Is shortage of heart donors a real problem? Insights from a Brazilian Mid‐West heart transplant program

They Deserve to Live: Impact of the Berlin Heart EXCOR on Small Children's Heart Transplant Waitlist in Low-Resource Settings

Background: In newly emerging economy countries, the shortage of pediatric donor hearts and poor healthcare infrastructure poses a significant challenge. Although mechanical circulatory support (MCS) has been proven effective in enhancing heart transplant waiting list outcomes, economic barriers hinder its widespread adoption. Methods: A single-center retrospective study reviewed children under 10 kg on the heart transplant (HTx) list from 2012 to 2023. Elective or priority status was assigned based on their clinical condition at the time of transplant. In cases of clinical decompensation, centrifugal pump and extracorporeal membrane oxygenation, transitioned to the Berlin Heart EXCOR (BHE) pediatric ventricular assist device (VAD) was employed. Pre- and post-HTx outcomes were analyzed with descriptive statistics, Cox regression, and competing survival risks. Results: Out of 81 infants on the HTx list, 61.7% (50/81) were in critical condition. The median wait time was 224 days, and 34% (28/81) died while waiting. Out of 37 transplanted patients, 6 (16%) had graft dysfunction, and 10 (27%) had acute renal injury. Survival to discharge was 84% (31/37). Patients who received the BHE exhibited higher chances of receiving a transplant (hazard ratio: 2.3; 95% confidence interval: 1.2-4.6; P = .01). Priority status or MCS use did not significantly impact mortality post-transplant. Conclusion: Advanced MCS technologies can potentially reduce the mortality risk on the pediatric HTx waitlist. The findings highlight the significant waiting time for HTx and the critical role of the BHE in improving outcomes in children, particularly those under 10 kg. The results advocate for the adoption of ventricular assist devices as a viable interim solution to bridge critically ill children to HTx, ultimately enhancing their chances of survival despite limited donor heart availability.

Cost-effectiveness of a centrifugal-flow pump for patients with advanced heart failure in Argentina

Background

Centrifugal-flow pumps are novel treatment options for patients with advanced heart failure (HF). This study estimated the incremental cost-effectiveness ratio (ICER) of centrifugal-flow pumps for patients with advanced HF in Argentina.

Methods

Two Markov models were developed to estimate the cost-effectiveness of a centrifugal-flow pump as destination therapy (DT) in patients with contraindication for heart transplantation, and as bridge-to-transplant (BTT), with a lifetime horizon using the third-party payer Social Security (SS) and Private Sector (PS) perspectives. Clinical, epidemiological, and quality-adjusted life years (QALY) parameters were retrieved from the literature. Direct medical costs were estimated through a micro-costing approach (exchange rate USD 1 = ARS 59.95).

Results

The centrifugal-flow pump as a DT increased the per patient QALYs by 3.5 and costs by ARS 8.1 million in both the SS and PS, with an ICER of ARS 2.3 million per QALY. Corresponding values for a centrifugal-flow pump as BTT were 0.74 QALYs and more than ARS 8 million, yielding ICERs of ARS 11 million per QALY (highly dependent on waiting times). For the 1, 3, and 5 GDP per QALY thresholds, the probability of a centrifugal-flow pump to be cost-effective for DT/BTT was around 2%/0%, 40%/0%, and 80%/1%, respectively.

Conclusion

The centrifugal-flow pump prolongs life and improves the quality of life at significantly higher costs. As in Argentina there is no current explicit cost-effectiveness threshold, the final decision on reimbursement will depend on the willingness to pay in each subsector. Nevertheless, the centrifugal-flow pump as a DT was more cost-effective than as a BTT.

Outcomes of Orthotopic Heart Transplantation in the Setting of Acute Kidney Injury and Renal Replacement Therapy

OBJECTIVE

Heart transplantation in the setting of renal insufficiency is controversial. The objective of this study was to perform a descriptive analysis of patients who underwent orthotopic heart transplantation and renal replacement therapy (RRT) due to acute kidney injury (AKI).

DESIGN

An observational cohort study with retrospective data collection.

SETTING

A tertiary care hospital.

PARTICIPANTS

Fifty-one patients underwent orthotopic heart transplantation with cardiogenic shock under inotrope dependence, with nine patients having preoperative RRT and 42 patients not having preoperative RRT.

INTERVENTIONS

There were no interventions.

MEASUREMENTS AND MAIN RESULTS

Hospital mortality occurred in eight (15.6%) patients. Although there were no significant differences between the study groups (preoperative RRT 33.3% v controls 11.9%, p = 0.1), this study was underpowered to detect differences in mortality. Dialysis also was required in 52.4% of patients who were not on preoperative RRT. All survivors had full recovery of kidney function with similar timing after transplant (18.5 days v 15 days, p = 0.75). Actuarial survival was 82.4%, 76.5%, and 66.5% at six months, one year, and five years, respectively. A cold ischemic time greater than 180 minutes (hazard ratio [HR] 4.37 95% confidence interval [CI] 1.51-12.6; p = 0.006) and pretransplant RRT (HR = 7.19 95% CI 1.13-45.7; p = 0.04) were independent predictors of long-term mortality.

CONCLUSIONS

In a health system with limited funding and availability of mechanical circulatory support, heart transplantation in the setting of AKI, RRT, and low Interagency Registry for Mechanically Assisted Circulatory Support profile was associated with important hospital mortality. Among hospital survivors, however, all patients had full renal recovery and by 25 months there was no difference in mortality between those who required preoperative RRT and those who did not.