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Gonzalez M, Watson E, Vandewalker R, Manandhar N, Trethowan B, Grayburn R, Tremblay LP, Lee S, Leacche M, Loyaga-Rendon R. Status 2 upgrade indication impacts posttransplant mortality in patients bridged with intraaortic balloon pump in the new heart allocation system. Am J Transplant 2024; 24:818-826. [PMID: 38101475 DOI: 10.1016/j.ajt.2023.12.009] [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] [Received: 03/30/2023] [Revised: 11/15/2023] [Accepted: 12/10/2023] [Indexed: 12/17/2023]
Abstract
To evaluate outcomes of patients undergoing heart transplants (HTs) using an intra-aortic balloon pump (IABP) under exception status. Adult patients supported by an IABP who underwent HT between November 18, 2018, and December 31, 2020, as documented in the United Network for Organ Sharing, were included. Patients were stratified according to requests for exception status. Kaplan-Meier methodology was used to look for differences in survival between groups. A total of 1284 patients were included; 492 (38.3%) were transplanted with an IABP under exception status. Exception status patients had higher body mass index, were more likely to be Black, and had longer waitlist times. Exception status patients received organs from younger donors, had a shorter ischemic time, and had a higher frequency of sex mismatch. The 1-year posttransplant survival was 93% for the nonexception and 88% for the exception IABP patients (hazard ratio: 1.85 [95% confidence interval: 1.12-2.86, P = .006]). The most common reason for requesting an exception status was inability to meet blood pressure criteria for extension (37% of patients). The most common reason for an extension request for an exception status was right ventricular dysfunction (24%). IABP patients transplanted under exception status have an increased 1-year mortality rate posttransplant compared with those without exception status.
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Affiliation(s)
- Matthew Gonzalez
- Advanced Heart Failure and Transplant Section, Corewell Health, Grand Rapids, Michigan, USA.
| | - Elizabeth Watson
- Advanced Heart Failure and Transplant Section, Corewell Health, Grand Rapids, Michigan, USA
| | - Rose Vandewalker
- Advanced Heart Failure and Transplant Section, Corewell Health, Grand Rapids, Michigan, USA
| | - Nabin Manandhar
- Cardiovascular Research Division, Corewell Health, Grand Rapids, Michigan, USA
| | - Brian Trethowan
- Cardiothoracic Surgery Division, Corewell Health, Grand Rapids, Michigan, USA
| | - Ryan Grayburn
- Advanced Heart Failure and Transplant Section, Corewell Health, Grand Rapids, Michigan, USA
| | - Louis P Tremblay
- Cardiothoracic Surgery Division, Corewell Health, Grand Rapids, Michigan, USA
| | - Sangjin Lee
- Advanced Heart Failure and Transplant Section, Corewell Health, Grand Rapids, Michigan, USA
| | - Marzia Leacche
- Cardiothoracic Surgery Division, Corewell Health, Grand Rapids, Michigan, USA
| | - Renzo Loyaga-Rendon
- Advanced Heart Failure and Transplant Section, Corewell Health, Grand Rapids, Michigan, USA
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2
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Schlendorf KH, Hsich EM. Heart-kidney transplantation: Is 2 really better than 1? J Heart Lung Transplant 2023; 42:1543-1545. [PMID: 37541405 DOI: 10.1016/j.healun.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/06/2023] Open
Affiliation(s)
| | - Eileen M Hsich
- Heart and Vascular Institute at the Cleveland Clinic, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
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3
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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.
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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
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4
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Francke M, Wolfson AM, Fong MW, Nattiv J, Pandya K, Kawaguchi ES, Villalon S, Mroz M, Sertic A, Cochran A, Ackerman MA, Melendrez M, Cartus R, Johnston KA, Okonkwo K, Ferrall J, DePasquale EC, Lee R, Vaidya AS. New UNOS allocation system associated with no added benefit in waitlist outcomes and worse post-transplant survival in heart-kidney patients. J Heart Lung Transplant 2023; 42:1529-1542. [PMID: 37394021 DOI: 10.1016/j.healun.2023.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/19/2023] [Accepted: 06/23/2023] [Indexed: 07/04/2023] Open
Abstract
BACKGROUND The 2018 United Network for Organ Sharing (UNOS) heart transplant policy change (PC) sought to improve waitlist risk stratification to decrease waitlist mortality and promote geographically broader sharing for high-acuity patients awaiting heart transplantation. Our analysis sought to determine the effect of the UNOS PC on outcomes in patients waiting for, or who have received, a heart-kidney transplantation. METHODS We analyzed adult (≥18 years old), first-time, heart-only and heart-kidney transplant candidates and recipients from the UNOS Registry. Patients were divided into pre-PC (PRE: October 18, 2016-May 30, 2018) and post-PC (POST: October 18, 2018-May 30, 2020) groups for comparison. Competing risks analysis (subdistribution and cause-specific hazards analyses) was performed to assess for differences in waitlist death/deterioration or heart transplantation. One-year post-transplant survival was assessed with Kaplan-Meier and Cox analyses. We included an interaction term (policy era × heart ± kidney) in our analyses to evaluate the effect of PC on outcomes in heart-kidney patients. RESULTS One-year post-transplant survival was similar (p = 0.83) for PRE heart-kidney and heart-only recipients, but worse (p < 0.001) for POST heart-kidney vs heart-only recipients. There was a policy-era interaction between heart-kidney and heart-only recipients (HR 1.92[1.04,3.55], p = 0.038) indicating a detrimental effect of policy on 1-year survival in POST vs PRE heart-kidney recipients. No added beneficial effect of PC on waitlist outcomes in heart-kidney vs heart-only candidates was observed. CONCLUSIONS There was no added policy-era benefit on waitlist outcomes for heart-kidney candidates when compared to heart-only candidates. POST heart-kidney recipients experienced worse 1-year survival compared to PRE heart-kidney recipients with no policy effect on heart-only recipients.
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Affiliation(s)
- Michael Francke
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Aaron M Wolfson
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California.
| | - Michael W Fong
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jonathan Nattiv
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kruti Pandya
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Eric S Kawaguchi
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Sylvia Villalon
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mark Mroz
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ashley Sertic
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ashley Cochran
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mary Alice Ackerman
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Marie Melendrez
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Rachel Cartus
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kori Ann Johnston
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kamso Okonkwo
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Joel Ferrall
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Eugene C DePasquale
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Raymond Lee
- Department of Cardiothoracic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California; USC CardioVascular Institute, Los Angeles, California
| | - Ajay S Vaidya
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
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5
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Vaidya AS, Lee ES, Kawaguchi ES, DePasquale EC, Pandya KA, Fong MW, Nattiv J, Villalon S, Sertic A, Cochran A, Ackerman MA, Melendrez M, Cartus R, Johnston KA, Lee R, Wolfson AM. Effect of the UNOS policy change on rates of rejection, infection, and hospital readmission following heart transplantation. J Heart Lung Transplant 2023; 42:1415-1424. [PMID: 37211332 DOI: 10.1016/j.healun.2023.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 04/04/2023] [Accepted: 05/15/2023] [Indexed: 05/23/2023] Open
Abstract
BACKGROUND The 2018 adult heart allocation policy sought to improve waitlist risk stratification, reduce waitlist mortality, and increase organ access. This system prioritized patients at greatest risk for waitlist mortality, especially individuals requiring temporary mechanical circulatory support (tMCS). Posttransplant complications are significantly higher in patients on tMCS before transplantation, and early posttransplant complications impact long-term mortality. We sought to determine if policy change affected early posttransplant complication rates of rejection, infection, and hospitalization. METHODS We included all adult, heart-only, single-organ heart transplant recipients from the UNOS registry with pre-policy (PRE) individuals transplanted between November 1, 2016, and October 31, 2017, and post-policy (POST) between November 1, 2018, and October 31, 2019. We used a multivariable logistic regression analysis to assess the effect of policy change on posttransplant rejection, infection, and hospitalization. Two COVID-19 eras (2019-2020, 2020-2021) were included in our analysis. RESULTS The majority of baseline characteristics were comparable between PRE and POST era recipients. The odds of treated rejection (p = 0.8), hospitalization (p = 0.69), and hospitalization due to rejection (p = 0.76) and infection (p = 0.66) were similar between PRE and POST eras; there was a trend towards reduced odds of rejection (p = 0.08). In both COVID eras, there was a clear reduction in rejection and treated rejection with no effect on hospitalization for rejection or infection. Odds of all-cause hospitalization was increased in both COVID eras. CONCLUSIONS The UNOS policy change improves access to heart transplantation for higher acuity patients without increasing early posttransplant rates of treated rejection or hospitalization for rejection or infection, factors which portend risk for long-term posttransplant mortality.
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Affiliation(s)
- Ajay S Vaidya
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California.
| | - Emily S Lee
- Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Eric S Kawaguchi
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Eugene C DePasquale
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kruti A Pandya
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Michael W Fong
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jonathan Nattiv
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sylvia Villalon
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Ashley Sertic
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Ashley Cochran
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Mary Alice Ackerman
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Marie Melendrez
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Rachel Cartus
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Kori Ann Johnston
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Raymond Lee
- Keck Medical Center of University of Southern California, Los Angeles, California
| | - Aaron M Wolfson
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
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6
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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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7
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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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8
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Agdamag AC, Riad S, Maharaj V, Jackson S, Fraser M, Charpentier V, Nzemenoh B, Martin CM, Alexy T. Temporary Mechanical Circulatory Support Use and Clinical Outcomes of Simultaneous Heart/Kidney Transplant Recipients in the Pre- and Post-heart Allocation Policy Change Eras. Transplantation 2023; 107:1605-1614. [PMID: 36706061 DOI: 10.1097/tp.0000000000004518] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The use of temporary mechanical circulatory support (tMCS) devices (intra-aortic balloon pump; Impella 2.5, CP, 5.0; venoarterial extracorporeal membrane oxygenation) increased significantly across the United States for heart transplant candidates after the allocation policy change. Whether this practice change also affected simultaneous heart-kidney (SHK) candidates and recipient survival is understudied. METHODS We used the Scientific Registry of Transplant Recipients database to identify adult SHK recipients between January 2010 and March 2022. The population was stratified into pre- and post-heart allocation change cohorts. Kaplan-Meier curves were generated to compare 1-y survival rates. A Cox proportional hazards model was used to investigate the effect of allocation period on patient survival. Recipient outcomes bridged with eligible tMCS devices were compared in the post-heart allocation era. In a separate analysis, SHK waitlist mortality was evaluated between the allocation eras. RESULTS A total of 1548 SHK recipients were identified, and 1102 were included in the final cohort (534 pre-allocation and 568 post-allocation change). tMCS utilization increased from 17.9% to 51.6% after the allocation change, with venoarterial extracorporeal membrane oxygenation use rising most significantly. However, 1-y post-SHK survival remained unchanged in the full cohort (log-rank P = 0.154) and those supported with any of the eligible tMCS devices. In a separate analysis (using a larger cohort of all SHK listings), SHK waitlist mortality at 1 y was significantly lower in the current allocation era ( P = 0.002). CONCLUSIONS Despite the remarkable increase in tMCS use in SHK candidates after the heart allocation change, 1 y posttransplant survival remained unchanged. Further studies with larger cohorts and longer follow-ups are needed to confirm these findings.
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Affiliation(s)
- Arianne C Agdamag
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Samy Riad
- Division of Nephrology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Valmiki Maharaj
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Scott Jackson
- Complex Care Analytics, Fairview Health Services, Minneapolis, MN
| | - Meg Fraser
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | | | - Bellony Nzemenoh
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Cindy M Martin
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN
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9
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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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10
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Wolfson AM, DePasquale EC, Fong MW, Pandya K, Zhou L, Kawaguchi ES, Thomas SS, Vaidya AS. UNOS policy change benefits high-priority patients without harming those at low priority. Am J Transplant 2022; 22:2931-2941. [PMID: 35975656 PMCID: PMC10087391 DOI: 10.1111/ajt.17173] [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: 03/25/2022] [Revised: 07/06/2022] [Accepted: 07/31/2022] [Indexed: 01/25/2023]
Abstract
The heart transplantation policy change (PC) has improved outcomes in high-acuity (Old 1A, New 1-3) patients, but the effect on low-priority (Old 1B/2, New 4-6) patients is unknown. We sought to determine if low-priority patient outcomes were compromised by benefits to high-priority patients by evaluating for interaction between PC and priority status (PS). We included adult first-time heart transplant candidates and recipients from the UNOS registry during a 19-month period before and after the PC. We compared clinical characteristics and performed competing risks and survival analyses stratified by PC and PS. There was a dependence of PC and PS on waitlist death/deterioration with an interaction sub-distribution hazard ratio (adjusted sdHR) of 0.59 (0.45-0.78), p-value < .001. There was a trend toward a benefit of PC on waitlist death/deterioration (adjusted sdHR: 0.86 [0.73-1.01]; p = .07) and an increase in heart transplantation (adjusted sdHR: 1.08 [1.02-1.14], p = .007) for low-priority patients. There was no difference in 1-year post-transplant survival (log-rank p = .22) when stratifying by PC and PS. PC did not negatively affect waitlisted or transplanted low-priority patients. High-priority, post-PC patients had a targeted reduction in waitlist death/deterioration and did not come at the expense of worse post-transplant survival.
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Affiliation(s)
- Aaron M Wolfson
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.,Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Eugene C DePasquale
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.,Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Michael W Fong
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.,Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Kruti Pandya
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.,Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Leon Zhou
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.,Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Eric S Kawaguchi
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Sunu S Thomas
- Cardiology Division, Massachusetts General Hospita, Boston, Massachusetts, USA
| | - Ajay S Vaidya
- Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.,Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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11
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Baran DA, Jaiswal A, Hennig F, Potapov E. Temporary Mechanical Circulatory Support: Devices, Outcomes and Future Directions. J Heart Lung Transplant 2022; 41:678-691. [DOI: 10.1016/j.healun.2022.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/15/2022] [Accepted: 03/22/2022] [Indexed: 12/22/2022] Open
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