanical circulatory support use with waitlist outcomes after the 2018 adult heart allocation policy change. METHODS The United Network for Organ Sharing database was queried for all single-organ, adult heart transplant candidates from November 2015 to October 2021. The study population was divided into 2 cohorts, prepolicy and postpolicy, centered around the rule change on October 18, 2018. The primary study outcome was center-level rate of poor waitlist outcome, defined as death or deterioration on the waitlist. Competing-risks regression was used to generate risk-adjusted rates of poor waitlist outcome at each center, while Pearson's correlation coefficient (r) was used to assess the significance of center-level temporary mechanical circulatory support use (defined as the proportion listed with temporary mechanical circulatory support) and poor waitlist outcome. RESULTS Of 22,077 transplant candidates included in analysis, 50.5% were listed during postpolicy. Compared to prepolicy, postpolicy candidates were more often listed with temporary mechanical circulatory support and less commonly listed with a durable left-ventricular assist device. The proportion of hospitals not using any temporary mechanical circulatory support decreased significantly from prepolicy to postpolicy (15% to 1%, P < .001). During prepolicy, center-level temporary mechanical circulatory support use showed no correlation with adjusted poor waitlist outcome. However, center-level temporary mechanical circulatory support use showed a negative correlation with poor waitlist outcome during postpolicy (r = -0.42, P < .001). CONCLUSION The 2018 adult heart allocation policy appears to benefit patients listed at high temporary mechanical circulatory support using centers, with significant interhospital variation in temporary mechanical circulatory support use in the new era. Given the growing role of temporary mechanical circulatory support on the heart transplant waitlist, greater standardization of its application is warranted.
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Affiliation(s)
- Samuel T Kim
- Division of Cardiac Surgery, Department of Surgery, Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA. http://www.twitter.com/CoreLabUCLA
| | - Zachary Tran
- Division of Cardiac Surgery, Department of Surgery, Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA. http://www.twitter.com/DrZacharyTran
| | - Yu Xia
- Division of Cardiac Surgery, Department of Surgery, Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA
| | - Russyan Mabeza
- Division of Cardiac Surgery, Department of Surgery, Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA. http://www.twitter.com/RussyanMabeza
| | - Roland Hernandez
- Division of Cardiac Surgery, Swedish Heart and Vascular Institute, Seattle, WA
| | - Peyman Benharash
- Division of Cardiac Surgery, Department of Surgery, Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA.
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17
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Truby LK, Farr M, Topkara VK. Critically appraising the 2018 United Network for Organ Sharing donor allocation policy: adding life boats or rearranging the deck chairs? Curr Opin Anaesthesiol 2022; 35:42-47. [PMID: 34772845 PMCID: PMC8765708 DOI: 10.1097/aco.0000000000001077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Due to the growing mismatch between donor supply and demand as well as unacceptably high transplant waitlist mortality, the heart organ allocation system was revised in October 2018. This review gives an overview of the changes in the new heart organ allocation system and its impact on heart transplant practice and outcomes in the United States. RECENT FINDINGS The 2018 heart allocation system offers a 6-tiered policy and therefore prioritizes the sickest patients on the transplant waitlist. Patients supported with temporary mechanical circulatory support devices are prioritized as Status 1 or Status 2, resulting in increased utilization of this strategy. Patients supported with durable left ventricular assist devices have been prioritized as Status 3 or 4, which has resulted in decreased utilization of this strategy. Broader geographic sharing in the new heart allocation system has resulted in prolonged donor ischemic times. Overall, the new heart allocation system has resulted in significantly lower candidate waitlist mortality, shorter waitlist times, and higher incidence of transplantation. SUMMARY The new United Network for Organ Sharing allocation policy confers significant advantages over the prior algorithm, allowing for decreased waitlist times and improved waitlist mortality without major impact on posttransplant survival.
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Affiliation(s)
- Lauren K. Truby
- Duke Molecular Physiology Institute, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Maryjane Farr
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Veli K. Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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18
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Narang N, Imamura T. Unintended consequences of achieving equity in the new heart allocation policy. J Card Surg 2021; 36:3629-3630. [PMID: 34242429 DOI: 10.1111/jocs.15799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 06/26/2021] [Accepted: 06/28/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
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