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Ide Bolet S, Sisti J, Cheng K, Dadparvar S. Quantitative lobar Tc99m-MAA SPECT/CT of the lung in pre-and post-procedural guidance for bronchoscopic lung volume reduction. Nucl Med Commun 2024; 45:770-778. [PMID: 38832427 DOI: 10.1097/mnm.0000000000001868] [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: 06/05/2024]
Abstract
METHODS This prospective study included 92 patients who underwent BLVR with quantitative SPECT/CT study pre- and post-procedure between November 2018 and June 2023. The mean age was 70 years (range 56-85). with 51 males and 41 females. SPECT/CT quantified perfusion for each lobe, and the lowest counts/volume ratio determined the procedural target. Postprocedure SPECT/CT assessed total atelectasis and perfusion shifts. The 6-minute walk test and pulmonary function tests were compared pre- and post-BLVR. RESULTS SPECT/CT-guided BLVR showed clinical benefits (decreased oxygen requirements) and physiological improvements in total lung capacity, forced expiratory volume, and forced vital capacity ( P < 0.05). Significant perfusion shifts were observed away from the target lobe, with unique patterns noted for ipsilateral and contralateral nontarget lobes ( P < 0.05). CONCLUSION Quantitative lobar SPECT/CT in preprocedural guidance for BLVR proved useful in identifying suitable targets in multi-lobe homogeneous emphysema, resulting in physiological and clinical improvements for this patient group. The perfusion shift information provided by SPECT/CT offers valuable insights for pulmonologists.
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Affiliation(s)
| | | | - Ke Cheng
- Lewis Katz School of Medicine,
- Center for Biostatistics and Epidemiology, Lewis Katz School of Medicine and
| | - Simin Dadparvar
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Temple University Hospital, Philadelphia, Pennsylvania, USA
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2
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Kumar A, Alam A, Flattery E, Dorsey M, Yongue C, Massie A, Patel S, Reyentovich A, Moazami N, Smith D. Bridge to Transplantation: Policies Impact Practices. Ann Thorac Surg 2024:S0003-4975(24)00290-X. [PMID: 38642820 DOI: 10.1016/j.athoracsur.2024.03.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/20/2024] [Accepted: 03/26/2024] [Indexed: 04/22/2024]
Abstract
Since the development of the first heart allocation system in 1988 to the most recent heart allocation system in 2018, the road to heart transplantation has continued to evolve. Policies were shaped with advances in temporary and durable left ventricular assist devices as well as prioritization of patients based on degree of illness. Herein, we review the changes in the heart allocation system over the past several decades and the impact of practice patterns across the United States.
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Affiliation(s)
- Akshay Kumar
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - Amit Alam
- Division of Cardiology, New York University Grossman School of Medicine, New York, New York
| | - Erin Flattery
- Division of Cardiology, New York University Grossman School of Medicine, New York, New York
| | - Michael Dorsey
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - Camille Yongue
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - Allan Massie
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - Suhani Patel
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - Alex Reyentovich
- Division of Cardiology, New York University Grossman School of Medicine, New York, New York
| | - Nader Moazami
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York.
| | - Deane Smith
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
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3
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Mazur M, Carmona Rubio A, Eisen HJ, Bhat G, Dowling R. Impact of the New Heart Allocation System on the Medium-Term Outcomes in Patients With Hypertrophic Cardiomyopathy. ASAIO J 2024:00002480-990000000-00471. [PMID: 38635492 DOI: 10.1097/mat.0000000000002216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024] Open
Abstract
The introduction of the new heart allocation system in the United States in 2018 resulted in an increase in the number of heart transplants (HT) performed among patients with hypertrophic cardiomyopathy (HCM). However, whether that affected medium-term post-HT outcomes in this group of patients remains unknown. We conducted an analysis of the United Network for Organ Sharing Transplant Database, including adults with HCM who underwent heart transplantation between 2015 and 2021. Patients were divided into two equal-duration eras: Era 1 (October 17, 2015, to October 17, 2018) and Era 2 (October 18, 2018, to October 18, 2021). In the studied period, 444 patients with HCM underwent HT: 204 in Era 1 and 240 in Era 2. In Era 2, the waitlist time was shorter, transplant rates were higher, patients were less frequently supported with inotropes but more often with an IABP, ischemic time was longer, and donor-to-recipient distance larger. Pre- and post-transplant functional status was comparable across the two eras, while the pre-HT employment rate was higher in the new system. The 3 year survival was unchanged across eras. In the new allocation system, despite more frequent mechanical circulatory support (MCS) use and increased ischemic time, the medium-term outcomes of patients with HCM remained favorable.
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Affiliation(s)
- Matylda Mazur
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio
| | - Andres Carmona Rubio
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Ohio
| | - Howard J Eisen
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Geetha Bhat
- Cardiovascular Department, Heart and Vascular Center, The Christ Hospital, Cincinnati, Ohio
| | - Robert Dowling
- Cardiovascular Department, Heart and Vascular Center, The Christ Hospital, Cincinnati, Ohio
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4
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Anderson S, Reck Dos Santos P, Langlais B, Campany M, Donato B, D'Cunha J. Lung Transplant Outcomes for Idiopathic Pulmonary Fibrosis: Are We Improving? Ann Thorac Surg 2024; 117:820-827. [PMID: 37625610 DOI: 10.1016/j.athoracsur.2023.07.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/05/2023] [Accepted: 07/31/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND After implementation of the Lung Allocation Score in 2005, idiopathic pulmonary fibrosis (IPF) emerged as the most common indication for lung transplantation (LT) in the United States. The age and comorbidity of patients undergoing LT have since increased, and the indications for LT have evolved. However, limited data have been used to analyze more recent outcomes among the IPF population. METHODS This study analyzed LTs for the primary indication of IPF by using the United Network for Organ Sharing database. An eras-based analysis was performed, comparing patient characteristics, survival, and related outcomes during 2005 to 2009 (era 1) and 2010 to 2014 (era 2) with χ2, Wilcoxon rank sum, and Kaplan-Meier analyses. The study compared 1-year survival from 2005 to 2020 and survival at milestones ranging from 1 month to 5 years. Two adjusted Cox proportional hazards models were conducted: 5-year survival by era and 1-year survival annually from 2010 to 2020. RESULTS From era 1 (n = 1818) to era 2 (n = 3227), the median age of LT recipients increased from 61 to 63 years (P < .001). The percentage of patients in the intensive care unit before LT climbed from 7.7% to 12.1% (P < .001), and the percentage of patients with diabetes grew from 17.9% to 19.4% (P = .003). Despite increased severity of illness, 5-year survival increased from 51.9% in era 1 to 55.2% in era 2 (P = .02). Adjusted modeling indicated that LT during era 2 featured a 17% hazard reduction compared with era 1 (hazard ratio, 0.83; 95% CI, 0.76-0.91). CONCLUSIONS Survival is improving for patients undergoing LT for IPF, despite the challenges of transplant recipients with progressively higher risk profiles.
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Affiliation(s)
- Scott Anderson
- Mayo Clinic Alix School of Medicine, Phoenix, Arizona; Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Pedro Reck Dos Santos
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Blake Langlais
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic Arizona, Phoenix, Arizona
| | - Megan Campany
- Mayo Clinic Alix School of Medicine, Phoenix, Arizona
| | - Britton Donato
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jonathan D'Cunha
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona.
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5
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Mazur M, Bhat G, Popjes E, Dowling R, Eisen HJ. Long-term post-transplantation outcomes in patients with hypertrophic cardiomyopathy: Single-center 35-year experience. Clin Transplant 2024; 38:e15265. [PMID: 38380687 DOI: 10.1111/ctr.15265] [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: 08/22/2023] [Revised: 01/11/2024] [Accepted: 02/01/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Heart transplantation (HT) is the only option for most patients with end-stage heart failure and hypertrophic cardiomyopathy (HCM) who fail medical therapy. Data on the long-term outcomes post-transplant in HCM individuals remain scarce. METHODS We analyzed data of 319 adult patients who underwent HT between 1984 and 2019. Patients were followed for cardiac allograft rejection, cardiac allograft vasculopathy (CAV), death, or re-transplantation. RESULTS Outcomes of 24 patients with HCM, 160 with ischemic, and 135 with dilated cardiomyopathy were compared. During a mean follow-up of 11.6 ± 7.2 (max 27.8), 16.7 ± 8.2 (max 32.7), and 16.1 ± 9.7 (max 34.6) years after HT in hypertrophic, ischemic, and dilated cardiomyopathy groups, respectively: 10-year survival rate was 67%, 62%, 69%, respectively (p = .04). Post-transplantation, HCM individuals more often than the other two studied groups required prolonged inotropic support (37%, 12%, 17%, respectively, p = .02), temporary mechanical circulatory support (45%, 13%, 14%, respectively, p < .01), and renal replacement therapy immediately post-HT (55%, 19%, 24%, respectively, p < .01). No significant inter-group differences were noted in the 10-year freedom from acute allograft rejection (38%, 46%, 43%, respectively, p = .38) or 10-year freedom from CAV (88%, 78%, 81%, respectively, p = .57). CONCLUSIONS The long-term post-transplant prognosis of adult patients with hypertrophic cardiomyopathy is favorable despite more challenging immediate post-HT course.
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Affiliation(s)
- Matylda Mazur
- Heart and Vascular Institute, Pennsylvania State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Geetha Bhat
- Heart and Vascular Institute, Pennsylvania State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Eric Popjes
- Heart and Vascular Institute, Pennsylvania State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Robert Dowling
- Heart and Vascular Institute, Pennsylvania State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Howard J Eisen
- Heart and Vascular Institute, Pennsylvania State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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6
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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.
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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.
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7
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Brugha R, Wu D, Spencer H, Marson L. Disparities in lung transplantation in children. Pediatr Pulmonol 2023. [PMID: 38131456 DOI: 10.1002/ppul.26813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 11/17/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
Lung transplantation is a recognized therapy for end-stage respiratory failure in children and young people. It is only available in selected countries and is limited by access to suitable organs. Data on disparities in access and outcomes for children undergoing lung transplantation are limited. It is clear from data from studies in adults, and from studies in other solid organ transplants in children, that systemic inequities exist in this field. While data relating specifically to pediatric lung transplantation are relatively sparse, professionals should be aware of the risk that healthcare systems may result in disparities in access and outcomes following lung transplantation in children.
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Affiliation(s)
- Rossa Brugha
- Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK
- Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Diana Wu
- General Surgery, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Helen Spencer
- Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK
| | - Lorna Marson
- Transplant Unit, Royal Infirmary Edinburgh, Edinburgh, UK
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8
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Iyengar A, Weingarten N, Herbst DA, Helmers MR, Kelly JJ, Meldrum D, Dominic J, Guevara-Plunkett S, Atluri P. Waitlist Trends in Heart-Liver Transplantation With Updated US Heart Allocation System. Ann Thorac Surg 2023; 116:1270-1275. [PMID: 35987345 DOI: 10.1016/j.athoracsur.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 07/10/2022] [Accepted: 08/01/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND In October 2018, the United States implemented a change in the donor heart allocation policy from a three-tiered to a six-tiered status system. The purpose of the current study was to examine changes in waitlist patterns among patients listed for concomitant heart-liver transplantation with implementation of the new allocation system. METHODS Patients listed for heart-liver transplantation between January 1, 2012, and June 30, 2021, were identified from the United Network for Organ Sharing database. Patients were grouped by era according to initial list date before or after October 18, 2018. Competing risks regression for mortality, transplantation, removal from waitlist due to illness was performed according to the method of Fine and Gray. Waitlist data were censored at 3 years from initial listing. RESULTS Overall, 523 patients were identified, of whom 310 were listed before (era 1, 59%) and 213 after (era 2, 41%) allocation change. Patients in era 1 were older, had more restrictive cardiomyopathy, and more preoperative inotrope use (all P < .05). However, patients in era 2 has longer ischemic times (3.5 ± 1.1 vs 3.1 ± 1.1 hours, P < .01) and more intraaortic balloon pump use (8.9% vs 3.9%, P = .016). Era 2 was associated with lower subdistribution hazard for death (hazard ratio 0.37; 95% CI, 0.13-1.02; P = .054) and increased transplantation (hazard ratio 1.35; 95% CI, 1.06-1.72; P = .015). CONCLUSIONS The implementation of the US donor heart allocation policy was associated with more preoperative intraaortic balloon pump use for patients listed for heart-liver transplantation. Despite that, the modern era was associated with lower waitlist mortality and more frequent transplantation, without increased risk of delisting due to illness.
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Affiliation(s)
- Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David A Herbst
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Danika Meldrum
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica Dominic
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sara Guevara-Plunkett
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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9
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Bakhtiyar SS, Sakowitz S, Ali K, Chervu N, Verma A, Si MS, Benharash P. Combined Heart-Liver vs Isolated Heart Transplantation in Adults With Congenital Heart Disease. Ann Thorac Surg 2023; 116:1260-1267. [PMID: 37059257 DOI: 10.1016/j.athoracsur.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/15/2023] [Accepted: 04/04/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Despite an increasing number of adults with congenital heart disease undergoing combined heart-liver transplantation (CHLT), there is a paucity of literature analyzing posttransplant outcomes. We analyzed the incidence and outcomes of congenital heart disease patients undergoing CHLT compared with those undergoing isolated heart transplantation (HT). METHODS This was a retrospective analysis of all adult (≥18 years) congenital heart disease patients undergoing CHLT or HT between 2000 and 2020 in the Organ Procurement and Transplantation Network database. The primary outcome was death at 30 days and 1 year after transplantation. RESULTS Of 1214 recipients included for analysis, 92 (8%) underwent CHLT and 1122 (92%) underwent HT. Patients undergoing CHLT and HT were similar in the distribution of age, sex, and serum bilirubin. Upon adjusted analysis with HT as the reference, undergoing CHLT was associated with a similar hazard of 30-day mortality between 2000 and 2017 (hazard ratio [HR], 0.51; 95% CI, 0.12-2.08; P = .35) and 2018 and 2020 (HR, 2.32; 95% CI, 0.88-6.13; P = .09). Similarly, there was no difference in the hazard of 1-year mortality for patients undergoing CHLT between 2000 and 2017 (HR, 0.60; 95% CI, 0.22-1.63; P = .32) and 2018 and 2020 (HR, 1.52; 95% CI, 0.66-3.53; P = .33) compared with HT. CONCLUSIONS The number of adults undergoing CHLT continues to rise. Given comparable survival outcomes between CHLT and HT, our findings demonstrate the former as a viable option for complex congenital heart disease patients with failing cavopulmonary circulation and associated liver disease. Future studies should delineate factors associated with early hepatic dysfunction to help identify congenital heart disease patients that would benefit from CHLT.
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Affiliation(s)
- Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, Los Angeles, California
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, Los Angeles, California
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, Los Angeles, California
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, Los Angeles, California
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, Los Angeles, California
| | - Ming-Sing Si
- Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California.
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10
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Ettenger R, Venick RS, Gritsch HA, Alejos JC, Weng PL, Srivastava R, Pearl M. Deceased donor organ allocation in pediatric transplantation: A historical narrative. Pediatr Transplant 2023; 27 Suppl 1:e14248. [PMID: 36468338 DOI: 10.1111/petr.14248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Since the earliest clinical successes in solid organ transplantation, the proper method of organ allocation for children has been a contentious subject. Over the past 30-35 years, the medical and social establishments of various countries have favored some degree of preference for children on the respective waiting lists. However, the specific policies to accomplish this have varied widely and changed frequently between organ type and country. METHODS Organ allocation policies over time were examined. This review traces the reasons behind and the measures/principles put in place to promote early deceased donor transplantation in children. RESULTS Preferred allocation in children has been approached in a variety of ways and with varying degrees of commitment in different solid organ transplant disciplines and national medical systems. CONCLUSION The success of policies to advantage children has varied significantly by both organ and medical system. Further work is needed to optimize allocation strategies for pediatric candidates.
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Affiliation(s)
- Robert Ettenger
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Robert S Venick
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Hans A Gritsch
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Juan C Alejos
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Patricia L Weng
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Rachana Srivastava
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Meghan Pearl
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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11
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Veno-Arterial Extracorporeal Membrane Oxygenation as a Bridge to Heart Transplant-Change of Paradigm. J Clin Med 2022; 11:jcm11237101. [PMID: 36498676 PMCID: PMC9736223 DOI: 10.3390/jcm11237101] [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: 10/20/2022] [Revised: 11/22/2022] [Accepted: 11/26/2022] [Indexed: 12/02/2022] Open
Abstract
Despite advances in medical therapy and mechanical circulatory support (MCS), heart transplant (HT) remains the gold standard therapy for end-stage heart failure. Patients in cardiogenic shock require prompt intervention to reverse hypoperfusion and end-organ damage. When medical therapy becomes insufficient, MCS should be considered. Historically, it has been reported that critically ill patients bridged with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) directly to HT have worse outcomes. However, when the heart allocation system gives the highest priority to patients on VA-ECMO support, those patients have a higher incidence of HT and a lower incidence of death or removal from the transplant list. Moreover, patients with a short waiting time on VA-ECMO have a similar hazard of mortality to non-ECMO patients. According to the reported data, bridging with VA-ECMO directly to HT may be a solution in the selection of critically ill patients when the anticipated waiting list time is short. However, when a prolonged waiting time is expected, more durable MCS should be considered. Regardless of the favorable results of the direct bridging to HT with ECMO in selected patients, the superiority of this strategy compared to the bridge-to-bridge strategy (ECMO to durable MCS) has not been established and further studies are mandatory in order to clarify this issue.
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12
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Greenberg JW, Morales DLS, Ahmed HF, Desai MV, Riggs KW, Hayes D, Lehenbauer DG, Hossain MM, Zafar F. Overly Selective Offer Acceptance is Associated With High Waitlist Mortality for the Most Ill Lung Transplant Candidates. Semin Thorac Cardiovasc Surg 2022:S1043-0679(22)00261-1. [PMID: 36356907 DOI: 10.1053/j.semtcvs.2022.11.001] [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: 10/24/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022]
Abstract
The demand for organs for lung transplantation (LTx) continues to outweigh supply. However, nearly 75% of donor lungs are never transplanted. LTx offer acceptance practices and the effects on waitlist/post-transplant outcomes by candidate clinical acuity are understudied. UNOS was used to identify all LTx candidates, donors, and offers from 2005 to 2019. Candidates were grouped by Lung Allocation Score (LAS; applicable post-2005, ages ≥12 years): LAS<40, 40-60, 61-80, and >80. Offer acceptance patterns, waitlist death/decompensation, and post-transplant survival (PTS) were compared. "Acceptable organ offers" were those from donors whose organs were accepted for transplantation. Approximately 3 million offers to 34,531 candidates were reviewed. Median waitlist durations were: 9 days-(LAS>80), 17 days-(LAS 61-80), 42 days-(LAS 40-60), 125 days-(LAS<40) (P < 0.001 between all). Per waitlist-day, offer rates were: total offers - 0.8/day-(LAS>80), 0.7/day-(LAS 61-80), 0.6/day-(LAS 40-60), 0.4/day-(LAS<40); acceptable offers - 0.34/day-(LAS>80), 0.32/day-(LAS 61-80), 0.24/day-(LAS 40-60), 0.15/day-(LAS<40) (both P < 0.001 between all LAS). Among patients who experienced waitlist mortality/decompensation, ≥1 acceptable offer was declined in 92% (3939/4270) of patients - 78% for LAS >80, 88% for LAS 61-80, 93% for LAS 40-60, and 96% for LAS <40. Thirty-day waitlist mortality/decompensation rates were: 46%-(LAS>80), 24%-(LAS 61-80), 5%-(LAS 40-60), <1%-(LAS<40) (P < 0.001 between all). PTS was equivalent between patients for whom the first/second offer vs later offers were accepted (all LAS P > 0.4). The first offers that LTx candidates receive (including acceptable organs) are declined for nearly all candidates. Healthier candidates can afford offer selectivity but more ill patients (LAS>60) cannot, experiencing exceedingly high 30-day waitlist mortality.
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Affiliation(s)
- Jason W Greenberg
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio..
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Hosam F Ahmed
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mallika V Desai
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Kyle W Riggs
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Don Hayes
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David G Lehenbauer
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Md M Hossain
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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13
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Waitlist Outcomes for Children With Congenital Heart Disease: Lessons Learned From Over 5000 Heart Transplant Listings in the United States. J Card Fail 2022; 28:982-990. [PMID: 35301110 DOI: 10.1016/j.cardfail.2022.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND We evaluated the impact of pediatric heart-allocation policy changes over time and the approval of the Berlin ventricular assist device (VAD) on waitlist (WL) outcomes for children with congenital heart disease (CHD). METHODS The Scientific Registry of Transplant Recipients database was evaluated to include all children (age < 18) with CHD and cardiomyopathy (CMP) on the WL between 1999 and 2019, divided into 4 eras: Era 1 (1999-2008); Era 2 (2009-2011); Era 3 (2012-2016); and Era 4 (2016-2019). WL characteristics and survival outcomes were evaluated for patients with CHD over time and were compared to those with CMP listed currently (Era 4). RESULTS We included 5185 children with CHD on the WL during the study period; 1999 (39%) were listed in Era 1; 693 (13%) in Era 2; 1196 (23%) in Era 3; and 1297 (25%) in Era 4. Compared to the CHD WL in eras 1 and 2, those in Era 4 were less likely to be infants (48% vs 49% vs 43%), on mechanical ventilation (30% vs 26% vs 19%), on extracorporeal membrane oxygenation (15% vs 9.7% vs 6.2%), and were more likely to be on a VAD (2.4% vs 2.2% vs 6.0%) (P < .05 for all). WL survival improved in children with CHD from Era 1 to Era 4 (P < .001). However, in Era 4, children with CHD had lower WL survival than those with CMP (P < .001). CONCLUSION Children with CHD are increasingly being listed with less advanced heart failure, and they have had improved WL survival over time; however, WL outcomes remain inferior to those with CMP. Advances in pediatric medical and VAD therapy may improve future WL outcomes.
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14
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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.
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15
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Crespo-Leiro MG, Costanzo MR, Gustafsson F, Khush KK, Macdonald PS, Potena L, Stehlik J, Zuckermann A, Mehra MR. Heart transplantation: focus on donor recovery strategies, left ventricular assist devices, and novel therapies. Eur Heart J 2022; 43:2237-2246. [PMID: 35441654 DOI: 10.1093/eurheartj/ehac204] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/07/2022] [Accepted: 04/06/2022] [Indexed: 12/18/2022] Open
Abstract
Heart transplantation is advocated in selected patients with advanced heart failure in the absence of contraindications. Principal challenges in heart transplantation centre around an insufficient and underutilized donor organ pool, the need to individualize titration of immunosuppressive therapy, and to minimize late complications such as cardiac allograft vasculopathy, malignancy, and renal dysfunction. Advances have served to increase the organ donor pool by advocating the use of donors with underlying hepatitis C virus infection and by expanding the donor source to use hearts donated after circulatory death. New techniques to preserve the donor heart over prolonged ischaemic times, and enabling longer transport times in a safe manner, have been introduced. Mechanical circulatory support as a bridge to transplantation has allowed patients with advanced heart failure to avoid progressive deterioration in hepato-renal function while awaiting an optimal donor organ match. The management of the heart transplantation recipient remains a challenge despite advances in immunosuppression, which provide early gains in rejection avoidance but are associated with infections and late-outcome challenges. In this article, we review contemporary advances and challenges in this field to focus on donor recovery strategies, left ventricular assist devices, and immunosuppressive monitoring therapies with the potential to enhance outcomes. We also describe opportunities for future discovery to include a renewed focus on long-term survival, which continues to be an area that is under-studied and poorly characterized, non-human sources of organs for transplantation including xenotransplantation as well as chimeric transplantation, and technology competitive to human heart transplantation, such as tissue engineering.
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Affiliation(s)
- Maria Generosa Crespo-Leiro
- Department of Cardiology, Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomedica A Coruña (INIBIC), Centro de Investigacion Biomedica en Red Cardiovascular (CIBERCV), As Xubias 84, 15006 A Coruña, Spain
| | | | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Luciano Potena
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Mandeep R Mehra
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
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16
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Du Y, Duan C, Yang Y, Yuan G, Zhou Y, Zhu X, Wei N, Hu Y. Heart Transplantation: A Bibliometric Review From 1990-2021. Curr Probl Cardiol 2022; 47:101176. [PMID: 35341797 DOI: 10.1016/j.cpcardiol.2022.101176] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/22/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND As the rapidly aging population and the rising incidence of end-stage heart failure (HF), extensive research has been conducted on heart transplantation (HTx). Bibliometrics harbors the function for describing the relationships of knowledge structures in different research fields and predicting the growth trend . METHODS The publications were searched and filtered based on the WOS core database. The target literature was visualized and analyzed by CiteSpace or VOSviewer . RESULTS In total, 19,998 published papers were obtained. There is a wave-like growth in HTx development. Most advanced research results are concentrated in a few developed countries, while the interactions with developing countries are still in infancy. The United States occupies a strong dominant position among active countries on HTx. Early research hotpots mostly focused on primary disease, survival risk factors, and complications. In recent years, the research frontiers have shifted steadily to clinical evaluation of immunosuppressants and diagnosis of acute rejection, cardiac re-injury with COVID-19, innovations in ventricular assist devices(VAD), and donation allocation strategies. The research directions of HTx are gradually shifting from observational studies to intervention research.
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Affiliation(s)
- Yihang Du
- Cardiovascular department, Guang'anmen Hospital, China Academy of Traditional Chinese Medicine Sciences, Beijing, China
| | - Chenglin Duan
- Cardiovascular department, Guang'anmen Hospital, China Academy of Traditional Chinese Medicine Sciences, Beijing, China; Beijing University of Chinese Medicine, Beijing, China
| | - Yihan Yang
- Cardiovascular department, Guang'anmen Hospital, China Academy of Traditional Chinese Medicine Sciences, Beijing, China; Beijing University of Chinese Medicine, Beijing, China
| | - Guozhen Yuan
- Cardiovascular department, Guang'anmen Hospital, China Academy of Traditional Chinese Medicine Sciences, Beijing, China
| | - Yan Zhou
- Cardiovascular department, Guang'anmen Hospital, China Academy of Traditional Chinese Medicine Sciences, Beijing, China; Beijing University of Chinese Medicine, Beijing, China
| | - Xueping Zhu
- Cardiovascular department, Guang'anmen Hospital, China Academy of Traditional Chinese Medicine Sciences, Beijing, China
| | - Namin Wei
- Beijing University of Chinese Medicine, Beijing, China
| | - Yuanhui Hu
- Cardiovascular department, Guang'anmen Hospital, China Academy of Traditional Chinese Medicine Sciences, Beijing, China.
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17
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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.
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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
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18
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Arjuna A, Olson MT, Walia R. Current trends in candidate selection, contraindications, and indications for lung transplantation. J Thorac Dis 2022; 13:6514-6527. [PMID: 34992831 PMCID: PMC8662491 DOI: 10.21037/jtd-2021-09] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 01/27/2021] [Indexed: 12/23/2022]
Abstract
Lung transplantation is an established treatment option that can improve quality of life and prolong survival for select patients diagnosed with end-stage lung disease. Given the gaps in organ donation and failures to make effective use of available organs, careful selection of candidates for lung transplant remains one of the most important considerations of the transplant community. Toward this end, we briefly reviewed recent trends in pretransplant evaluation, candidate selection, organ allocation, and organ preservation techniques. Since the latest consensus statement regarding appropriate selection of lung transplant candidates, many advances in the science and practice of lung transplantation have emerged and influenced our perspective of ‘contraindications’ to transplant. These advances have made it increasingly possible to pursue lung transplant in patients with risk factors for decreased survival—namely, older recipient age, increased body mass index, previous chest surgery, poorer nutritional status, and presence of chronic infection, cardiovascular disease, or extrapulmonary comorbid conditions. Therefore, we reviewed the updated evidence demonstrating the prognostic impact of these risk factors in lung transplant recipients. Lastly, we reviewed the salient evidence for current trends in disease-specific indications for lung transplantation, such as chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, cystic fibrosis, emphysema due to alpha-1 antitrypsin deficiency, and pulmonary arterial hypertension, among other less common end-stage diseases. Overall, lung transplant remains an exciting field with considerable hope for patients as they experience remarkable improvements in quality of life and survival in the modern era.
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Affiliation(s)
- Ashwini Arjuna
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Michael T Olson
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.,University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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19
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Haywood N, Mehaffey JH, Kilbourne S, Mannem H, Weder M, Lau C, Krupnick AS, Agarwal A. Influence of broader geographic allograft sharing on outcomes and cost in smaller lung transplant centers. J Thorac Cardiovasc Surg 2022; 163:339-345. [PMID: 33008575 PMCID: PMC7474916 DOI: 10.1016/j.jtcvs.2020.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/21/2020] [Accepted: 09/01/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE On November 24, 2017, Organ Procurement and Transplantation Network implemented a change to lung allocation replacing donor service area with a 250 nautical mile radius around donor hospitals. We sought to evaluate the experience of a small to medium size center following implementation. METHODS Patients (47 pre and 54 post) undergoing lung transplantation were identified from institutional database from January 2016 to October 2019. Detailed chart review and analysis of institutional cost data was performed. Univariate analysis was performed to compare eras. RESULTS Similar short-term mortality and primary graft dysfunction were observed between groups. Decreased local donation (68% vs 6%; P < .001), increased travel distance (145 vs 235 miles; P = .004), travel cost ($8626 vs $14,482; P < .001), and total procurement cost ($60,852 vs $69,052; P = .001) were observed postimplementation. We also document an increase in waitlist mortality postimplementation (6.9 vs 31.6 per 100 patient-years; P < .001). CONCLUSIONS Following implementation of the new allocation policy in a small to medium size center, several changes were in accordance with policy intention. However, concerning shifts emerged, including increased waitlist mortality and resource utilization. Continued close monitoring of transplant centers stratified by size and location are paramount to maintaining global availability of lung transplantation to all Americans regardless of geographic residence or socioeconomic status.
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Affiliation(s)
- Nathan Haywood
- Division of Thoracic & Cardiovascular Surgery, University of Virginia Health System, Charlottesville, Va
| | - J Hunter Mehaffey
- Division of Thoracic & Cardiovascular Surgery, University of Virginia Health System, Charlottesville, Va
| | - Sarah Kilbourne
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Va
| | - Hannah Mannem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Va
| | - Max Weder
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Va
| | - Christine Lau
- Division of Thoracic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, Md
| | - Alexander S Krupnick
- Division of Thoracic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, Md
| | - Avinash Agarwal
- Division of Transplantation, Department of Surgery, University of Virginia Health System, Charlottesville, Va.
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20
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Rodriguez ER, Santos-Martins C, Tan CD. Pathology of cardiac transplantation. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00023-2] [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: 10/17/2022] Open
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21
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Sabatino ME, Williams ML, Okwuosa IS, Akhabue E, Kim JH, Russo MJ, Setoguchi S. 30-Year Trends in Graft Survival After Heart Transplant: Modeled Analyses of a Transplant Registry. Ann Thorac Surg 2021; 113:1436-1444. [PMID: 34555375 DOI: 10.1016/j.athoracsur.2021.08.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/20/2021] [Accepted: 08/09/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Heart failure is an epidemic in the United States, and transplantation remains the most definitive therapy. We describe multi-decade trends in post-transplant graft survival, adjusted for concurrent changes in the population, over the 30 years antecedent to the most recent heart allocation policy change. METHODS Scientific Registry of Transplant Recipients data were used to identify all primary adult heart recipients 1989 through 2017. We described temporal changes in population characteristics (recipient/donor demographics and comorbidities, pretransplant interventions, clinical transplant measures, and providers). The primary outcome was graft survival, defined as freedom from all-cause death and graft failure, within 6 months post-transplant. Modified Poisson logistic regression estimated relative changes in risk of outcomes compared to 1989, with and without adjustment for changing population characteristics. We identified risk factors, quantified by associated risk ratios. RESULTS Among 56,488 primary adult heart recipients, we observed 5,529 (9.8%) all-cause deaths and 1,933 (3.4%) graft failure events within 6 months post-transplant. Prevalence of known recipient risk factors increased over time. Unadjusted modeling demonstrated a significant 30-year improvement in graft survival, averaging 2.6% (95%CI:2.4-2.9%) per year (p-for-trend<0.001). After adjusting for population changes, the 30-year trend remained significant and graft survival improved on average 3.0% (95%CI:2.6-3.3%) yearly. Regression modeling identified multiple predictors of graft survival. Modeling two additional outcomes of 6-month mortality and 6-month graft failure produced like results. CONCLUSIONS Short-term graft survival after heart transplantation has improved significantly leading up to the 2018 heart allocation policy change, despite concurrent increase in prevalence of higher risk population characteristics.
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Affiliation(s)
- Marlena E Sabatino
- Rutgers Robert Wood Johnson Medical School, Department of Surgery, Division of Cardiothoracic Surgery, 125 Paterson St, New Brunswick, NJ
| | - Matthew L Williams
- Perelman School of Medicine, University of Pennsylvania, Department of Surgery, Division of Cardiovascular Surgery, 3400 Civic Center Blvd, Philadelphia, PA
| | - Ike S Okwuosa
- Feinberg School of Medicine, Northwestern University, Department of Medicine, Division of Cardiology, 420 E Superior St, Chicago, IL
| | - Ehimare Akhabue
- Rutgers Robert Wood Johnson Medical School, Department of Medicine, 125 Paterson St, New Brunswick, NJ; Robert Wood Johnson University Hospital, 1 Robert Wood Johnson Place, New Brunswick, NJ
| | - Jung Hyun Kim
- Institute for Health, Health Care Policy and Aging Research, 112 Paterson St, New Brunswick, NJ
| | - Mark J Russo
- Rutgers Robert Wood Johnson Medical School, Department of Surgery, Division of Cardiothoracic Surgery, 125 Paterson St, New Brunswick, NJ; Robert Wood Johnson University Hospital, 1 Robert Wood Johnson Place, New Brunswick, NJ
| | - Soko Setoguchi
- Rutgers Robert Wood Johnson Medical School, Department of Medicine, 125 Paterson St, New Brunswick, NJ; Robert Wood Johnson University Hospital, 1 Robert Wood Johnson Place, New Brunswick, NJ; Institute for Health, Health Care Policy and Aging Research, 112 Paterson St, New Brunswick, NJ.
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22
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Cascino TM, Stehlik J, Cherikh WS, Cheng Y, Watt TMF, Brescia AA, Thompson MP, McCullough JS, Zhang M, Shore S, Golbus JR, Pagani FD, Likosky DS, Aaronson KD. A challenge to equity in transplantation: Increased center-level variation in short-term mechanical circulatory support use in the context of the updated U.S. heart transplant allocation policy. J Heart Lung Transplant 2021; 41:95-103. [PMID: 34666942 DOI: 10.1016/j.healun.2021.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/31/2021] [Accepted: 09/06/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The United States National Organ Procurement Transplant Network (OPTN) implemented changes to the adult heart allocation system to reduce waitlist mortality by improving access for those at greater risk of pre-transplant death, including patients on short-term mechanical circulatory support (sMCS). While sMCS increased, it is unknown whether the increase occurred equitably across centers. METHODS The OPTN database was used to assess changes in use of sMCS at time of transplant in the 12 months before (pre-change) and after (post-change) implementation of the allocation system in October 2018 among 5,477 heart transplant recipients. An interrupted time series analysis comparing use of bridging therapies pre- and post-change was performed. Variability in the proportion of sMCS use at the center level pre- and post-change was determined. RESULTS In the month pre-change, 9.7% of patients were transplanted with sMCS. There was an immediate increase in sMCS transplant the following month to 32.4% - an absolute and relative increase of 22.7% and 312% (p < 0.001). While sMCS use was stable pre-change (monthly change 0.0%, 95% CI [-0.1%,0.1%]), there was a continuous 1.2%/month increase post-change ([0.6%,1.8%], p < 0.001). Center-level variation in sMCS use increased substantially after implementation, from a median (interquartile range) of 3.85% (10%) pre-change to 35.7% (30.6%) post-change (p < 0.001). CONCLUSIONS Use of sMCS at time of transplant increased immediately and continued to expand following heart allocation policy changes. Center-level variation in use of sMCS at the time of transplant increased compared to pre-change, which may have negatively impacted equitable access to heart transplantation.
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Affiliation(s)
- Thomas M Cascino
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
| | | | - Yulin Cheng
- United Network for Organ Sharing, Richmond, Virginia
| | - Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Alexander A Brescia
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Michael P Thompson
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Jeffrey S McCullough
- Department of Health Management and Policy and Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Min Zhang
- Department of Health Management and Policy and Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Supriya Shore
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Jessica R Golbus
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, Michigan
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23
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Scire E, Jeong KY, Gaurke M, Prusak B, Sulmasy DP. Rationing With Respect to Age During a Pandemic: A Comparative Analysis of State Pandemic Preparedness Plans. Chest 2021; 161:504-513. [PMID: 34506791 PMCID: PMC8423769 DOI: 10.1016/j.chest.2021.08.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/10/2021] [Accepted: 08/31/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Faced with possible shortages due to COVID-19, many states updated or rapidly developed crisis standards of care (CSCs) and other pandemic preparedness plans (PPPs) for rationing resources, particularly ventilators. RESEARCH QUESTION How have US states incorporated the controversial standard of rationing by age and/or life-years into their pandemic preparedness plans? STUDY DESIGN AND METHODS This was an investigator-initiated, textual analysis conducted from April to June 2020, querying online resources and in-state contacts to identify PPPs published by each of the 50 states and for Washington, DC. Analysis included the most recent versions of CSC documents and official state PPPs containing triage guidance as of June 2020. Plans were categorized as rationing by (A) short-term survival (≤ 1 year), (B) 1 to 5 expected life-years, (C) total life-years, (D) "fair innings," that is, specific age cutoffs, or (O) other. The primary measure was any use of age and/or life-years. Plans were further categorized on the basis of whether age/life-years was a primary consideration. RESULTS Thirty-five states promulgated PPPs addressing the rationing of critical care resources. Seven states considered short-term prognosis, seven considered whether a patient had 1 to 5 expected life-years, 13 rationed by total life-years, and one used the fair innings principle. Seven states provided only general ethical considerations. Seventeen of the 21 plans considering age/life-years made it a primary consideration. Several plans borrowed heavily from a few common sources, although use of terminology was inconsistent. Many documents were modified in light of controversy. INTERPRETATION Guidance with respect to rationing by age and/or life-years varied widely. More than one-half of PPPs, many following a few common models, included age/life-years as an explicit rationing criterion; the majority of these made it a primary consideration. Terminology was often vague, and many plans evolved in response to pushback. These findings have ethical implications for the care of older adults and other vulnerable populations during a pandemic.
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Affiliation(s)
- Emily Scire
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Bernard Prusak
- Department of Philosophy and McGowan Center for Ethics and Social Responsibility, King's College, Wilkes-Barre, PA
| | - Daniel P Sulmasy
- School of Medicine, Georgetown University, Washington, DC; Department of Philosophy, Georgetown University, Washington, DC; Kennedy Institute of Ethics, Georgetown University, Washington, DC.
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Gaurke M, Prusak B, Jeong KY, Scire E, Sulmasy DP. Life-Years & Rationing in the Covid-19 Pandemic: A Critical Analysis. Hastings Cent Rep 2021; 51:18-29. [PMID: 34529846 PMCID: PMC8653336 DOI: 10.1002/hast.1283] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Prominent bioethicists have promoted the preservation of life-years as a rationing strategy in response to the Covid-19 pandemic. Yet the philosophical justification for maximizing life-years is underdeveloped and has a complex history that is not reflected in recent literature. In this article, we offer a critical investigation of the use of life-years, arguing that evidence of public support for the life-years approach is thin and that organ transplantation protocols (heavily cited in pandemic-response protocols) do not provide a precedent for seeking to save the most life-years. We point out that many state emergency-response plans ultimately rejected or severely attenuated the meaning of saving the most life-years, and we argue that philosophical arguments in support of rationing by life-years are remarkably wanting. We conclude by offering a fair alternative that adheres to the standard duties of beneficence, respect for persons, and justice.
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Moore LP, Weimer DL. The Geography of Life and Death: Evidence and Values in the Evolution of U.S. Liver Transplant Rules. WORLD MEDICAL & HEALTH POLICY 2021. [DOI: 10.1002/wmh3.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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26
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Nutritional Risk Index: A Predictive Metric for Mortality After Lung Transplant. Ann Thorac Surg 2021; 112:214-220. [DOI: 10.1016/j.athoracsur.2020.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 07/08/2020] [Accepted: 08/06/2020] [Indexed: 02/07/2023]
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Lyu DM, Goff RR, Chan KM. The Lung Allocation Score and Its Relevance. Semin Respir Crit Care Med 2021; 42:346-356. [PMID: 34030198 DOI: 10.1055/s-0041-1729541] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Lung transplantation in the United States, under oversight by the Organ Procurement Transplantation Network (OPTN) in the 1990s, operated under a system of allocation based on location within geographic donor service areas, wait time of potential recipients, and ABO compatibility. On May 4, 2005, the lung allocation score (LAS) was implemented by the OPTN Thoracic Organ Transplantation Committee to prioritize patients on the wait list based on a balance of wait list mortality and posttransplant survival, thus eliminating time on the wait list as a factor of prioritization. Patients were categorized into four main disease categories labeled group A (obstructive lung disease), B (pulmonary hypertension), C (cystic fibrosis), and D (restrictive lung disease/interstitial lung disease) with variables within each group impacting the calculation of the LAS. Implementation of the LAS led to a decrease in the number of wait list deaths without an increase in 1-year posttransplant survival. LAS adjustments through the addition, modification or elimination of covariates to improve the estimates of patient severity of illness, have since been made in addition to establishing criteria for LAS value exceptions for pulmonary hypertension patients. Despite the success of the LAS, concerns about the prioritization, and transplantation of older, sicker individuals have made some aspects of the LAS controversial. Future changes in US lung allocation are anticipated with the current development of a continuous distribution model that incorporates the LAS, geographic distribution, and unaccounted aspects of organ allocation into an integrated score.
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Affiliation(s)
- Dennis M Lyu
- Division of Pulmonary and Critical Care Medicine, Michigan Medicine/University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Rebecca R Goff
- Department of Research Science, United Network for Organ Sharing, Richmond, Virginia
| | - Kevin M Chan
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, Michigan Medicine/University of Michigan School of Medicine, Ann Arbor, Michigan
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Stern LK, Velleca A, Nishihara K, Shen A, Zaliznyak M, Patel J, Hamilton MA, Ramzy D, Esmailian F, Kobashigawa JA, Kittleson MM. Impact of the United Network for organ sharing 2018 donor heart allocation system on transplant morbidity and mortality. Clin Transplant 2021; 35:e14181. [PMID: 33277716 DOI: 10.1111/ctr.14181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/14/2020] [Accepted: 11/27/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND While the revised UNOS HTx donor allocation system aimed to minimize waitlist mortality by prioritizing more critically ill transplant candidates, there is concern for increased post-transplant morbidity and mortality. We examined the impact of the revised allocation system on waitlist and post-transplant outcomes at a high-volume transplant center. METHODS One hundred and sixty nine adult patients underwent first-time single-organ HTx one year before (Era 1:79 patients) and after (Era 2:90 patients) implementation of the new allocation system (10/18/2018). Clinical characteristics, waitlist outcomes, and post-transplant morbidity and mortality were compared. RESULTS Era 2 patients were twice as likely to be transplanted on temporary mechanical circulatory support (43% vs. 19%, p < .0001). While Era 2 waitlist time was shorter (10 vs. 43 days, p < .001), exception status requests (21.1% vs. 17.9%) and waitlist mortality (3.3% vs. 2.2%) were similar. There was no difference in primary graft dysfunction, intensive care unit or hospital length of stay, readmissions, rejection, allograft vasculopathy, or 1-year survival (91.1% vs. 93.7%). CONCLUSIONS In a high-volume center, the revised HTx allocation system shortened waitlist time with no significant change in waitlist mortality or observed impact on post-transplant outcomes. With careful patient selection, the revised allocation system may optimize waitlist and post-transplant outcomes.
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Affiliation(s)
- Lily K Stern
- Department of Cardiology, Smidt Heart Institute, Los Angeles, CA, USA
| | - Angela Velleca
- Comprehensive Transplant Center, Cedars-Sinai, Los Angeles, CA, USA
| | - Keith Nishihara
- Department of Cardiology, Smidt Heart Institute, Los Angeles, CA, USA
| | - Adriana Shen
- Department of Cardiology, Smidt Heart Institute, Los Angeles, CA, USA
| | - Michael Zaliznyak
- Department of Cardiology, Smidt Heart Institute, Los Angeles, CA, USA
| | - Jignesh Patel
- Department of Cardiology, Smidt Heart Institute, Los Angeles, CA, USA
| | | | - Danny Ramzy
- Department of Cardiac Surgery, Smidt Heart Institute, Los Angeles, CA, USA
| | - Fardad Esmailian
- Department of Cardiac Surgery, Smidt Heart Institute, Los Angeles, CA, USA
| | - Jon A Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Los Angeles, CA, USA
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Impact of New UNOS Allocation Criteria on Heart Transplant Practices and Outcomes. Transplant Direct 2020; 7:e642. [PMID: 33335981 PMCID: PMC7738116 DOI: 10.1097/txd.0000000000001088] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/27/2020] [Indexed: 01/01/2023] Open
Abstract
Background In October 2018, a new heart allocation policy was implemented with intent of prioritizing the sickest patients and decreasing waitlist time. We examined the effects of the new policy on transplant practices and outcomes 1 year before and 1 year after the change. Methods Transplant recipients from October 2017 to September 2019 at our institution were identified and divided into 2 cohorts, a preallocation and postallocation criteria change. Patient demographics, clinical data, and bridging strategy were assessed. Early outcomes including ischemic time, severe primary graft dysfunction, need for renal replacement therapy, and duration of hospital stay were investigated. Results In the 12 months before the change, 38 patients were transplanted as compared to 33 patients in the 12 months after the change. The average wait-time to transplant decreased after the allocation change (49 versus 313 d, P = 0.02). Patients were more likely to be bridged with an intra-aortic balloon pump (45% versus 3%) and less likely to be supported with a durable left ventricular assist device (LVAD) after the change (24% versus 82%). There was an increase in total ischemic time after the change (177 versus 117 min, P ≤ 0.01). There were no significant differences in other early posttransplant outcomes. Conclusions Implementation of the new allocation system for heart transplantation resulted in dramatic changes in the bridging strategy utilized at our institution. Temporary mechanical support usage increased following the change and the number of recipients supported with durable LVADs decreased. Early posttransplant outcomes appear similar.
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Griffin JM, DeFilippis EM, Rosenblum H, Topkara VK, Fried JA, Uriel N, Takeda K, Farr MA, Maurer MS, Clerkin KJ. Comparing outcomes for infiltrative and restrictive cardiomyopathies under the new heart transplant allocation system. Clin Transplant 2020; 34:e14109. [PMID: 33048376 DOI: 10.1111/ctr.14109] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/07/2020] [Accepted: 10/03/2020] [Indexed: 01/24/2023]
Abstract
The new heart transplantation (HT) allocation policy was introduced on 10/18/2018. Using the UNOS registry, we examined early outcomes following HT for restrictive cardiomyopathy, hypertrophic cardiomyopathy, cardiac sarcoidosis, or cardiac amyloidosis compared to the old system. Those listed who had an event (transplant, death, or waitlist removal) prior to 10/17/2018 were in Era 1, and those listed on or after 10/18/2018 were in Era 2. The primary endpoint was death on the waitlist or delisting due to clinical deterioration. A total of 1232 HT candidates were included, 855 (69.4%) in Era 1 and 377 (30.6%) in Era 2. In Era 2, there was a significant increase in the use of temporary mechanical circulatory support and a reduction in the primary endpoint, (20.9 events per 100 PY (Era 1) vs. 18.6 events per 100 PY (Era 2), OR 1.98, p = .005). Median waitlist time decreased (91 vs. 58 days, p < .001), and transplantation rate increased (119.0 to 204.7 transplants/100 PY for Era 1 vs Era 2). Under the new policy, there has been a decrease in waitlist time and waitlist mortality/delisting due to clinical deterioration, and an increase in transplantation rates for patients with infiltrative, hypertrophic, and restrictive cardiomyopathies without any effect on post-transplant 6-month survival.
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Affiliation(s)
- Jan M Griffin
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Ersilia M DeFilippis
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Hannah Rosenblum
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Veli K Topkara
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Justin A Fried
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Nir Uriel
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | - Maryjane A Farr
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Mathew S Maurer
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Kevin J Clerkin
- Milstein Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Shore S, Golbus JR, Aaronson KD, Nallamothu BK. Changes in the United States Adult Heart Allocation Policy: Challenges and Opportunities. Circ Cardiovasc Qual Outcomes 2020; 13:e005795. [PMID: 32988232 DOI: 10.1161/circoutcomes.119.005795] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Supriya Shore
- Department of Cardiovascular Disease, Division of Internal Medicine, University of Michigan, Ann Arbor
| | - Jessica R Golbus
- Department of Cardiovascular Disease, Division of Internal Medicine, University of Michigan, Ann Arbor
| | - Keith D Aaronson
- Department of Cardiovascular Disease, Division of Internal Medicine, University of Michigan, Ann Arbor
| | - Brahmajee K Nallamothu
- Department of Cardiovascular Disease, Division of Internal Medicine, University of Michigan, Ann Arbor
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Affiliation(s)
- Monica M Colvin
- Cardiovascular Division, Advanced Heart Failure and Transplantation, Michigan Medicine/University of Michigan (M.M.C.)
| | - Donna M Mancini
- Cardiovascular Division, Advanced Heart Failure and Transplantation, Mount Sinai Health System (D.M.M.)
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Gerull WD, Yang Z, Kreisel D, Nava R, Meyers BF, Patterson GA, Kozower BD, Hachem RR, Witt C, Byers D, Kulkarni H, Guillamet RV, Marklin G, Puri V. Local versus distant lung donor procurement does not influence short-term clinical outcomes. J Thorac Cardiovasc Surg 2020; 162:1284-1293.e4. [PMID: 32977961 DOI: 10.1016/j.jtcvs.2020.07.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/22/2020] [Accepted: 07/30/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The purpose of this study was to recognize clinically meaningful differences in lung transplant outcomes based on local or distant lung procurement. This could identify if the lung allocation policy change would influence patient outcomes. METHODS This single-center retrospective cohort study analyzed adult patients who underwent lung transplant from 2006 to 2017. Donor and recipient data were abstracted from a collaborative, prospective registry shared by our local organ procurement organization, and tertiary medical center. Short-term outcomes, 1-year survival, and hospitalization costs were compared between local and distant lung transplants defined by donor service area. RESULTS Of the 722 lung transplants performed, 392 (54%) had local donors and 330 (46%) had distant donors. Donors were similar in age and cause of death. Recipients were significantly different in diagnosis and local recipients had lower median lung allocation scores (local, 37.3 and distant, 44.9; P < .01). Distant lung transplants had longer total ischemic times (local, 231 ± 52 minutes and distant, 313 ± 48 minutes; P < .01). The rate of major complications, length of hospital stay, and 1-year survival were similar between groups. Distant lung transplants were associated with higher median overall cost (local, $183,542 and distant, $229,871; P < .01). Local lung transplants were more likely to be performed during daytime (local, 333 out of 392 [85%] and distant, 291 out of 330 [61%]; P < .01). CONCLUSIONS Local lung transplants are associated with shorter ischemic times, lower cost, and greater likelihood of daytime surgery. Short- and intermediate-term outcomes are similar for lung transplants from local and distant donors. The new lung allocation policy, with higher proportion of distant lung transplants, is likely to incur greater costs but provide similar outcomes.
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Affiliation(s)
- William D Gerull
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo.
| | - Zhizhou Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
| | - Ruben Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St Louis, Mo
| | - Chad Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St Louis, Mo
| | - Derek Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St Louis, Mo
| | - Hrishikesh Kulkarni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St Louis, Mo
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St Louis, Mo
| | | | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
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Kim JL, Reader BF, Dumond C, Lee Y, Mokadam NA, Black SM, Whitson BA. Pegylated-Catalase Is Protective in Lung Ischemic Injury and Oxidative Stress. Ann Thorac Surg 2020; 111:1019-1027. [PMID: 32710846 DOI: 10.1016/j.athoracsur.2020.05.131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/04/2020] [Accepted: 05/18/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Lung transplant ischemia-reperfusion injury is typified by toxic metabolites and oxygen free radicals leading to worse graft function. Catalase is an enzyme involved in oxidative-stress detoxification. We hypothesize that direct delivery of highly concentrated polyethylene glycol-catalase (PEG-CAT) during normothermic ex vivo lung perfusion (EVLP) significantly reduces ischemia-reperfusion injury. METHODS To demonstrate protection, primary culture porcine endothelial cells were treated with PEG-CAT (0 to 1250 U/mL) in a model of oxidative stress (400 μM H2o2). In vivo, rat lungs were subjected to 0 hours or 1 hour of warm ischemic injury and 2 hours of EVLP with or without PEG-CAT. Perfusate was collected throughout the perfusion duration and tissue was collected at the end. Tissue and perfusate underwent analysis for markers of apoptosis and a biometric signature of lung health. RESULTS Uptake of PEG-CAT into primary endothelial cells was demonstrated with Alexa Fluor 488-labeled PEG-CAT. Oxidatively stressed cells pretreated with PEG-CAT had significantly decreased cytotoxicity and caspase 3/7 activity and increased cell viability and cell membrane integrity. In a rat model of warm ischemia with EVLP, PEG-CAT improved allograft viability as measured by indications of cell membrane integrity (lactate dehydrogenase and hyaluronic acid), presence of vasoconstrictive peptides (endothelin-1 and big endothelin-1) released from endothelial cells, and reduced apoptosis (terminal deoxynucleotidyl transferase dUTP nick-end labeling). CONCLUSIONS In vitro and ex vivo, PEG-CAT protects against oxidative stress-induced cytotoxicity, maintains cellular metabolism, and mitigates lung ischemia-reperfusion in an experimental model. Together, these data suggest that PEG-CAT is a potential therapeutic target for donor organs at risk for ischemia-reperfusion injury.
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Affiliation(s)
- Jung-Lye Kim
- COPPER Laboratory, Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Brenda F Reader
- COPPER Laboratory, Ohio State University Wexner Medical Center, Columbus, Ohio; Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Curtis Dumond
- COPPER Laboratory, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Yonggyu Lee
- COPPER Laboratory, Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nahush A Mokadam
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sylvester M Black
- COPPER Laboratory, Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio; Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bryan A Whitson
- COPPER Laboratory, Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio; Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, Ohio.
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Yang Z, Gerull WD, Gauthier JM, Meyers BF, Kozower BD, Patterson GA, Nava RG, Hachem RR, Witt CA, Byers DE, Marklin GF, Ridolfi G, Liu J, Kreisel D, Puri V. Shipping Lungs Greater Distances Increases Costs Without Cutting Waitlist Mortality. Ann Thorac Surg 2020; 110:1691-1697. [PMID: 32511997 DOI: 10.1016/j.athoracsur.2020.04.086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 03/30/2020] [Accepted: 04/19/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND On November 24, 2017, a change in lung allocation policy was initiated to replace the donor service area with a 250-nautical-mile radius circle around the donor hospital. We aim to analyze the consequences of this change, including organ acquisition cost and transplant outcomes, at the national level. METHODS Data on adult patients undergoing lung transplantation between April 27, 2017, and June 22, 2018 (30 weeks before to 30 weeks after allocation policy change) were extracted from the Scientific Registry of Transplant Recipients database. Patients were classified into pre-change and post-change subgroups. Six-month overall survival was evaluated by Kaplan-Meier analysis. Organ acquisition costs were compared between the pre-change and post-change groups. RESULTS Of the 3317 adult patients removed from the waiting list during the study period (pre-change 1637 vs post-change 1680), 2734 underwent transplantation (pre-change 1371 of 1637 [83.8%] vs post-change 1363 of 1680 [81.1%]), and 382 died or became too sick to be transplanted (pre-change 168 of 1637 [10.3%] vs post-change 214 of 1680 [12.7%], P = .077). Six-month survival rates of transplanted patients were similar between the two groups. However, average organ acquisition costs increased after policy change (pre-change $50,735 ± $10,858 vs post-change $53,440 ± $10,247, P < .001) with an increase in nonlocal donors (pre-change 44.3% vs post-change 68.9%, P < .001). CONCLUSIONS Organ acquisition costs and resource utilization increased with the new lung allocation policy, whereas deaths on the waiting list or after transplantation did not decrease. Further optimization of the allocation policy is necessary to balance access to transplant and proper stewardship of human and financial resources.
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Affiliation(s)
- Zhizhou Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri
| | - William D Gerull
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri
| | - Jason M Gauthier
- Department of Surgery, Washington University, St Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonology and Critical Care, Washington University, St Louis, Missouri
| | - Chad A Witt
- Division of Pulmonology and Critical Care, Washington University, St Louis, Missouri
| | - Derek E Byers
- Division of Pulmonology and Critical Care, Washington University, St Louis, Missouri
| | | | | | - Jingxia Liu
- Department of Surgery, Washington University, St Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Missouri.
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Taylor LJ, Fiedler AG. Balancing supply and demand: Review of the 2018 donor heart allocation policy. J Card Surg 2020; 35:1583-1588. [DOI: 10.1111/jocs.14609] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Lauren J. Taylor
- Division of Cardiothoracic Surgery, Department of Surgery University of Wisconsin Madison Wisconsin
| | - Amy G. Fiedler
- Division of Cardiothoracic Surgery, Department of Surgery University of Wisconsin Madison Wisconsin
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Hauerwaas A, Weisenfeld U. The impact of systemic innovations for transforming transplant systems. Lessons learned from the German lung transplantation system. A qualitative study. Health Syst (Basingstoke) 2020; 9:76-93. [PMID: 32284853 DOI: 10.1080/20476965.2019.1604086] [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: 09/25/2018] [Accepted: 03/22/2019] [Indexed: 10/26/2022] Open
Abstract
The aim of this paper is to demonstrate the potential of the systemic innovations approach for transforming transplantation systems. It explores potential leverage points for intervening in the LTx-system as well as possible paths of transformation. We present possible transition pathways giving the example of the German Lung transplantation system that teeters on the brink of collapse due to system failures and organ scarcity and illustrate systemic innovations as core mechanisms for systems change in health systems. Desk research and semi-structured experts interviews provided qualitative data for a deductive-inductive coding and a rigorous qualitative content analysis of the data. Depending on the systemic innovations chosen to achieve systems change, transplant systems follow different transformational paths: from a collapse to a leapfrogging towards a non-human transplantation system. Thus, global health areas like transplantation benefit from analysis on systemic innovations as these support researchers, public policy and regulators by developing transformative strategies in healthcare systems.
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Affiliation(s)
- Antoniya Hauerwaas
- Institute of Management and Organisation, Leuphana University, Lueneburg, Germany
| | - Ursula Weisenfeld
- Institute of Management and Organisation, Leuphana University, Lueneburg, Germany
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38
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Increased Calculated Panel Reactive Antigen Is Associated With Increased Waitlist Time and Mortality in Lung Transplantation. Ann Thorac Surg 2020; 110:414-423. [PMID: 32251655 DOI: 10.1016/j.athoracsur.2020.02.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 02/01/2020] [Accepted: 02/26/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Sensitized candidates with unacceptable antigens are a group that demands special attention in organ transplantation. Calculated panel reactive antigen (cPRA) is not used to modify allocation priorities in lung transplantation. The impact of cPRA on waiting list time and mortality is unknown. METHODS We performed a retrospective review of candidates for lung transplantation listed from May 2005 to 2018. Data from the Organ Procurement and Transplantation Network/United Network for Organ Sharing STAR (Standard Analysis and Research) dataset was paired with additional unacceptable human leukocyte antigen (UA-HLA) data, which were used to calculate the listing cPRA. Candidates were stratified based on the lack of UA-HLAs or cPRA level for candidates with unacceptable antigens reported. Unadjusted competing risks and adjusted subdistribution hazard models were fit. RESULTS A total of 29,085 candidates met inclusion criteria for analysis. Of these, 23,562 (81%) with no UA-HLAs, 3472 (11.9%) with a cPRA less than 50, and 2051 with a cPRA greater than or equal to 50 (7.1%). On adjusted analysis, a cPRA greater than or equal to 50 was independently associated with increased waitlist mortality at 1 year (hazard ratio, 1.71; 95% confidence interval, 1.55-1.88; P < .001) and decreased rate of transplantation (71.9% vs 69.5% vs 44.4%; P < .001). Furthermore, patients with a cPRA greater than or equal to 50 had a longer waitlist time compared with a cPRA less than 50 and no UA-HLA candidates (mean 293.69 days vs 162.38 days and 143.26 days, respectively; P < .001). However, once transplanted, posttransplant survival among the cohorts was similar. CONCLUSIONS Further evaluation of organ allocation with consideration of a candidate's cPRA may be warranted in order to optimize equity in access to transplants.
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Impact and Implications following the November 2017 Emergency Change to the United States Lung Allocation Policy. Ann Am Thorac Soc 2020; 17:795-799. [PMID: 32068435 DOI: 10.1513/annalsats.201911-818ps] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Risk Indices in Deceased-donor Organ Allocation for Transplantation: Review From an Australian Perspective. Transplantation 2019; 103:875-889. [PMID: 30801513 DOI: 10.1097/tp.0000000000002613] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Over the last decade, organ donation and transplantation rates have increased in Australia and worldwide. Donor and recipient characteristics for most organ types have generally broadened, resulting in the need to consider more complex data in transplant decision-making. As a result of some of these pressures, the Australian software used for donor and recipient data management is currently being updated. Because of the in-built capacity for improved data management, organ allocation processes will have the opportunity to be significantly reviewed, in particular the possible use of risk indices (RIs) to guide organ allocation and transplantation decisions. We aimed to review RIs used in organ allocation policies worldwide and to compare their use to current Australian protocols. Significant donor, recipient, and transplant variables in the indices were summarized. We conclude that Australia has the opportunity to incorporate greater use of RIs in its allocation policies and in transplant decision-making processes. However, while RIs can assist with organ allocation and help guide prognosis, they often have significant limitations which need to be properly appreciated when deciding how to best use them to guide clinical decisions.
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Siminoff LA, Gardiner HM, Wilson-Genderson M, Shafer TJ. How Inaccurate Metrics Hide the True Potential for Organ Donation in the United States. Prog Transplant 2019; 28:12-18. [PMID: 29592635 DOI: 10.1177/1526924818757939] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND There is a discrepancy between the reported increase in donor conversion rates and the number of organs available for transplant. METHODS Secondary analysis of data obtained from the Scientific Registry of Transplant Recipients from January 2003 through December 2015 was performed. The primary outcomes were the (1) number of brain-dead donors from whom solid organs were recovered and (2) number of the organs transplanted. Descriptive statistics and growth plots were used to examine the trajectory of organ donation, recovery, and transplantation outcomes over the 11-year period. RESULTS From 2003 to 2006, the number of brain-dead donors increased from 6187 to 7375, remaining relatively stable at approximately 7200 thereafter. The average eligible deaths per organ procurement organization dropped from 182.7 (standard deviation [SD]: 131.3) in 2003 to 149.3 (SD: 111.4) in 2015. This suggests a total of 12 493 unrealized potential donors (2006-2015). CONCLUSIONS Since 2006, a steady decline in the number of donor-eligible deaths was reported. In 2003, the reported eligible deaths was 11 326. This number peaked in 2004 at 11 346, tumbling to 9781 eligible donors in 2015, despite a 9% increase in the US population. From 2006 to 2015, the data indicate an artificial depression and underestimation of the true potential of brain-dead donors in the United States of conservatively 12 493 donors or 39 728 missing organs. New metrics providing objective but verifiable counts of the donor pool are needed.
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Affiliation(s)
- Laura A Siminoff
- 1 College of Public Health, Temple University, Philadelphia, PA, USA
| | - Heather M Gardiner
- 2 College of Public Health, Department of Social and Behavioral Sciences, Temple University, Philadelphia, PA, USA
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Abstract
Lung transplantation is a valuable therapeutic option for many patients with severe lung disease who have exhausted other medical or surgical therapies. However, since lungs are not a manufacturable organ like artificial heart valves or left ventricular assist devices, and since they are a limited resource compared to number of patients requiring the organs, the Department of Health and Human Services set the Final Rule of organ allocation in 1998. This led to development and implementation of Lung Allocation Score (LAS) in 2005. The score broadly divides lung diseases into 4 diagnostic criteria with a coefficient factor given to each category. The score is based on the prognostic factors of each patient to determine the risk of mortality without a transplant combined with the probability of patient survival post-transplant. Most of the guidelines for "Indications for referral and listing in lung transplant" is based on consensus opinion as there is limited amount of robust data and trials about this topic. The International Society for Heart and Lung Transplant (ISHLT) has published three editions for candidate selection and listing. In this article, we have attempted to highlight the guidelines and incorporated other disease specific prognostic factors that are not captured in the LAS. Ultimately, there are other factors like geographic location, height, blood group, preformed antibodies, transplant center experience, past wait times and transplant rate, availability of organs, etc., which also play a role especially when considering listing a patient for lung transplant. We also highlighted a representative disease in each category and most criteria for that disease will apply to other diseases in that category. Finally, this article does not delve into the history and reasoning behind each guideline but is meant to provide a general overview of indications and contraindications applicable in the field of adult lung transplantation.
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Affiliation(s)
- Omar Shweish
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Goutham Dronavalli
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
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Comber EM, Palchesko RN, Ng WH, Ren X, Cook KE. De novo lung biofabrication: clinical need, construction methods, and design strategy. Transl Res 2019; 211:1-18. [PMID: 31103468 DOI: 10.1016/j.trsl.2019.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/10/2019] [Accepted: 04/25/2019] [Indexed: 01/22/2023]
Abstract
Chronic lung disease is the 4th leading cause of death in the United States. Due to a shortage of donor lungs, alternative approaches to support failing, native lungs have been attempted, including mechanical ventilation and various forms of artificial lungs. However, each of these support methods causes significant complications when used for longer than a few days and are thus not capable of long-term support. For artificial lungs, complications arise due to interactions between the artificial materials of the device and the blood of the recipient. A potential new approach is the fabrication of lungs from biological materials, such that the gas exchange membranes provide a more biomimetic blood-contacting interface. Recent advancements with three-dimensional, soft-tissue biofabrication methods and the engineering of thin, basement membranes demonstrate the potential of fabricating a lung scaffold from extracellular matrix materials. This scaffold could then be seeded with endothelial and epithelial cells, matured within a bioreactor, and transplanted. In theory, this fully biological lung could provide improved, long-term biocompatibility relative to artificial lungs, but significant work is needed to perfect the organ design and construction methods. Like artificial lungs, biofabricated lungs do not need to follow the shape and structure of a native lung, allowing for simpler manufacture. However, various functional requirements must still be met, including stable, efficient gas exchange for a period of years. Design decisions depend on the disease state, how the organ is implanted, and the latest biofabrication methods available in a rapidly evolving field.
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Affiliation(s)
- Erica M Comber
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania.
| | - Rachelle N Palchesko
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Wai Hoe Ng
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Xi Ren
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Keith E Cook
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
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Blackstone EH, Rajeswaran J, Cruz VB, Hsich EM, Koprivanac M, Smedira NG, Hoercher KJ, Thuita L, Starling RC. Continuously Updated Estimation of Heart Transplant Waitlist Mortality. J Am Coll Cardiol 2019; 72:650-659. [PMID: 30071995 DOI: 10.1016/j.jacc.2018.05.045] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 05/07/2018] [Accepted: 05/09/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Heart transplant allocation in the United States is made on the basis of coarse tiers, defined by mechanical circulatory devices and therapy for advanced heart failure, updated infrequently as a patient's condition deteriorates. Thus, many patients die awaiting heart transplantation. What is needed is a tool that continuously updates risk of mortality as a patient's condition changes to inform clinical decision making. OBJECTIVES This study sought to develop a decision aid that aggregates adverse events and measures of end-organ function into a continuously updated waitlist mortality estimate. METHODS From 2008 to 2013, 414 patients were listed for heart transplantation at Cleveland Clinic, Cleveland, Ohio. The endpoint was waitlist death. Pre-listing patient characteristics and events and laboratory results during listing were analyzed. At each event or measurement change, mortality was recomputed from the resulting model. RESULTS There were 77 waitlist deaths, with 1- and 4-year survival of 85% and 57%, respectively. When time-varying events and measurements were incorporated into a mortality model, pre-listing patient characteristics became nonsignificant. Neurological events (hazard ratio [HR]: 13.5; 95% confidence interval [CI]: 7.63 to 23.8), new requirement for dialysis (HR: 3.67; 95% CI: 1.88 to 7.14), more respiratory complications (HR: 1.79 per episode; 95% CI: 1.23 to 2.59), and higher serum bilirubin (p < 0.0001) and creatinine (p < 0.0001) yielded continuously updated estimates of patient-specific mortality across the waitlist period. CONCLUSIONS Mortality risk for patients with advanced heart failure who are listed for transplantation is related to adverse events and end-organ dysfunction that change over time. A continuously updated mortality estimate, combined with clinical evaluation, may inform status changes that could reduce mortality on the heart transplant waiting list.
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Affiliation(s)
- Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vincent B Cruz
- Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Eileen M Hsich
- Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas G Smedira
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Katherine J Hoercher
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Randall C Starling
- Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
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Rudasill SE, Sanaiha Y, Kwon M, Mardock AL, Khoury H, Omari B, Rabkin DG, Benharash P. Understanding lung transplant listing practices: Survival in lung transplant candidates who improve clinically to delisting. Surgery 2019; 166:1142-1147. [PMID: 31421870 DOI: 10.1016/j.surg.2019.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/14/2019] [Accepted: 07/06/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Occasionally, lung transplant candidates improve to the point where they are removed from the transplant list. We sought to determine the characteristics and outcomes of lung transplant candidates who improved to delisting both before and after implementation of the lung allocation score. METHODS Using the United Network for Organ Sharing database, we reviewed all adult patients listed for lung transplant between 1987 and 2012. The last permanent status change was classified into transplanted, improved to delisting (improved), or deteriorated to delisting (deteriorated). Survival time was calculated using the linked date of death from the Social Security Administration. Survival analysis was performed via the Kaplan-Meier method, and adjusted multivariable logistic regressions identified characteristics predicting improvement to delisting. RESULTS Of 13,688 candidates, 12,188 (89.0%) were transplanted, 454 (3.3%) improved, and 1,046 (7.6%) deteriorated. The 5-year mortality was greater in improved (hazard ratio = 1.21 [1.07-1.38], P = .002) and deteriorated (hazard ratio = 3.36 [3.11-3.64], P < .001) candidates relative to those transplanted; however, 1-year survival was greater in improved versus transplanted candidates (75.9% vs 67.2%, log rank P < .001). Older, female patients listed for primary pulmonary hypertension and retransplantation were more likely to improve to delisting. The proportion of improved patients varied by hospital quartile volume (P < .001) and the United Network for Organ Sharing geographic region (P < .001). The number of patients improving to delisting decreased after implementation of the lung allocation score. CONCLUSION Lung transplant candidates improving to delisting faced less short-term but greater long-term mortality relative to transplanted candidates. Given that the improved population decreased dramatically after implementation of the lung allocation score, redefining patient listing criteria appears to have improved patient appropriateness for transplant.
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Affiliation(s)
- Sarah E Rudasill
- Cardiovascular Outcomes Research Laboratories (CORELAB) at the David Geffen School of Medicine, University of California, Los Angeles
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB) at the David Geffen School of Medicine, University of California, Los Angeles
| | - Murray Kwon
- Division of Cardiac Surgery, University of California, Los Angeles
| | - Alexandra L Mardock
- Cardiovascular Outcomes Research Laboratories (CORELAB) at the David Geffen School of Medicine, University of California, Los Angeles
| | - Habib Khoury
- Cardiovascular Outcomes Research Laboratories (CORELAB) at the David Geffen School of Medicine, University of California, Los Angeles
| | - Bassam Omari
- Department of Surgery, Harbor UCLA Medical Center, Los Angeles, CA
| | - David G Rabkin
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB) at the David Geffen School of Medicine, University of California, Los Angeles; Division of Cardiac Surgery, University of California, Los Angeles.
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Time Is a Precious Commodity: 2018 OPTN Policy Change and the Potential to Lower Heart Transplant Waitlist Time in the Sickest Patients. Curr Cardiol Rep 2019; 21:67. [DOI: 10.1007/s11886-019-1150-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Miller PE, Pawar S, Vaccaro B, McCullough M, Rao P, Ghosh R, Warier P, Desai NR, Ahmad T. Predictive Abilities of Machine Learning Techniques May Be Limited by Dataset Characteristics: Insights From the UNOS Database. J Card Fail 2019; 25:479-483. [DOI: 10.1016/j.cardfail.2019.01.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 01/15/2019] [Accepted: 01/23/2019] [Indexed: 12/21/2022]
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Martin AK, Renew JR, Jayaraman AL, Murray AW, Fritz AV, Ramakrishna H. Analysis of Outcomes in Lung Transplantation. J Cardiothorac Vasc Anesth 2019; 33:1455-1466. [DOI: 10.1053/j.jvca.2018.06.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Indexed: 01/04/2023]
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Mooney JJ, Yang L, Hedlin H, Mohabir P, Dhillon GS. Multiple listing in lung transplant candidates: A cohort study. Am J Transplant 2019; 19:1098-1108. [PMID: 30253057 PMCID: PMC6433482 DOI: 10.1111/ajt.15124] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 01/25/2023]
Abstract
Lung transplant candidates can be waitlisted at more than one transplant center, a practice known as multiple listing. The factors associated with multiple listing and whether multiple listing modifies waitlist mortality or likelihood of lung transplant is unknown. US lung transplant waitlist candidates were identified as either single or multiple listed using data from the Scientific Registry of Transplant Recipients. Characteristics of single and multiple listed candidates were compared and multivariable logistic regression was used to estimate associations with multiple listing. Multiple listed candidates were matched to single listed candidates using a combination of exact and propensity score matching methods. Cox proportional hazard models were used to estimate the relationship of multiple listing on waitlist mortality and receiving a transplant. Multiple listing occurred in 2.3% of lung transplant waitlist candidates. Younger age, female gender, white race, short stature, high antibody sensitization, college or postcollege education, lower lung allocation score, and a cystic fibrosis diagnosis were independently associated with multiple listing. Multiple listing was associated with an increased likelihood of lung transplant (adjusted hazard ratio [aHR] 2.74, 95% CI 2.37 to 3.16) but was not associated with waitlist mortality (aHR 0.99, 95% CI 0.68 to 1.44).
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Affiliation(s)
- Joshua J. Mooney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, CA
| | - Lingyao Yang
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, CA
| | - Haley Hedlin
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, CA
| | - Paul Mohabir
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, CA
| | - Gundeep S Dhillon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, CA
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Meyer KC. Balancing fairness and efficacy in lung allocation for transplantation: unfinished business. Thorax 2018; 74:16-17. [PMID: 30446619 DOI: 10.1136/thoraxjnl-2018-212634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2018] [Indexed: 11/04/2022]
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