Association of Gender and Race With Allocation of Advanced Heart Failure Therapies

Importance

Racial bias is associated with the allocation of advanced heart failure therapies, heart transplants, and ventricular assist devices. It is unknown whether gender and racial biases are associated with the allocation of advanced therapies among women.

Objective

To determine whether the intersection of patient gender and race is associated with the decision-making of clinicians during the allocation of advanced heart failure therapies.

Design, Setting, and Participants

In this qualitative study, 46 US clinicians attending a conference for an international heart transplant organization in April 2019 were interviewed on the allocation of advanced heart failure therapies. Participants were randomized to examine clinical vignettes that varied 1:1 by patient race (African American to white) and 20:3 by gender (women to men) to purposefully target vignettes of women patients to compare with a prior study of vignettes of men patients. Participants were interviewed about their decision-making process using the think-aloud technique and provided supplemental surveys. Interviews were analyzed using grounded theory methodology, and surveys were analyzed with Wilcoxon tests.

Exposure

Randomization to clinical vignettes.

Main Outcomes and Measures

Thematic differences in allocation of advanced therapies by patient race and gender.

Results

Among 46 participants (24 [52%] women, 20 [43%] racial minority), participants were randomized to the vignette of a white woman (20 participants [43%]), an African American woman (20 participants [43%]), a white man (3 participants [7%]), and an African American man (3 participants [7%]). Allocation differences centered on 5 themes. First, clinicians critiqued the appearance of the women more harshly than the men as part of their overall impressions. Second, the African American man was perceived as experiencing more severe illness than individuals from other racial and gender groups. Third, there was more concern regarding appropriateness of prior care of the African American woman compared with the white woman. Fourth, there were greater concerns about adequacy of social support for the women than for the men. Children were perceived as liabilities for women, particularly the African American woman. Family dynamics and finances were perceived to be greater concerns for the African American woman than for individuals in the other vignettes; spouses were deemed inadequate support for women. Last, participants recommended ventricular assist devices over transplantation for all racial and gender groups. Surveys revealed no statistically significant differences in allocation recommendations for African American and white women patients.

Conclusions and Relevance

This national study of health care professionals randomized to clinical vignettes that varied only by gender and race found evidence of gender and race bias in the decision-making process for offering advanced therapies for heart failure, particularly for African American women patients, who were judged more harshly by appearance and adequacy of social support. There was no associated between patient gender and race and final recommendations for allocation of advanced therapies. However, it is possible that bias may contribute to delayed allocation and ultimately inequity in the allocation of advanced therapies in a clinical setting.

Left ventricular assist device recovery: does duration of mechanical support matter?

Heart failure is a widespread condition in the United States that is predicted to significantly increase in prevalence in the next decade. Many heart failure patients are given a left ventricular assist device (LVAD) while they wait for a heart transplant, while those that are not able to undergo a heart transplant may be given an LVAD permanently. However, past studies have observed a small subset of heart failure patients that recovered cardiac function of their native heart after being placed on an LVAD. As a result, some patients have been able to have their LVAD explanted and no longer needed a heart transplant. In this review, we analyzed the data of 15 studies that observed recovery of cardiac function in LVAD patients in order to investigate the effects that duration of LVAD support has on patient outcomes. From our review, we identified that there may be negative consequences of prolonged duration of mechanical support such as myocardial atrophy and abnormal calcium cycling as well as circumstances that may allow for a longer duration of LVAD support such as in patients using a continuous-flow LVAD, non-ischemic cardiomyopathy patients, and the specific pharmacological therapy.

One-year follow-up of heart transplant recipient with cardiac rehabilitation: A case report

INTRODUCTION

Heart transplantation (HT) is known to be the final therapy for patients with advanced heart failure; however, the exercise capacity of these patients remains under the aged-predicted value after HT. Many studies have described the effectiveness and safety of cardiac rehabilitation (CR) in HT recipients. Nevertheless, long-term follow-up data of HT recipients undergoing CR are insufficient, and there is a lack of evidence on the long-term effects of CR. In this case report, we present the long-term benefits of CR in an HT recipient, including serial follow-up clinical data over 1 year.

PATIENT CONCERNS

A 48-year-old female patient underwent HT because of advanced dilated cardiomyopathy.

DIAGNOSIS

Cardiopulmonary exercise test showed reduced exercise capacity and pulmonary function. The grip power and quadriceps muscle strength were also decreased after HT.

INTERVENTIONS

The patient underwent a phase I CR program for 3 months, followed by a phase III CR program for 7 months. In the beginning, moderate-intensity continuous training was conducted. Thereafter, high-intensity interval training was implemented after a period of adjustment for interval training.

OUTCOMES

The exercise capacity, 6-min walk distance, muscle strength, and vital capacity were improved after CR.

CONCLUSION

CR in HT recipients may improve muscle strength and pulmonary function as well as exercise capacity, without serious cardiovascular complications. Phase III CR may help maintain exercise capacity in these patients.

The Effects of Ethanol on the Heart: Alcoholic Cardiomyopathy

Alcoholic-dilated Cardiomyopathy (ACM) is the most prevalent form of ethanol-induced heart damage. Ethanol induces ACM in a dose-dependent manner, independently of nutrition, vitamin, or electrolyte disturbances. It has synergistic effects with other heart risk factors. ACM produces a progressive reduction in myocardial contractility and heart chamber dilatation, leading to heart failure episodes and arrhythmias. Pathologically, ethanol induces myocytolysis, apoptosis, and necrosis of myocytes, with repair mechanisms causing hypertrophy and interstitial fibrosis. Myocyte ethanol targets include changes in membrane composition, receptors, ion channels, intracellular [Ca²⁺] transients, and structural proteins, and disrupt sarcomere contractility. Cardiac remodeling tries to compensate for this damage, establishing a balance between aggression and defense mechanisms. The final process of ACM is the result of dosage and individual predisposition. The ACM prognosis depends on the degree of persistent ethanol intake. Abstinence is the preferred goal, although controlled drinking may still improve cardiac function. New strategies are addressed to decrease myocyte hypertrophy and interstitial fibrosis and try to improve myocyte regeneration, minimizing ethanol-related cardiac damage. Growth factors and cardiomyokines are relevant molecules that may modify this process. Cardiac transplantation is the final measure in end-stage ACM but is limited to those subjects able to achieve abstinence.

Use of genetic risks in pediatric organ transplantation listing decisions: A national survey

There is a limited supply of organs for all those who need them for survival. Thus, careful decisions must be made about who is listed for transplant. Studies show that manifesting genetic disease can impact listing eligibility. What has not yet been studied is the impact genetic risks for future disease have on a patient's chance to be listed. Surveys were emailed to 163 pediatric liver, heart, and kidney transplant programs across the United States to elicit views and experiences of key clinicians regarding each program's use of genetic risks (ie, predispositions, positive predictive testing) in listing decisions. Response rate was 42%. Sixty-four percent of programs have required genetic testing for specific indications prior to listing decisions. Sixteen percent have required it without specific indications, suggesting that genetic testing may be used to screen candidates. Six percent have chosen not to list patients with secondary findings or family histories of genetic conditions. In hypothetical scenarios, programs consider cancer predispositions and adult-onset neurological conditions to be relative contraindications to listing (61%, 17%, and 8% depending on scenario), and some consider them absolute contraindications (5% and 3% depending on scenario). Only 3% of programs have formal policies for these scenarios, but all consult genetic specialists at least "sometimes" for results interpretation. Our study reveals that pediatric transplant programs are using future onset genetic risks in listing decisions. As genetic testing is increasingly adopted into pediatric medicine, further study is needed to prevent possible inappropriate use of genetic information from impacting listing eligibility.

Perioperative Management of the Cardiac Transplant Recipient

Management of the cardiac transplant recipient includes careful titration of inotropes and vasopressors. Recipient pulmonary hypertension and ventilatory status must be optimized to prevent allograft right ventricular failure. Vasoplegia, coagulopathy, arrhythmias, and renal dysfunction also require careful management to achieve an optimal outcome. Primary graft dysfunction (PGD) can be an ominous problem after cardiac transplantation. Although mild degrees of PGD may be managed medically, mechanical circulatory support with extracorporeal membrane oxygenation or temporary ventricular assist devices may be required. Retransplantation may be necessary in some cases.

Association between quality of life and prognosis of candidate patients for heart transplantation: a cross-sectional study

OBJECTIVE

to verify the association between the prognostic scores and the quality of life of candidates for heart transplantation.

METHOD

a descriptive cross-sectional study with a convenience sample of 32 outpatients applying to heart transplantation. The prognosis was rated by the Heart Failure Survival Score (HFSS) and the Seattle Heart Failure Model (SHFM); and the quality of life by the Minnesota Living With Heart Failure Questionnaire (MLHFQ) and the Kansas City Cardiomyopathy Questionnaire (KCCQ). The Pearson correlation test was applied.

RESULTS

the correlations found between general quality of life scores and prognostic scores were (HFSS/MLHFQ r = 0.21), (SHFM/MLHFQ r = 0.09), (HFSS/KCCQ r = -0.02), (SHFM/KCCQ r = -0.20).

CONCLUSION

the weak correlation between the prognostic and quality of life scores suggests a lack of association between the measures, i.e., worse prognosis does not mean worse quality of life and the same statement is true in the opposite direction.

Current Status of Left Ventricular Assist Device Therapy

Congestive heart failure (HF) remains a serious burden in the Western World. Despite advances in pharmacotherapy and resynchronization, many patients have progression to end-stage HF. These patients may be candidates for heart transplant or left ventricular assist device (LVAD) therapy. Heart transplants are limited by organ shortages and in some cases by patient comorbidities; therefore, LVAD therapy is emerging as a strategy of bridge to transplant or as a destination therapy in patients ineligible for transplant. Patients initially ineligible for a transplant may, in certain cases, become eligible for transplant after physiologic improvement with LVAD therapy, and a small number of patients with an LVAD may have sufficient recovery of myocardial function to allow device explantation. This clinically oriented review will describe (1) the most frequently used pump types and aspects of the continuous-flow physiology and (2) the clinical indications for and the shift toward the use of LVADs in less sick patients with HF. Additionally, we review complications of LVAD therapy and project future directions in this field. We referred to the Interagency Registry for Mechanically Assisted Circulatory Support, landmark trials, and results from recently published studies as major sources in obtaining recent outcomes, and we searched for related published literature via PubMed. This review focuses primarily on clinical practice for primary care physicians and non-HF cardiologists in the United States.

Cardiac organ donor management

There is a critical shortage of donor organs. According to the United Network for Organ Sharing (UNOS), 20% of organs are discarded after procurement. Many of these may be potentially salvageable. Brain death is particularly detrimental to cardiac function. The initial sympathetic storm can produce direct myocardial injury. The ensuing spinal shock reduces global oxygen delivery. There is a change to anaerobic metabolism due to global mitochondrial dysfunction. Diabetes insipidus worsens hypovolemia and thyroid deficiency impairs cardiac function. Inadequate replacement of blood loss from trauma and coagulopathy worsens anemia and oxygen delivery. In the mid-1990s, the Papworth Hospital group in the UK advocated early invasive hemodynamic monitoring and administration of a ‘hormonal cocktail’, consisting of triiodothyronine (T3), vasopressin, methylprednisolone and insulin. This has been widely accepted and is endorsed by UNOS. Ventricular function, volume status and adequacy of resuscitation should be guided by invasive monitoring and serial echocardiography. Dopamine or epinephrine is used for inotropic support. If hypotension persists, vasopressin should be added which may allow reduction of inotropes. Donor lung function and ventilation should be optimized. Recently, two large retrospective studies have shown that, with aggressive pharmacological and hormonal resuscitation, a significant increase in the number and quality of organs harvested can be achieved.

Ex-vivo perfusion of donor hearts for human heart transplantation (PROCEED II): a prospective, open-label, multicentre, randomised non-inferiority trial

BACKGROUND

The Organ Care System is the only clinical platform for ex-vivo perfusion of human donor hearts. The system preserves the donor heart in a warm beating state during transport from the donor hospital to the recipient hospital. We aimed to assess the clinical outcomes of the Organ Care System compared with standard cold storage of human donor hearts for transplantation.

METHODS

We did this prospective, open-label, multicentre, randomised non-inferiority trial at ten heart-transplant centres in the USA and Europe. Eligible heart-transplant candidates (aged >18 years) were randomly assigned (1:1) to receive donor hearts preserved with either the Organ Care System or standard cold storage. Participants, investigators, and medical staff were not masked to group assignment. The primary endpoint was 30 day patient and graft survival, with a 10% non-inferiority margin. We did analyses in the intention-to-treat, as-treated, and per-protocol populations. This trial is registered with ClinicalTrials.gov, number NCT00855712.

FINDINGS

Between June 29, 2010, and Sept 16, 2013, we randomly assigned 130 patients to the Organ Care System group (n=67) or the standard cold storage group (n=63). 30 day patient and graft survival rates were 94% (n=63) in the Organ Care System group and 97% (n=61) in the standard cold storage group (difference 2·8%, one-sided 95% upper confidence bound 8·8; p=0·45). Eight (13%) patients in the Organ Care System group and nine (14%) patients in the standard cold storage group had cardiac-related serious adverse events.

INTERPRETATION

Heart transplantation using donor hearts adequately preserved with the Organ Care System or with standard cold storage yield similar short-term clinical outcomes. The metabolic assessment capability of the Organ Care System needs further study.

FUNDING

TransMedics.

Performance of goodness-of-fit tests for the Cox proportional hazards model with time-varying covariates

There are few readily-implemented tests for goodness-of-fit for the Cox proportional hazards model with time-varying covariates. Through simulations, we assess the power of tests by Cox (J R Stat Soc B (Methodol) 34(2):187-220, 1972), Grambsch and Therneau (Biometrika 81(3):515-526, 1994), and Lin et al. (Biometrics 62:803-812, 2006). Results show that power is highly variable depending on the time to violation of proportional hazards, the magnitude of the change in hazard ratio, and the direction of the change. Because these characteristics are unknown outside of simulation studies, none of the tests examined is expected to have high power in real applications. While all of these tests are theoretically interesting, they appear to be of limited practical value.

[General recommendations for medical treatment after heart transplantation]

Heart transplantation remains the treatment of choice in selected patients with severe heart failure (HF) despite optimal medical therapy. Since long-term survival after HTX is improving, there is a growing need for evidence-based strategies that reduce long-term mortality resulting from both immunological and non-immunological risk. This manuscript summarizes recommendations for treatment of transplant vasculopathy, malignancy after transplantation, and prevention of corticosteroid induced bone disease. Based on actual understanding of cardiovascular risk factors in the population, preservation of renal function, prevention and treatment of hyperlipidemia and diabetes, as well as blood pressure control play an important role in the long-term follow-up after heart transplantation.

Considering death: the third British heart transplant, 1969

On May 29, 1969, London’s newspapers carried dramatic headlines:“Donor’s Heart ‘Switched Off’ by Doctors.” Margaret Sinsbury had died in Guy’s Hospital, after which her heart was removed and transplanted. This, the third British heart transplant, crystallized the deep concerns that were by then swirling around the wider transplant enterprise, notably whether the people from whom organs were being taken were dead or had been made so. Yet a year earlier, to reassure the public in this regard, a formula had been devised at the U.K. Health Ministries’ MacLennan Conference to enable death to be certified based on cerebral rather than cardiac indicators. This was the first such formula in the English-speaking world, and it included safeguards to protect the interests of dying patients who were considered to be potential organ donors. However, the third British heart transplant revealed these protections to be a chimera, and brought such operations there to a halt for a decade.

Multiple listing for pediatric heart transplantation in the U.S.A.: analysis of OPTN registry data from 1995 through 2009

Multiple listing is associated with shorter waitlist durations and increased likelihood of transplantation for renal candidates. Little is known about multiple listing in pediatric heart transplantation. We examined the prevalence and outcomes of multiple listing using OPTN data from 1995 through 2009. Characteristics and waitlist outcomes of propensity-score-matched single- and multiple-listed patients were compared. Multiple listing occurred in 23 of 6290 listings (0.4%). Median days between listings was 35 (0-1015) and median duration of multiple listings was 32 days (3-363). Among multiple-listed patients, there were trends toward less ECMO use (0% vs. 11%, p = 0.1) and more frequent requirement for a prospective cross-match (17% vs. 8%, p = 0.08). Multiple-listed patients more commonly had private insurance (78% vs. 56%; p = 0.03). Urgency status at listing was similar between groups (1/1A: 61% vs. 64%, 1B/2: 39 vs. 36%; p = 0.45) as were weight, age, diagnosis, ventilator/inotrope use, and median income (each p ≥ 0.17). There was a trend toward increased incidence of heart transplantation for multiple-listed patients at three, six, and 24 months (50%, 65%, 80%) vs. single-listed patients (40%, 54%, 64%; p = 0.11). Multiple listing for pediatric heart transplantation in the USA occurs infrequently and is more common in patients with private insurance.

Impairment of heart rate recovery after peak exercise predicts poor outcome after pediatric heart transplantation

BACKGROUND

A blunted heart rate recovery (HRR) from peak exercise is associated with adverse outcome in adults with ischemic heart disease. We assessed HRR after pediatric heart transplantation (HTx) and its prognostic use.

METHODS AND RESULTS

Between 2004 and 2010 we performed 360 maximal exercise tests (median, 2 tests/patient; range, 1-7) in 128 children (66 men; age at test, 14 ± 3 years) who received HTx (age, 8.5 ± 5.1 years) because of cardiomyopathy (66%) or congenital heart defects (34%). The change in heart rate from peak exercise to 1 minute of recovery was measured as HRR and was expressed as Z score calculated from reference data obtained in 160 healthy children. HRR was impaired soon after HTx (average in first 2 years Z=-1.9 ± 3.5) but improved afterward (Z=+0.52/y), such that HRR Z score normalized in most patients by 6 years after HTx (average, 0.6 ± 1.8). A subsequent decline in HRR Z score was noted from 6 years after HTx (rate of Z=-0.11/y). After 27 ± 15 months from the most recent exercise test, 19 patients died or were re-heart transplantation. For the follow-up after 6 years, HRR Z score was the only predictor of death/re-heart transplantation (P=0.003). Patients in the lowest quartile of HRR Z score had a much higher 5-year event rate (event-free rate, 29% versus 84%; hazard ratio, 7.0; P=0.0013).

CONCLUSIONS

HRR is blunted soon after HTx but normalizes at ≈ 6 years, potentially as a result of parasympathetic reinnervation of the graft, but then declines. This late decline in HRR Z score is associated with worse outcome.

[Cardiac graft allocation]

Until 2004, French rules for cardiac graft allocation were aimed at ensuring uniform organ distribution on the national scale, while logically giving priority to local teams. The allocation was center-based, with transplant MDs choosing the most suitable recipient from the local waiting list. In 2004, two national priority lists were added to the French cardiac graft allocation system. High Emergency 1 (HE1) is for patients with unstable hemodynamic status (on inotropes or ECMO), while High Emergency 2 (HE2) is for patients who develop complications during long-term circulatory support. Data from the French Biomedicines Agency show significantly poorer survival for HE1 patients than for HE2 patients. However, this should not lead to the conclusion that HE2 is a better strategy, as mortality during long-term circulatory support is not taken into account, and it is well known that the survival benefit of transplantation is significantly better in HE1 patients. Furthermore, the risk related to the quality of the cardiac graft must be taken into account. Indeed, the decision to transplant or not to transplant an HE1 patient with a given graft will impact not only the survival of the patient concerned, but also the waiting time of the other patients on the list, independently of allocation rules. This is also true for the criteria used to place a patient on the waiting list. Each cardiac transplantation team considers the level of risk before adding a patient to the waiting list, and this will impact not only the individual candidate but also the entire waiting list. Thus, even if allocation rules aim to provide all patients with the same chance of being transplanted across the entire country, the medical decision to accept a cardiac graft and to register a patient on the waiting list will make this process somewhat heterogeneous. This allows cardiac transplantation to be adapted to each individual case, independently of the rules. However, a multidisciplinary decision process is necessary to ensure fairness.

Early and late outcomes after cardiac retransplantation

BACKGROUND

Cardiac retransplantation remains the most viable option for patients with allograft heart failure; however, careful patient selection is paramount considering limited allograft resources. We analyzed clinical outcomes following retransplantation in an academic, tertiary care institution.

METHODS

Between 1981 and 2011, 593 heart transplantations, including 22 retransplantations were performed at our institution. We analyzed the preoperative demographic characteristics, cause of allograft loss, short- and long-term surgical outcomes and cause of death among patients who had cardiac retransplantations.

RESULTS

Twenty-two patients underwent retransplantation: 10 for graft vascular disease, 7 for acute rejection and 5 for primary graft failure. Mean age at retransplantation was 43 (standard deviation [SD] 15) years; 6 patients were women. Thirteen patients were critically ill preoperatively, requiring inotropes and/or mechanical support. The median interval between primary and retransplantation was 2.2 (range 0-16) years. Thirty-day mortality was 31.8%, and conditional (> 30 d) 1-, 5- and 10-year survival after retransplantation were 93%, 79% and 59%, respectively. A diagnosis of allograft vasculopathy (p = 0.008) and an interval between primary and retransplantation greater than 1 year (p = 0.016) had a significantly favourable impact on 30-day mortality. The median and mean survival after retransplantation were 3.3 and 5 (SD 6, range 0-18) years, respectively; graft vascular disease and multiorgan failure were the most common causes of death.

CONCLUSION

Long-term outcomes for primary and retransplantation are similar if patients survive the 30-day postoperative period. Retransplantation within 1 year of the primary transplantation resulted in a high perioperative mortality and thus may be a contraindication to retransplantation.

Regression analysis for cumulative incidence probability under competing risks and left-truncated sampling

The cumulative incidence function provides intuitive summary information about competing risks data. Via a mixture decomposition of this function, Chang and Wang (Statist. Sinca 19:391-408, 2009) study how covariates affect the cumulative incidence probability of a particular failure type at a chosen time point. Without specifying the corresponding failure time distribution, they proposed two estimators and derived their large sample properties. The first estimator utilized the technique of weighting to adjust for the censoring bias, and can be considered as an extension of Fine's method (J R Stat Soc Ser B 61: 817-830, 1999). The second used imputation and extends the idea of Wang (J R Stat Soc Ser B 65: 921-935, 2003) from a nonparametric setting to the current regression framework. In this article, when covariates take only discrete values, we extend both approaches of Chang and Wang (Statist Sinca 19:391-408, 2009) by allowing left truncation. Large sample properties of the proposed estimators are derived, and their finite sample performance is investigated through a simulation study. We also apply our methods to heart transplant survival data.

Baseline differences in the HF-ACTION trial by sex

BACKGROUND

In patients with heart failure (HF), assessment of functional capacity plays an important prognostic role. Both 6-minute walk and cardiopulmonary exercise testing have been used to determine physical function and to determine prognosis and even listing for transplantation. However, as in HF trials, the number of women reported has been small, and the cutoffs for transplantation have been representative of male populations and extrapolated to women. It is also well known that peak VO(2) as a determinant of fitness is inherently lower in women than in men and potentially much lower in the presence of HF. Values for a female population from which to draw for this important determination are lacking.

METHODS

The HF-ACTION trial randomized 2,331 patients (28% women) with New York Heart Association class II-IV HF due to systolic dysfunction to either a formal exercise program in addition to optimal medical therapy or to optimal medical therapy alone without any formal exercise training. To characterize differences between men and women in the interpretation of final cardiopulmonary exercise testing models, the interaction of individual covariates with sex was investigated in the models of (1) VE/VCO(2), (2) VO(2) at ventilatory threshold (VT), (3) distance on the 6-minute walk, and (4) peak VO(2).

RESULTS

The women were younger than the men and more likely to have a nonischemic etiology and a higher ejection fraction. Dose of angiotensin converting enzyme inhibitor (ACEI) was lower in the women, on average. The lower ACEI dose may reflect the higher use of angiotensin II receptor blocker (ARB) in women. Both the peak VO(2) and the 6-minute walk distance were significantly lower in the women than in the men. Perhaps the most significant finding in this dataset of baseline characteristics is that the peak VO(2) for women was significantly lower than that for men with similar ventricular function and health status.

CONCLUSION

Therefore, in a well-medicated, stable, class II-IV HF cohort of patients who are able to exercise, women have statistically significantly lower peak VO(2) and 6-minute walk distance than men with similar health status and ventricular function. These data should prompt careful thought when considering prognostic markers for women and listing for cardiac transplant.

Current status of cardiac transplantation and mechanical circulatory support

Cardiac transplantation and mechanical circulatory support are possible options for improving survival and quality of life in patients with isolated cardiac disease and end-stage heart failure. Transplantation is limited by donor availability but has a median survival of 10 years. Post-transplant immunosuppression is often transplant center dependent, but a tacrolimus and mycophenolate mofetil-based regimen may be preferred. Sirolimus may reduce the progression rate of transplant vasculopathy. There has been a trend toward continuous-flow left ventricular assist devices because of their increased durability and reduced size. A variety of surgical and percutaneous ventricular assist devices may be used as a bridge to decision on a patient's candidacy for transplantation. Mechanical circulatory support as destination therapy has not been widely implemented because of poor device durability, but this is expected to change with newer devices. Mechanical circulatory support as a bridge to myocardial recovery has been successful only in a few patients.

[Criteria for the acceptable heart donor: maximizing the use of hearts recovered from potential donors in Israel]

The shortage of available donor hearts limits the number of cardiac transplantations worldwide and in Israel as well. This organ shortage results in 15%-20% annual mortality of heart transplant candidates. For the sub-group of hospitalized decompensated heart failure patients depending on continuous inotropic support (Status I), the annual mortality is over 50%. Suboptimal utilization of donor hearts has been one of the reasons for the organ shortage. In 2004, only 42% of the potential donor hearts in Israel were eventually transplanted. The objective of this report is to define guidelines regarding the suitability of potential cardiac donors allowing more liberal criteria for accepting borderline donor hearts. Implementing the new guidelines will permit the utilization of organs that otherwise would have been discarded.

Cardiac transplantation in HIV-positive patients: are we there yet?

The epidemiology and clinical picture in human immunodeficiency virus (HIV) infection has evolved tremendously over the years, leaving health-care professionals having to cope with continuously transforming challenges in the management of HIV-infected patients.

Marginal cardiac allografts do not have increased primary graft dysfunction in alternate list transplantation

BACKGROUND

Clinical success with modern heart transplantation (HT) has led to the development of an alternate list (AL) HT strategy, matching marginal cardiac allografts with recipients who do not meet standard criteria for HT. Marginal allografts may be at an increased risk for primary graft dysfunction (PGD), the leading cause of early mortality after HT.(1) The incidence of PGD in AL HT relative to standard list (SL) HT has not been evaluated, and may contribute to the greater mortality associated with AL HT.(2) The objective of this study was to determine the incidence of and predictors for PGD.

METHODS AND RESULTS

A retrospective analysis was performed on 260 consecutive adult patients undergoing either SL HT (n=207) or AL HT (n=53) at our institution from 1/2000 to 1/2005. PGD was defined by requirement for mechanical circulatory support immediately post-HT or more broadly as the need for either mechanical support or high-dose inotrope (epinephrine > or = 0.07 microg/kg/min). Donor hearts allocated to AL recipients were turned down for SL HT for reasons that included coronary disease, left ventricular dysfunction or hypertrophy, and high-dose inotropic requirement. AL HT recipients were significantly older, with a higher proportion of diabetes mellitus and ischemic cardiomyopathy. Both groups experienced a similar incidence of significant rejection, but overall mortality was higher in the AL HT group. (2) The incidence of PGD did not differ between AL and SL HT recipients. Pre-transplant VAD and prolonged total ischemic times (> or = 4.5 hours) were independent predictors of PGD.

CONCLUSIONS

Select marginal donor hearts used in AL HT do not have an increased incidence of PGD. Pre-transplant VAD and prolonged ischemic times are more important determinants of PGD. These data support continued aggressive utilization of marginal donor hearts in AL HT.

Use of the Internet by United States Heart Transplant Centers to Promote Transparency in the Process of Patient Selection

Organ transplantation is an ethically complex technology, in part because organs are very scarce and supply does not meet demand. Organ allocation must use a process that is fair, and the process should be open for public review and revision. We explored the transparency of the heart transplant patient selection process in the United States terming transparency as hospital use of their transplant program Web site to disclose their policies to potential patients. The Web sites of all heart transplant centers belonging to the U.S. Organ Procurement and Transplantation Network were reviewed for content pertaining to patient selection criteria for placement on the transplant waiting list. All 132 heart transplant centers have a Web site that discusses their transplant program; however, 84% (n = 111) do not publish their medical listing criteria on their Web site. Only 15% (n = 20) expressly indicate the requirement for a psychosocial evaluation. Few centers (n = 9) utilize their Web site to discuss use of a formal data review committee to decide which patients to list for transplantation. In order to demystify and correct false assumptions about the transplant listing process, wait listing criteria should be transparent to the public and Internet disclosure can facilitate this end. Our findings lay the foundation for future prospective studies.

Pharmacokinetic Study and Limited Sampling Strategy of Cyclosporine in Japanese Heart Transplant Recipients

BACKGROUND

The purpose of this study was to characterize the pharmacokinetics of cyclosporine (CsA) in Japanese heart transplant patients, and to optimise the monitoring strategy based on measurements of the area under the curve of plasma concentration absorption phase or 2 h post-dose concentrations (C(2)).

METHODS AND RESULTS

At defined time periods during the first year after transplantation, the area under the curve for the CsA serum concentration from 0 to 4 h (AUC(0-4 h)) was evaluated. Pharmacokinetic parameters and renal function at 1 month and 12 months after transplantation were compared in 7 Japanese patients. The highest coefficient of determination between CsA AUC(0-4 h) and a single concentration was observed using C2 (r2 =0.838). For CsA pharmacokinetics, the mean measurement of whole blood trough levels value at 12 months was significantly lower than at 1 month after transplantation (p=0.026). The mean serum creatinine level at 12 months was significantly higher than at 1 month (1.00 mg/dl vs 0.73 p=0.0194).

CONCLUSION

A single-time-point model that includes C2 is useful for predicting CsA AUC(0-4 h) in Japanese heart transplant patients. Mean C2 values >1,000 ng/ml were obtained in patients with no rejection at 1 month and 12 months after transplantation; however, renal impairment may occur.

Use of Quality Index in the Evaluation of Organ Procurement and Transplant Programs in a University Hospital

AIM

To evaluate organ procurement efficiency at Hospital Clinic of Barcelona (HCP), a University Hospital, in 2000 and 2003 compared with other Catalan, other Spanish, and American (US) results.

METHODS

Efficacy rate of the donor procurement was calculated per million population per year (pmp/y). Efficacy rate in kidney, liver, and heart transplantation was calculated also in pmp/y. We evaluated 1-year graft survival.

RESULTS

During this period, the average rate number of donors was 49.1 pmp/y in HCP, 38 in Catalonia, 33.4 in Spain, and 21.7 in the United States. The average rate of kidney transplantation was 74 pmp/y in HCP, 55 in Catalonia, 47 in Spain, and 24.6 in the United States. The average rate of liver transplantation was 44.5, 26.6, 23.2, and 18 pmp/y, respectively. The average rate of heart transplantation was 13.3, 8.5, 7.8, and 6.4 pmp/y, respectively. One-year graft survival in HCP was 90.6% for kidney, 89.5% for liver, and 88.2% for heart transplants.

DISCUSSION

The results show that organ procurement and transplantation programs in HCP are efficient. The organizational model is based on a hospital transplant coordinator and efficient, well-trained transplant teams.

Improving outcomes in heart transplantation: the potential of proliferation signal inhibitors

Graft failure and mortality among heart transplant recipients remains higher than in populations receiving renal transplants. A major cause of graft loss is cardiac allograft vasculopathy (CAV), a condition characterized by diffuse thickening of coronary blood vessels. CAV often progresses silently, with major cardiac events (eg, ventricular arrhythmia) being the first presentation. Better diagnosis and monitoring of CAV is now possible with intravascular ultrasonography, a sensitive technique for measuring intimal thickness. To date, immunosuppressants have shown little efficacy for preventing CAV. However, a new class of agents, proliferation signal inhibitors (sirolimus and everolimus), have shown considerable efficacy in this regard and for preventing rejection. In an open-label trial, sirolimus therapy was associated with less intimal and medial proliferation than azathioprine. More robust evidence is available from a larger-scale, double-blind trial involving everolimus. At 12-month follow-up the incidence of CAV was significantly lower in patients receiving everolimus (35.7% and 30.4% for everolimus 1.5 and 3.0 mg/d vs 52.8% for azathioprine; P < .05). Sirolimus and everolimus were also associated with a lower rate of cytomegalovirus infection. As with other immunosuppressants, these agents are associated with adverse events (eg, hyperlipidemia), but they can be managed. Coadministration with calcineurin inhibitors (CNIs) can exacerbate CNI-related nephrotoxicity, but evidence suggests that everolimus administered with reduced-exposure cyclosporine in the maintenance phase preserves renal function without loss of immunosuppressive efficacy. Reduced CNI dosing in de novo patients is also a potential future benefit. Proliferation signal inhibitors have considerable potential for improving outcomes in heart transplantation.

Revision of the 1990 working formulation for the standardization of nomenclature in the diagnosis of heart rejection

In 1990, an international grading system for cardiac allograft biopsies was adopted by the International Society for Heart Transplantation. This system has served the heart transplant community well, facilitating communication between transplant centers, especially with regard to patient management and research. In 2004, under the direction of the International Society for Heart and Lung Transplantation (ISHLT), a multidisciplinary review of the cardiac biopsy grading system was undertaken to address challenges and inconsistencies in its use and to address recent advances in the knowledge of antibody-mediated rejection. This article summarizes the revised consensus classification for cardiac allograft rejection. In brief, the revised (R) categories of cellular rejection are as follows: Grade 0 R--no rejection (no change from 1990); Grade 1 R--mild rejection (1990 Grades 1A, 1B and 2); Grade 2 R--moderate rejection (1990 Grade 3A); and Grade 3 R--severe rejection (1990 Grades 3B and 4). Because the histologic sub-types of Quilty A and Quilty B have never been shown to have clinical significance, the "A" and "B" designations have been eliminated. Recommendations are also made for the histologic recognition and immunohistologic investigation of acute antibody-mediated rejection (AMR) with the expectation that greater standardization of the assessment of this controversial entity will clarify its clinical significance. Technical considerations in biopsy processing are also addressed. This consensus revision of the Working Formulation was approved by the ISHLT Board of Directors in December 2004.