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Zhou AL, Daskam ML, Ruck JM, Akbar AF, Larson EL, Casillan AJ, Kilic A. Outcomes of Heart Transplant Using High Donor Sequence Number Offers. J Surg Res 2024; 300:325-335. [PMID: 38838430 DOI: 10.1016/j.jss.2024.05.008] [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: 12/17/2023] [Revised: 04/30/2024] [Accepted: 05/08/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Higher donor sequence numbers (DSNs) might spark provider concern about poor donor quality. We evaluated characteristics of high-DSN offers used for transplant and compared outcomes of high- and low-DSN transplants. MATERIALS AND METHODS Adult isolated heart transplants between January 1, 2015, and December 31, 2022, were identified from the organ procurement and transplantation network database and stratified into high (≥42) and low (<42) DSN. Postoperative outcomes, including predischarge complications, hospital length of stay, and survival at 1 and 3 y, were evaluated using multivariable regressions. RESULTS A total of 21,217 recipients met the inclusion criteria, with 2131 (10.0%) classified as high-DSN. Donor factors associated with greater odds of high-DSN at acceptance included older age, higher creatinine, diabetes, hypertension, and lower left ventricular ejection fraction. Recipients accepting high-DSN offers were older and more likely to be female, of blood type O, and have lower status at transplant. High- and low-DSN transplants had similar likelihood of stroke (3.2% versus 3.5%; P = 0.97), dialysis (12.3% versus 13.5%; P = 0.12), pacemaker implant (2.3% versus 2.1%; P = 0.64), had similar lengths of stay (16 [12-24] versus 16 [12-25] days, P = 0.38), and survival at 1 (91.6% versus 91.6%; aHR 0.85 [0.72-1.02], P = 0.08) and 3 y (84.2% versus 85.1%; aHR 0.91 [0.79-1.05], P = 0.21) post-transplant. CONCLUSIONS High-DSN (≥42) was not an independent risk factor for post-transplant mortality and should not be the sole deterrent to acceptance. Accepting high-DSN organs may increase access to transplantation for lower-status candidates.
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Affiliation(s)
- Alice L Zhou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Maria L Daskam
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jessica M Ruck
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Armaan F Akbar
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Emily L Larson
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Alfred J Casillan
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
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Yuzefpolskaya M, Colombo PC. Capturing the Evolving Landscape of Primary Graft Dysfunction After Heart Transplantation: Will Achilles Ever Overtake the Tortoise? J Card Fail 2024; 30:816-818. [PMID: 38460671 DOI: 10.1016/j.cardfail.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 02/29/2024] [Indexed: 03/11/2024]
Affiliation(s)
- Melana Yuzefpolskaya
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York.
| | - Paolo C Colombo
- Division of Cardiovascular Medicine, Department of Cardiology, New York Presbyterian Hospital, Columbia University, New York, New York
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3
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Panicker AJ, Prokop LJ, Hacke K, Jaramillo A, Griffiths LG. Outcome-based Risk Assessment of Non-HLA Antibodies in Heart Transplantation: A Systematic Review. J Heart Lung Transplant 2024:S1053-2498(24)01683-8. [PMID: 38796046 DOI: 10.1016/j.healun.2024.05.012] [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: 11/06/2023] [Revised: 05/15/2024] [Accepted: 05/19/2024] [Indexed: 05/28/2024] Open
Abstract
BACKGROUND Current monitoring after heart transplantation (HT) employs repeated invasive endomyocardial biopsies (EMB). Although positive EMB confirms rejection, EMB fails to predict impending, subclinical, or EMB-negative rejection events. While non-human leukocyte antigen (non-HLA) antibodies have emerged as important risk factors for antibody-mediated rejection after HT, their use in clinical risk stratification has been limited. A systematic review of the role of non-HLA antibodies in rejection pathologies has the potential to guide efforts to overcome deficiencies of EMB in rejection monitoring. METHODS Databases were searched to include studies on non-HLA antibodies in HT recipients. Data collected included the number of patients, type of rejection, non-HLA antigen studied, association of non-HLA antibodies with rejection, and evidence for synergistic interaction between non-HLA antibodies and donor-specific anti-human leukocyte antigen antibody (HLA-DSA) responses. RESULTS A total of 56 studies met the inclusion criteria. Strength of evidence for each non-HLA antibody was evaluated based on the number of articles and patients in support versus against their role in mediating rejection. Importantly, despite previous intense focus on the role of anti-major histocompatibility complex class I chain-related gene A (MICA) and anti-angiotensin II type I receptor antibodies (AT1R) in HT rejection, evidence for their involvement was equivocal. Conversely, the strength of evidence for other non-HLA antibodies supports that differing rejection pathologies are driven by differing non-HLA antibodies. CONCLUSIONS This systematic review underscores the importance of identifying peri-HT non-HLA antibodies. Current evidence supports the role of non-HLA antibodies in all forms of HT rejection. Further investigations are required to define the mechanisms of action of non-HLA antibodies in HT rejection.
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Affiliation(s)
- Anjali J Panicker
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, Minnesota; Department of Immunology, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Larry J Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota
| | - Katrin Hacke
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona
| | - Andrés Jaramillo
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona
| | - Leigh G Griffiths
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Department of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, Minnesota.
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Zhang L, Arenas Hoyos I, Helmer A, Banz Y, Zubler C, Lese I, Hirsiger S, Constantinescu M, Rieben R, Gultom M, Olariu R. Transcriptome profiling of immune rejection mechanisms in a porcine vascularized composite allotransplantation model. Front Immunol 2024; 15:1390163. [PMID: 38840906 PMCID: PMC11151749 DOI: 10.3389/fimmu.2024.1390163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/06/2024] [Indexed: 06/07/2024] Open
Abstract
Background Vascularized composite allotransplantation (VCA) offers the potential for a biological, functional reconstruction in individuals with limb loss or facial disfigurement. Yet, it faces substantial challenges due to heightened immune rejection rates compared to solid organ transplants. A deep understanding of the genetic and immunological drivers of VCA rejection is essential to improve VCA outcomes. Methods Heterotopic porcine hindlimb VCA models were established and followed until reaching the endpoint. Skin and muscle samples were obtained from VCA transplant recipient pigs for histological assessments and RNA sequencing analysis. The rejection groups included recipients with moderate pathological rejection, treated locally with tacrolimus encapsulated in triglycerol-monostearate gel (TGMS-TAC), as well as recipients with severe end-stage rejection presenting evident necrosis. Healthy donor tissue served as controls. Bioinformatics analysis, immunofluorescence, and electron microscopy were utilized to examine gene expression patterns and the expression of immune response markers. Results Our comprehensive analyses encompassed differentially expressed genes, Gene Ontology, and Kyoto Encyclopedia of Genes and Genomes pathways, spanning various composite tissues including skin and muscle, in comparison to the healthy control group. The analysis revealed a consistency and reproducibility in alignment with the pathological rejection grading. Genes and pathways associated with innate immunity, notably pattern recognition receptors (PRRs), damage-associated molecular patterns (DAMPs), and antigen processing and presentation pathways, exhibited upregulation in the VCA rejection groups compared to the healthy controls. Our investigation identified significant shifts in gene expression related to cytokines, chemokines, complement pathways, and diverse immune cell types, with CD8 T cells and macrophages notably enriched in the VCA rejection tissues. Mechanisms of cell death, such as apoptosis, necroptosis and ferroptosis were observed and coexisted in rejected tissues. Conclusion Our study provides insights into the genetic profile of tissue rejection in the porcine VCA model. We comprehensively analyze the molecular landscape of immune rejection mechanisms, from innate immunity activation to critical stages such as antigen recognition, cytotoxic rejection, and cell death. This research advances our understanding of graft rejection mechanisms and offers potential for improving diagnostic and therapeutic strategies to enhance the long-term success of VCA.
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Affiliation(s)
- Lei Zhang
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, Bern, Switzerland
- Department for BioMedical Research, Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Isabel Arenas Hoyos
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, Bern, Switzerland
| | - Anja Helmer
- Department for BioMedical Research, Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Yara Banz
- Institute of Pathology, Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Cédric Zubler
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, Bern, Switzerland
| | - Ioana Lese
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, Bern, Switzerland
- Department for BioMedical Research, Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Stefanie Hirsiger
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, Bern, Switzerland
| | - Mihai Constantinescu
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, Bern, Switzerland
| | - Robert Rieben
- Department for BioMedical Research, Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Mitra Gultom
- Department for BioMedical Research, Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, Bern, Switzerland
- Department for BioMedical Research, Faculty of Medicine, University of Bern, Bern, Switzerland
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Ben Brahim B, Arenas Hoyos I, Zhang L, Vögelin E, Olariu R, Rieben R. Tacrolimus-loaded Drug Delivery Systems in Vascularized Composite Allotransplantation: Lessons and Opportunities for Local Immunosuppression. Transplantation 2024:00007890-990000000-00769. [PMID: 38773862 DOI: 10.1097/tp.0000000000005049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
Long-term systemic immunosuppression is needed for vascularized composite allotransplantation (VCA). The high rate of acute rejection episodes in the first posttransplant year, the development of chronic rejection, and the adverse effects that come along with this treatment, currently prevent a wider clinical application of VCA. Opportunistic infections and metabolic disturbances are among the most observed side effects in VCA recipients. To overcome these challenges, local immunosuppression using biomaterial-based drug delivery systems (DDS) have been developed. The aim of these systems is to provide high local concentrations of immunosuppressive drugs while reducing their systemic load. This review provides a summary of recently investigated local DDS with different mechanisms of action such as on-demand, ultrasound-sensitive, or continuous drug delivery. In preclinical models, ranging from rodent to porcine and nonhuman primate models, this approach has been shown to reduce systemic tacrolimus (TAC) load and adverse effects, while prolonging graft survival. Localized immunosuppression using biomaterial-based DDS represents an encouraging approach to enhance graft survival and reduce toxic side effects of immunosuppressive drugs in VCA patients. Preclinical models using TAC-releasing DDS have demonstrated high local immunosuppressive effects with a low systemic burden. However, to reduce acute rejection events in translational animal models or in the clinical reality, the use of additional low-dose systemic TAC treatment may be envisaged. Patients may benefit through efficient graft immunosuppression and survival with negligible systemic adverse effects, resulting in better compliance and quality of life.
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Affiliation(s)
- Bilal Ben Brahim
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Isabel Arenas Hoyos
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Department of Plastic and Hand Surgery, Inselspital Bern University Hospital, Bern, Switzerland
| | - Lei Zhang
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Department of Plastic and Hand Surgery, Inselspital Bern University Hospital, Bern, Switzerland
| | - Esther Vögelin
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Department of Plastic and Hand Surgery, Inselspital Bern University Hospital, Bern, Switzerland
| | - Radu Olariu
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Department of Plastic and Hand Surgery, Inselspital Bern University Hospital, Bern, Switzerland
| | - Robert Rieben
- Department for BioMedical Research, University of Bern, Bern, Switzerland
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Gregory V, Okumura K, Isath A, Levine A, De La Pena C, Shimamura J, Spielvogel D, Kai M, Ohira S. Impact of Left Ventricular Unloading on Outcome of Heart Transplant Bridging With Extracorporeal Membrane Oxygenation Support in New Allocation Policy. J Am Heart Assoc 2024; 13:e033590. [PMID: 38742529 PMCID: PMC11179799 DOI: 10.1161/jaha.123.033590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/01/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND The new heart allocation policy places veno-arterial extracorporeal membrane oxygenation (VA-ECMO)-supported heart transplant (HT) candidates at the highest priority status. Despite increasing evidence supporting left ventricular (LV) unloading during VA-ECMO, the effect of LV unloading on transplant outcomes following bridging to HT with VA-ECMO remains unknown. METHODS AND RESULTS From October 18, 2018 to March 21, 2023, 624 patients on VA-ECMO at the time of HT were identified in the United Network for Organ Sharing database and were divided into 2 groups: VA-ECMO alone (N=384) versus VA-ECMO with LV unloading (N=240). Subanalysis was performed in the LV unloading group: Impella (N=106) versus intra-aortic balloon pump (N=134). Recipient age was younger in the VA-ECMO alone group (48 versus 53 years, P=0.018), as was donor age (VA-ECMO alone, 29 years versus LV unloading, 32 years, P=0.041). One-year survival was comparable between groups (VA-ECMO alone, 88.0±1.8% versus LV unloading, 90.4±2.1%; P=0.92). Multivariable Cox hazard model showed LV unloading was not associated with posttransplant mortality after HT (hazard ratio, 0.92; P=0.70). Different LV unloading methods had similar 1-year survival (intra-aortic balloon pump, 89.2±3.0% versus Impella, 92.4±2.8%; P=0.65). Posttransplant survival was comparable between different Impella versions (Impella 2.5, versus Impella CP, versus Impella 5.0, versus Impella 5.5). CONCLUSIONS Under the current allocation policy, LV unloading did not impact waitlist outcome and posttransplant survival in patients bridged to HT with VA-ECMO, nor did mode of LV unloading. This highlights the importance of a tailored approach in HT candidates on VA-ECMO, where routine LV unloading may not be universally necessary.
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Affiliation(s)
| | - Kenji Okumura
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
| | - Ameesh Isath
- Department of Cardiology Westchester Medical Center Valhalla NY USA
| | - Avi Levine
- New York Medical College Valhalla NY USA
- Department of Cardiology Westchester Medical Center Valhalla NY USA
| | - Corazon De La Pena
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
| | - Junichi Shimamura
- New York Medical College Valhalla NY USA
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
| | - David Spielvogel
- New York Medical College Valhalla NY USA
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
| | - Masashi Kai
- Division of Cardiac Surgery Beth Israel Deaconess Medical Center Boston MA USA
| | - Suguru Ohira
- New York Medical College Valhalla NY USA
- Division of Cardiothoracic Surgery, Department of Surgery Westchester Medical Center Valhalla NY USA
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Khush K, Hall S, Kao A, Raval N, Dhingra R, Shah P, Bellumkonda L, Ravichandran A, Van Bakel A, Uriel N, Patel S, Pinney S, DePasquale E, Baran DA, Pinney K, Oreschak K, Kobulnik J, Shen L, Teuteberg J. Surveillance with dual noninvasive testing for acute cellular rejection after heart transplantation: Outcomes from the Surveillance HeartCare Outcomes Registry. J Heart Lung Transplant 2024:S1053-2498(24)01659-0. [PMID: 38759766 DOI: 10.1016/j.healun.2024.05.003] [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: 02/06/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Molecular testing with gene-expression profiling (GEP) and donor-derived cell-free DNA (dd-cfDNA) is increasingly used in the surveillance for acute cellular rejection (ACR) after heart transplant. However, the performance of dual testing over each test individually has not been established. Further, the impact of dual noninvasive surveillance on clinical decision-making has not been widely investigated. METHODS We evaluated 2,077 subjects from the Surveillance HeartCare Outcomes Registry registry who were enrolled between 2018 and 2021 and had verified biopsy data and were categorized as dual negative, GEP positive/dd-cfDNA negative, GEP negative/dd-cfDNA positive, or dual positive. The incidence of ACR and follow-up testing rates for each group were evaluated. Positive likelihood ratios (LRs+) were calculated, and biopsy rates over time were analyzed. RESULTS The incidence of ACR was 1.5% for dual negative, 1.9% for GEP positive/dd-cfDNA negative, 4.3% for GEP negative/dd-cfDNA positive, and 9.2% for dual-positive groups. Follow-up biopsies were performed after 8.8% for dual negative, 14.2% for GEP positive/dd-cfDNA negative, 22.8% for GEP negative/dd-cfDNA positive, and 35.4% for dual-positive results. The LR+ for ACR was 1.37, 2.91, and 3.90 for GEP positive, dd-cfDNA positive, and dual-positive testing, respectively. From 2018 to 2021, biopsies performed between 2 and 12-months post-transplant declined from 5.9 to 5.3 biopsies/patient, and second-year biopsy rates declined from 1.5 to 0.9 biopsies/patient. At 2 years, survival was 94.9%, and only 2.7% had graft dysfunction. CONCLUSIONS Dual molecular testing demonstrated improved performance for ACR surveillance compared to single molecular testing. The use of dual noninvasive testing was associated with lower biopsy rates over time, excellent survival, and low incidence of graft dysfunction.
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Affiliation(s)
- Kiran Khush
- Divison of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Shelley Hall
- Department of Cardiology, Baylor University Medical Center, Dallas, Texas
| | - Andrew Kao
- Division of Cardiology, St. Luke's Health System Kansas City Mid America Heart Institute, Kansas City, Missouri
| | - Nirav Raval
- Transplant Institute, AdventHealth Transplant Institute, Orlando, Florida
| | - Ravi Dhingra
- Advanced Heart Failure and Transplant Program, Froedtert and Medical College of Wisconsin, University of Wisconsin-Madison, Madison, Wisconsin
| | - Palak Shah
- Cardiovascular Genomics Center, Inova Heart and Vascular Institute, Fairfax, Virginia
| | - Lavanya Bellumkonda
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ashwin Ravichandran
- Advanced Heart Failure and Transplant Cardiology, St Vincent Heart Center, Indianapolis, Indiana
| | - Adrian Van Bakel
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Nir Uriel
- Department of Cardiology, New York Presbyterian, New York, New York
| | - Snehal Patel
- Cardiology Division, Montefiore-Einstein, Bronx, New York
| | - Sean Pinney
- Department of Cardiology, Mount Sinai Morningside, New York, New York
| | - Eugene DePasquale
- Heart Failure, Heart Transplantation and Mechanical Circulatory Support, University of Southern California, Los Angeles, California
| | - David A Baran
- Advanced Heart Failure, Transplant and Mechanical Circulatory Support, Cleveland Clinic Florida, Westin, Florida
| | | | | | | | - Ling Shen
- Biostatistics, CareDx, Brisbane, California
| | - Jeffrey Teuteberg
- Divison of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California.
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8
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Gjesdal G, Rylance RT, Bergh N, Dellgren G, Braun OÖ, Nilsson J. Waiting list and post-transplant outcome in Sweden after national centralization of heart transplant surgery. J Heart Lung Transplant 2024:S1053-2498(24)01658-9. [PMID: 38744355 DOI: 10.1016/j.healun.2024.04.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 04/21/2024] [Accepted: 04/27/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Previous studies have demonstrated an association between transplantation rate per center and postoperative mortality after heart transplantation. In 2011, Sweden centralized heart transplants and waiting lists, reducing the number of centers from 3 to 2. We aimed to assess the active waiting time and pre- and post-transplant mortality before and after centralization. METHODS Heart transplantations performed in Sweden between January 1, 2001 and December 31, 2020 were included. Background and donor organ supply data were collected from Scandiatransplant, the Swedish Thoracic Transplant Registry, and the Swedish Cardiac Surgery Registry. The Fine and Gray methods were applied to visualize cumulative incidence curves and conduct competing risk regressions. A Cox model was used to adjust for factors influencing time to post-transplant death. RESULTS When comparing the two eras, the median active waiting time increased from 54 to 71 days (p = 0.015). The risk of mortality on the waiting list decreased in the later era (subhazard ratio 0.43; [95% confidence interval {CI} 0.25-0.74]; p = 0.002). The number of heart transplantation procedures (including pediatric patients) increased by 53%. There was a significant difference in organ utilization between eras (p = 0.033; chi-square test). 30-day and 1-year survival post-transplant rates for adults increased from 90.8% to 97.8% (p < 0.001) and from 87.9% to 94.6% (p < 0.001), respectively. 1-year mortality was reduced by 63% (hazard ratio 0.37; 95% CI 0.22-0.61). CONCLUSIONS This nationwide study examined patients listed for and undergoing heart transplantation before and after the centralization of waiting lists and surgeries in Sweden. Waiting list mortality decreased, and 1-year post-transplantation survival was improved.
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Affiliation(s)
- Grunde Gjesdal
- Cardiology Unit, Department of Clinical Sciences, Lund University, Lund, Sweden; Department of Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden.
| | - Rebecca Tremain Rylance
- Cardiology Unit, Department of Clinical Sciences, Lund University, Lund, Sweden; Department of Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Niklas Bergh
- Department of Transplantation, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Göran Dellgren
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oscar Ö Braun
- Cardiology Unit, Department of Clinical Sciences, Lund University, Lund, Sweden; Department of Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Johan Nilsson
- Cardiothoracic Surgery and Bioinformatic Unit, Department of Translational Medicine, Lund University, Lund, Sweden; Department of Thoracic and Vascular Surgery, Skåne University Hospital, Lund, Sweden
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Patel AV, Stevens AJ, White R, Aravindan S, Barry LW, Rauck RC. Hip, knee, and shoulder arthroplasty in patients with a history of solid organ transplant: A review. J Orthop 2024; 51:116-121. [PMID: 38371351 PMCID: PMC10867558 DOI: 10.1016/j.jor.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/03/2024] [Indexed: 02/20/2024] Open
Abstract
Solid organ transplants (SOT) have evolved into life-saving interventions for end-stage diseases affecting vital organs. Advances in transplantation techniques, donor selection, and immunosuppressive therapies have enhanced outcomes, leading to a growing demand for SOT. Patients with a solid organ transplant are living long enough to develop the same pathologies which are indicated for joint replacement surgery in the general population. SOT patients who undergo a total hip, knee, or shoulder arthroplasty do similarly in the context of clinical outcomes and implant survival when compared to the general population. These immunosuppressed patients tend to have higher complication rates in the short-term following surgery. Prudent management of these patients in the short-term may be necessary, but patients can expect to do well otherwise.
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Affiliation(s)
- Akshar V. Patel
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Andrew J. Stevens
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Ryan White
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | | | - Louis W. Barry
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Ryan C. Rauck
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH, USA
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10
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Hannan HA, Goldberg DS. Racial and Gender Disparities in Transplantation of Hepatitis C+ Hearts and Lungs. J Heart Lung Transplant 2024; 43:780-786. [PMID: 38163451 DOI: 10.1016/j.healun.2023.12.012] [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: 10/04/2023] [Revised: 12/15/2023] [Accepted: 12/24/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Transplanting organs from hepatitis C virus (HCV)-infected donors into HCV-negative recipients has led to thousands of more transplants in the United States since 2016. Studies have demonstrated disparities in utilization of kidneys from these donors due to gender and education. It is still unknown, however, if the same disparities are seen in heart and lung transplantation. METHODS We used Organ Procurement and Transplantation/United Network for Organ Sharing data on all isolated heart and lung transplants from November 1, 2018, to March 31, 2023, classifying donors based on their HCV nucleic acid test (NAT) result: HCV-NAT- vs HCV-NAT+. We fit separate mixed-effects logistic regression models (outcome: HCV-NAT+ donor) for heart and lung transplants. Primary covariates included (1) race/ethnicity, (2) sex, (3) education level, (4) insurance type, and (5) transplant year. RESULTS The study included 26,108 adults (14,189 isolated heart transplant recipients and 11,919 isolated lung transplant recipients). A total of 993 (7.0%) heart transplants involved an HCV-NAT+ donor, compared to 457 (3.8%) lung transplants. In multivariable models among all isolated heart transplant recipients, women were significantly less likely to receive an HCV-NAT+ donor heart (odds ratio [OR]: 0.79, 95% confidence interval [CI]: 0.67-0.92, p = 0.003), as were Asian patients (OR: 0.52, 95% CI: 0.31-0.86, p = 0.01). In multivariable models among all isolated lung transplant recipients, Asians were significantly less likely to receive HCV-NAT+ transplants (OR: 0.31, 95% CI: 0.12-0.77, p = 0.01). CONCLUSIONS There are disparities in utilization of heart and lungs from HCV-NAT+ donors, with women and Asian patients being significantly less likely to receive these transplants.
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Affiliation(s)
- Helen A Hannan
- University of Michigan College of Literature, Science, and the Arts, Ann Arbor, Michigan
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida.
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11
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Breathett K, Knapp SM, Lewsey SC, Mohammed SF, Mazimba S, Dunlay SM, Hicks A, Ilonze OJ, Morris AA, Tedford RJ, Colvin MM, Daly RC. Differences in Donor Heart Acceptance by Race and Gender of Patients on the Transplant Waiting List. JAMA 2024; 331:1379-1386. [PMID: 38526480 PMCID: PMC10964157 DOI: 10.1001/jama.2024.0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/02/2024] [Indexed: 03/26/2024]
Abstract
Importance Barriers to heart transplant must be overcome prior to listing. It is unclear why Black men and women remain less likely to receive a heart transplant after listing than White men and women. Objective To evaluate whether race or gender of a heart transplant candidate (ie, patient on the transplant waiting list) is associated with the probability of a donor heart being accepted by the transplant center team with each offer. Design, Setting, and Participants This cohort study used the United Network for Organ Sharing datasets to identify organ acceptance with each offer for US non-Hispanic Black (hereafter, Black) and non-Hispanic White (hereafter, White) adults listed for heart transplant from October 18, 2018, through March 31, 2023. Exposures Black or White race and gender (men, women) of a heart transplant candidate. Main Outcomes and Measures The main outcome was heart offer acceptance by the transplant center team. The number of offers to acceptance was assessed using discrete time-to-event analyses, nonparametrically (stratified by race and gender) and parametrically. The hazard probability of offer acceptance for each offer was modeled using generalized linear mixed models adjusted for candidate-, donor-, and offer-level variables. Results Among 159 177 heart offers with 13 760 donors, there were 14 890 candidates listed for heart transplant; 30.9% were Black, 69.1% were White, 73.6% were men, and 26.4% were women. The cumulative incidence of offer acceptance was highest for White women followed by Black women, White men, and Black men (P < .001). Odds of acceptance were less for Black candidates than for White candidates for the first offer (odds ratio [OR], 0.76; 95% CI, 0.69-0.84) through the 16th offer. Odds of acceptance were higher for women than for men for the first offer (OR, 1.53; 95% CI, 1.39-1.68) through the sixth offer and were lower for the 10th through 31st offers. Conclusions and Relevance The cumulative incidence of heart offer acceptance by a transplant center team was consistently lower for Black candidates than for White candidates of the same gender and higher for women than for men. These disparities persisted after adjusting for candidate-, donor-, and offer-level variables, possibly suggesting racial and gender bias in the decision-making process. Further investigation of site-level decision-making may reveal strategies for equitable donor heart acceptance.
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Affiliation(s)
- Khadijah Breathett
- Krannert Cardiovascular Research Center, Division of Cardiovascular Medicine, Indiana University, Indianapolis
| | - Shannon M. Knapp
- Krannert Cardiovascular Research Center, Division of Cardiovascular Medicine, Indiana University, Indianapolis
| | - Sabra C. Lewsey
- Division of Cardiovascular Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Selma F. Mohammed
- Division of Cardiovascular Medicine, Creighton University, Omaha, Nebraska
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville
- AdventHealth, Orlando, Florida
| | - Shannon M. Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Albert Hicks
- Division of Cardiovascular Medicine, University of Maryland, Baltimore
| | - Onyedika J. Ilonze
- Krannert Cardiovascular Research Center, Division of Cardiovascular Medicine, Indiana University, Indianapolis
| | - Alanna A. Morris
- Division of Cardiovascular Medicine, Emory University, Atlanta, Georgia
| | - Ryan J. Tedford
- Division of Cardiovascular Medicine, Medical University of South Carolina, Charleston
| | - Monica M. Colvin
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor
| | - Richard C. Daly
- Department of Cardiothoracic Surgery, Mayo Clinic, Rochester, Minnesota
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12
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Heidenreich PA, Lewis EF, Khush KK. Is Equity Being Traded for Access to Heart Transplant? JAMA 2024; 331:1365-1367. [PMID: 38526454 DOI: 10.1001/jama.2024.0812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Affiliation(s)
- Paul A Heidenreich
- Department of Medicine, Stanford University School of Medicine, Stanford, California
- VA Palo Alto Health Care System, Palo Alto, California
| | - Eldrin F Lewis
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Kiran K Khush
- Department of Medicine, Stanford University School of Medicine, Stanford, California
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13
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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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14
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Order KE, Rodig NM. Pediatric Kidney Transplantation: Cancer and Cancer Risk. Semin Nephrol 2024:151501. [PMID: 38580568 DOI: 10.1016/j.semnephrol.2024.151501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
Children with end-stage kidney disease (ESKD) face a lifetime of complex medical care, alternating between maintenance chronic dialysis and kidney transplantation. Kidney transplantation has emerged as the optimal treatment of ESKD for children and provides important quality of life and survival advantages. Although transplantation is the preferred therapy, lifetime exposure to immunosuppression among children with ESKD is associated with increased morbidity, including an increased risk of cancer. Following pediatric kidney transplantation, cancer events occurring during childhood or young adulthood can be divided into two broad categories: post-transplant lymphoproliferative disorders and non-lymphoproliferative solid tumors. This review provides an overview of cancer incidence, types, outcomes, and preventive strategies in this population.
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Affiliation(s)
- Kaitlyn E Order
- Division of Nephrology, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Nancy M Rodig
- Division of Nephrology, Department of Pediatrics, Boston Children's Hospital, Boston, MA.
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15
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Alam AH, Van Zyl J, Shakoor HI, Farsakh D, Abdelrehim AB, Maliakkal N, Jamil AK, Patel R, Felius J, McKean S, Hall SA. The impact of active cytomegalovirus infection on donor-derived cell-free DNA testing in heart transplant recipients. Clin Transplant 2024; 38:e15287. [PMID: 38477177 DOI: 10.1111/ctr.15287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/06/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Little is known about the relationship between cytomegalovirus (CMV) infections and donor-derived cell-free DNA (dd-cfDNA) in heart transplant recipients. METHODS In our study, CMV and dd-cfDNA results were prospectively collected on single-organ heart transplant recipients. If the CMV study was positive, a CMV study with dd-cfDNA was repeated 1-3 months later. The primary aim was to compare dd-cfDNA between patients with positive and negative CMV results. RESULTS Of 44 patients enrolled between August 2022 and April 2023, 12 tested positive for CMV infections, 25 were included as controls, and seven patients with a viral infection without CMV were excluded. Baseline characteristics did not differ significantly between CMV-positive and CMV-negative patients with the exception of a later median time post-transplant in the CMV-positive group (253 days vs. 120 days, p = .03). Dd-cfDNA levels were significantly higher in patients with CMV infections compared to those without (p < .001) with more patients in the CMV positive group showing dd-cfDNA results ≥.12% (75% vs. 8%, p < .001) and ≥.20% (58% vs. 8%, p = .002). Each 1 log10 copy/ml reduction in CMV viral load from visit 1 to visit 2 was associated with a.23% reduction in log10 dd-cfDNA (p = .002). CONCLUSION Our findings suggest that active CMV infections may raise dd-cfDNA levels in patients following heart transplantation. Larger studies are needed to validate these preliminary findings.
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Affiliation(s)
- Amit H Alam
- Division of Cardiology, New York University Langone Health, New York, New York, USA
| | - Johanna Van Zyl
- Texas A&M University Health Science Center College of Medicine, Dallas, Texas, USA
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Hira I Shakoor
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Dana Farsakh
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Ahmad B Abdelrehim
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Neville Maliakkal
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Aayla K Jamil
- Texas A&M University Health Science Center College of Medicine, Dallas, Texas, USA
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Raksha Patel
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Joost Felius
- Texas A&M University Health Science Center College of Medicine, Dallas, Texas, USA
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Staci McKean
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Shelley A Hall
- Texas A&M University Health Science Center College of Medicine, Dallas, Texas, USA
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
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16
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Steggerda JA, Heeger PS. The Promise of Complement Therapeutics in Solid Organ Transplantation. Transplantation 2024:00007890-990000000-00655. [PMID: 38361233 DOI: 10.1097/tp.0000000000004927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Transplantation is the ideal therapy for end-stage organ failure, but outcomes for all transplant organs are suboptimal, underscoring the need to develop novel approaches to improve graft survival and function. The complement system, traditionally considered a component of innate immunity, is now known to broadly control inflammation and crucially contribute to induction and function of adaptive T-cell and B-cell immune responses, including those induced by alloantigens. Interest of pharmaceutical industries in complement therapeutics for nontransplant indications and the understanding that the complement system contributes to solid organ transplantation injury through multiple mechanisms raise the possibility that targeting specific complement components could improve transplant outcomes and patient health. Here, we provide an overview of complement biology and review the roles and mechanisms through which the complement system is pathogenically linked to solid organ transplant injury. We then discuss how this knowledge has been translated into novel therapeutic strategies to improve organ transplant outcomes and identify areas for future investigation. Although the clinical application of complement-targeted therapies in transplantation remains in its infancy, the increasing availability of new agents in this arena provides a rich environment for potentially transformative translational transplant research.
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Affiliation(s)
- Justin A Steggerda
- Division of Abdominal Transplant Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Peter S Heeger
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
- Division of Nephrology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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17
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Kittleson MM. Optimizing Beneficence and Justice in Heart Transplant Allocation. JAMA 2024; 331:480-481. [PMID: 38349382 DOI: 10.1001/jama.2023.27157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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18
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Zhang KC, Narang N, Jasseron C, Dorent R, Lazenby KA, Belkin MN, Grinstein J, Mayampurath A, Churpek MM, Khush KK, Parker WF. Development and Validation of a Risk Score Predicting Death Without Transplant in Adult Heart Transplant Candidates. JAMA 2024; 331:500-509. [PMID: 38349372 PMCID: PMC10865158 DOI: 10.1001/jama.2023.27029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/11/2023] [Indexed: 02/15/2024]
Abstract
Importance The US heart allocation system prioritizes medically urgent candidates with a high risk of dying without transplant. The current therapy-based 6-status system is susceptible to manipulation and has limited rank ordering ability. Objective To develop and validate a candidate risk score that incorporates current clinical, laboratory, and hemodynamic data. Design, Setting, and Participants A registry-based observational study of adult heart transplant candidates (aged ≥18 years) from the US heart allocation system listed between January 1, 2019, and December 31, 2022, split by center into training (70%) and test (30%) datasets. Adult candidates were listed between January 1, 2019, and December 31, 2022. Main Outcomes and Measures A US candidate risk score (US-CRS) model was developed by adding a predefined set of predictors to the current French Candidate Risk Score (French-CRS) model. Sensitivity analyses were performed, which included intra-aortic balloon pumps (IABP) and percutaneous ventricular assist devices (VAD) in the definition of short-term mechanical circulatory support (MCS) for the US-CRS. Performance of the US-CRS model, French-CRS model, and 6-status model in the test dataset was evaluated by time-dependent area under the receiver operating characteristic curve (AUC) for death without transplant within 6 weeks and overall survival concordance (c-index) with integrated AUC. Results A total of 16 905 adult heart transplant candidates were listed (mean [SD] age, 53 [13] years; 73% male; 58% White); 796 patients (4.7%) died without a transplant. The final US-CRS contained time-varying short-term MCS (ventricular assist-extracorporeal membrane oxygenation or temporary surgical VAD), the log of bilirubin, estimated glomerular filtration rate, the log of B-type natriuretic peptide, albumin, sodium, and durable left ventricular assist device. In the test dataset, the AUC for death within 6 weeks of listing for the US-CRS model was 0.79 (95% CI, 0.75-0.83), for the French-CRS model was 0.72 (95% CI, 0.67-0.76), and 6-status model was 0.68 (95% CI, 0.62-0.73). Overall c-index for the US-CRS model was 0.76 (95% CI, 0.73-0.80), for the French-CRS model was 0.69 (95% CI, 0.65-0.73), and 6-status model was 0.67 (95% CI, 0.63-0.71). Classifying IABP and percutaneous VAD as short-term MCS reduced the effect size by 54%. Conclusions and Relevance In this registry-based study of US heart transplant candidates, a continuous multivariable allocation score outperformed the 6-status system in rank ordering heart transplant candidates by medical urgency and may be useful for the medical urgency component of heart allocation.
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Affiliation(s)
- Kevin C. Zhang
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois
- Department of Medicine, University of Illinois-Chicago
| | - Carine Jasseron
- Agence de la Biomédecine, Direction Prélèvement Greffe Organes-Tissus, Saint-Denis La Plaine, France
| | - Richard Dorent
- Agence de la Biomédecine, Direction Prélèvement Greffe Organes-Tissus, Saint-Denis La Plaine, France
| | - Kevin A. Lazenby
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Mark N. Belkin
- Department of Medicine, University of Chicago, Chicago, Illinois
| | | | - Anoop Mayampurath
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison
| | | | - Kiran K. Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - William F. Parker
- Department of Medicine, University of Chicago, Chicago, Illinois
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
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19
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Borkowski P, Singh N, Borkowska N. Advancements in Heart Transplantation: Donor-Derived Cell-Free DNA as Next-Generation Biomarker. Cureus 2024; 16:e54018. [PMID: 38476807 PMCID: PMC10930105 DOI: 10.7759/cureus.54018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 03/14/2024] Open
Abstract
Heart failure, particularly in its advanced stages, significantly impacts quality of life. Despite progress in Guideline-Directed Medical Therapy (GDMT) and invasive treatments, heart transplantation (HT) remains the primary option for severe cases. However, complications such as graft rejection present significant challenges that necessitate effective monitoring. Endomyocardial biopsy (EMB) is the gold standard for detecting rejection, but its invasive nature, associated risks, and healthcare costs have shifted interest in non-invasive techniques. Donor-derived cell-free DNA (dd-cfDNA) has gained attention as a promising non-invasive biomarker for monitoring graft rejection. Compared to EMB, dd-cfDNA detects graft rejection early and enables clinicians to adjust immunosuppression promptly. Despite its advantages, dd-cfDNA testing faces challenges, such as the need for specialized technology and potential inaccuracies due to other clinical conditions. Additionally, dd-cfDNA cannot yet differentiate between types of graft rejection, and its effectiveness in chronic rejection remains unclear. Research is ongoing to set precise standards for dd-cfDNA levels, which would enhance its diagnostic accuracy and help in clinical decisions. The article also points to the future of HT monitoring, which may involve combining dd-cfDNA with other biomarkers and integrating artificial intelligence to improve diagnostic capabilities and personalize patient care. Furthermore, it emphasizes both global and racial inequalities in dd-cfDNA testing and the ethical issues related to its use in transplant medicine.
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Affiliation(s)
- Pawel Borkowski
- Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, USA
| | - Nikita Singh
- Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, USA
| | - Natalia Borkowska
- Pediatrics, SPZOZ (Samodzielny Publiczny Zakład Opieki Zdrowotnej) Krotoszyn, Krotoszyn, POL
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20
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Bitar A, Colvin MM. Beyond Tiers: Examination of the French Heart Allocation System. Circ Heart Fail 2024; 17:e011312. [PMID: 38299339 DOI: 10.1161/circheartfailure.123.011312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/20/2023] [Indexed: 02/02/2024]
Affiliation(s)
- Abbas Bitar
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (A.B., M.M.C.)
| | - Monica M Colvin
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (A.B., M.M.C.)
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21
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Nogueiras-Álvarez R, García-Sáiz MDM. Off-Label Immunosuppressant Drugs in Solid Organ Transplantation. PHARMACY 2024; 12:17. [PMID: 38392924 PMCID: PMC10893541 DOI: 10.3390/pharmacy12010017] [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: 12/02/2023] [Revised: 01/13/2024] [Accepted: 01/17/2024] [Indexed: 02/25/2024] Open
Abstract
Once a solid organ transplantation (SOT) has been performed, it is necessary to prescribe immunosuppressant medication to prevent graft rejection. This task has the peculiarity that many of these drugs do not have specific indications for transplant use in the technical data sheets. We performed a review of different immunosuppressive drugs' information available at European and American regulatory agencies in order to analyze the approved indications by the type of SOT. In our work, besides showing these differences between different indication approvals in different SOT modalities, we also attempted to reflect other differences under the approved indications according to age group, formulation type, geographical area, etc. Although consensus documents on the subject have been published, the access to immunosuppressants depends on each country's regulation and healthcare system, and off-label prescription is a reality that healthcare professionals need to be familiar with.
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Affiliation(s)
| | - María del Mar García-Sáiz
- Clinical Pharmacology Service, Marqués de Valdecilla University Hospital, 39008 Santander, Spain;
- Department of Physiology and Pharmacology, University of Cantabria, 39012 Santander, Spain
- IDIVAL, 39004 Santander, Spain
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22
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Cascino TM, Cogswell R, Shah P, Cowger JA, Molina EJ, Shah KB, Grinstein J, Wood KL, Gosev I, Kanwar MK. Equitable Access to Advanced Heart Failure Therapies in the United States: A Call to Action. J Card Fail 2024; 30:78-84. [PMID: 37884168 DOI: 10.1016/j.cardfail.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/17/2023] [Accepted: 09/19/2023] [Indexed: 10/28/2023]
Affiliation(s)
- Thomas M Cascino
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI
| | - Rebecca Cogswell
- Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Palak Shah
- Cardiovascular Medicine, Inova Heart and Vascular Institute, Falls Church, VA
| | | | | | - Keyur B Shah
- The Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | | | - Katherine L Wood
- Division of Cardiothoracic Surgery, University of Rochester, Rochester, NY
| | - Igor Gosev
- Division of Cardiothoracic Surgery, University of Rochester, Rochester, NY
| | - Manreet K Kanwar
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI; Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA.
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23
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Enríquez-Vázquez D, Barge-Caballero E, González-Vílchez F, Almenar-Bonet L, García-Cosío Carmena MD, González-Costello J, Gómez-Bueno M, Castel-Lavilla MÁ, Díaz-Molina B, Martínez-Sellés M, Mirabet-Pérez S, De la Fuente-Galán L, Hervás-Sotomayor D, Rangel-Sousa D, Garrido-Bravo IP, Blasco-Peiró T, Juan-Aracil GR, Muñiz J, Crespo-Leiro MG. Sex, Temporary Mechanical Circulatory Support, and Heart Transplantation: Insights From a Multi-Institutional Spanish Registry. JACC. HEART FAILURE 2023; 11:1763-1766. [PMID: 37715770 DOI: 10.1016/j.jchf.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/25/2023] [Indexed: 09/18/2023]
Affiliation(s)
- Daniel Enríquez-Vázquez
- Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Eduardo Barge-Caballero
- Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
| | | | - Luis Almenar-Bonet
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Hospital Universitario Politécnico La Fe, Valencia, Spain
| | - María Dolores García-Cosío Carmena
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Hospital Universitario Doce de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain
| | - José González-Costello
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Hospital Universitari de Bellvitge, Institut d'investigació Biomédica de Bellvitge (IDIBELL), Universitat de Barcelona, L'Hospitalet de Llobregat (Barcelona), Spain
| | - Manuel Gómez-Bueno
- Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain; Hospital Universitario Puerta de Hierro, Majadahonda (Madrid), Spain
| | - María Ángeles Castel-Lavilla
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Hospital General Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Sonia Mirabet-Pérez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Luis De la Fuente-Galán
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | | | - Iris P Garrido-Bravo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | | | | | - Javier Muñiz
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Universidade de A Coruña, A Coruña, Spain
| | - María G Crespo-Leiro
- Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Hospital Clínica Universidad de Navarra, Pamplona, Spain
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24
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Cascino TM. Emerging Opportunities to Reduce Racial, Ethnic, and Gender Disparities in Advanced Heart Failure Care. JACC. HEART FAILURE 2023; 11:1408-1410. [PMID: 37589613 DOI: 10.1016/j.jchf.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 06/28/2023] [Accepted: 07/05/2023] [Indexed: 08/18/2023]
Affiliation(s)
- Thomas M Cascino
- University of Michigan, Division of Cardiovascular Disease, Ann Arbor, Michigan, USA.
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25
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Kwon JH, Blanding WM, Shorbaji K, Scalea JR, Gibney BC, Baliga PK, Kilic A. Waitlist and Transplant Outcomes in Organ Donation After Circulatory Death: Trends in the United States. Ann Surg 2023; 278:609-620. [PMID: 37334722 DOI: 10.1097/sla.0000000000005947] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
OBJECTIVES To summarize waitlist and transplant outcomes in kidney, liver, lung, and heart transplantation using organ donation after circulatory death (DCD). BACKGROUND DCD has expanded the donor pool for solid organ transplantation, most recently for heart transplantation. METHODS The United Network for Organ Sharing registry was used to identify adult transplant candidates and recipients in the most recent allocation policy eras for kidney, liver, lung, and heart transplantation. Transplant candidates and recipients were grouped by acceptance criteria for DCD versus brain-dead donors [donation after brain death (DBD)] only and DCD versus DBD transplant, respectively. Propensity matching and competing-risks regression was used to model waitlist outcomes. Survival was modeled using propensity matching and Kaplan-Meier and Cox regression analysis. RESULTS DCD transplant volumes have increased significantly across all organs. Liver candidates listed for DCD organs were more likely to undergo transplantation compared with propensity-matched candidates listed for DBD only, and heart and liver transplant candidates listed for DCD were less likely to experience death or clinical deterioration requiring waitlist inactivation. Propensity-matched DCD recipients demonstrated an increased mortality risk up to 5 years after liver and kidney transplantation and up to 3 years after lung transplantation compared with DBD. There was no difference in 1-year mortality between DCD and DBD heart transplantation. CONCLUSIONS DCD continues to expand access to transplantation and improves waitlist outcomes for liver and heart transplant candidates. Despite an increased risk for mortality with DCD kidney, liver, and lung transplantation, survival with DCD transplant remains acceptable.
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Affiliation(s)
- Jennie H Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Walker M Blanding
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Joseph R Scalea
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC
| | - Barry C Gibney
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Prabhakar K Baliga
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
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26
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Tcheandjieu C, Cappola TP. Diversifying the Genetic Landscape of Heart Disease. JAMA 2023; 330:415-416. [PMID: 37526732 PMCID: PMC10874675 DOI: 10.1001/jama.2023.12375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Affiliation(s)
| | - Thomas P Cappola
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
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27
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Madan S, Chan MAG, Saeed O, Hemmige V, Sims DB, Forest SJ, Goldstein DJ, Patel SR, Jorde UP. Early Outcomes of Adult Heart Transplantation From COVID-19 Infected Donors. J Am Coll Cardiol 2023; 81:2344-2357. [PMID: 37204379 PMCID: PMC10191151 DOI: 10.1016/j.jacc.2023.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/10/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND There is a paucity of data on heart transplantation (HT) using COVID-19 donors. OBJECTIVES This study investigated COVID-19 donor use, donor and recipient characteristics, and early post-HT outcomes. METHODS Between May 2020 and June 2022, study investigators identified 27,862 donors in the United Network for Organ Sharing, with 60,699 COVID-19 nucleic acid amplification testing (NAT) performed before procurement and with available organ disposition. Donors were considered "COVID-19 donors" if they were NAT positive at any time during terminal hospitalization. These donors were subclassified as "active COVID-19" (aCOV) donors if they were NAT positive within 2 days of organ procurement, or "recently resolved COVID-19" (rrCOV) donors if they were NAT positive initially but became NAT negative before procurement. Donors with NAT-positive status >2 days before procurement were considered aCOV unless there was evidence of a subsequent NAT-negative result ≥48 hours after the last NAT-positive result. HT outcomes were compared. RESULTS During the study period, 1,445 "COVID-19 donors" (COVID-19 NAT positive) were identified; 1,017 of these were aCOV, and 428 were rrCOV. Overall, 309 HTs used COVID-19 donors, and 239 adult HTs from COVID-19 donors (150 aCOV, 89 rrCOV) met study criteria. Compared with non-COV, COVID-19 donors used for adult HT were younger and mostly male (∼80%). Compared with HTs from non-COV donors, recipients of HTs from aCOV donors had increased mortality at 6 months (Cox HR: 1.74; 95% CI: 1.02-2.96; P = 0.043) and 1 year (Cox HR: 1.98; 95% CI: 1.22-3.22; P = 0.006). Recipients of HTs from rrCOV and non-COV donors had similar 6-month and 1-year mortality. Results were similar in propensity-matched cohorts. CONCLUSIONS In this early analysis, although HTs from aCOV donors had increased mortality at 6 months and 1 year, HTs from rrCOV donors had survival similar to that seen in recipients of HTs from non-COV donors. Continued evaluation and a more nuanced approach to this donor pool are needed.
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Affiliation(s)
- Shivank Madan
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA.
| | | | - Omar Saeed
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Vagish Hemmige
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Daniel B Sims
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Stephen J Forest
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Daniel J Goldstein
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Snehal R Patel
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
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