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Feng I, Kurlansky PA, Zhao Y, Patel K, Moroi MK, Vinogradsky AV, Latif F, Sayer G, Uriel N, Naka Y, Takeda K. Bridge to simultaneous heart-kidney transplantation via extracorporeal life support: National outcomes in the new heart allocation policy era. J Heart Lung Transplant 2024:S1053-2498(24)01809-6. [PMID: 39245425 DOI: 10.1016/j.healun.2024.08.020] [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: 01/11/2024] [Revised: 07/10/2024] [Accepted: 08/19/2024] [Indexed: 09/10/2024] Open
Abstract
BACKGROUND Since United Network for Organ Sharing (UNOS) revised their heart allocation policy in 2018, usage of veno-arterial extracorporeal life support (VA-ECLS) has dramatically increased as a bridge to transplant. This study investigated outcomes of VA-ECLS patients bridged to simultaneous heart-kidney transplant (SHK) in the new policy era. METHODS This study included 774 adult patients from the UNOS database who received SHK between 10/18/18 and 12/31/21 and compared patients bridged to transplant on VA-ECLS (n = 50) with those not bridged (n = 724). RESULTS At baseline, SHK recipients bridged from VA-ECLS were younger (50.5 vs 58.0 years, p = 0.007), had higher estimated glomerular filtration rate (eGFR) at time of transplant (47.6 vs 30.1, p < 0.001), and spent fewer days on the waitlist (7.0 vs 33.5 days, p < 0.001). In the perioperative period, VA-ECLS was associated with higher rates of temporary dialysis (56.0% vs 28.0%, p < 0.001) but similar 2-year cumulative incidence of chronic dialysis (7.5% vs 5.4%, p = 0.800) and renal allograft failure (12.0% vs 8.1%, p = 0.500) compared to non-ECLS cohort. However, VA-ECLS patients had decreased survival to discharge (76.0% vs 92.7%, p < 0.001) and 2-year post-transplant survival (71.7% vs 83.0%, p = 0.004), as well as greater 2-year cumulative incidence of cardiac allograft failure (10.0% vs 2.7%, p = 0.002). Multivariable analyses found VA-ECLS at time of transplant to be independently associated with 2-year post-transplant mortality (HR [95% CI]: 3.40 [1.66-6.96], p = 0.001) and cardiac allograft failure (sub-distribution hazard ratio [SHR] [95% CI]: 8.51 [2.77-26.09], p < 0.001). CONCLUSION Under the new allocation policy, patients bridged to SHK from VA-ECLS displayed greater early mortality and cardiac allograft failure but similar renal outcomes compared to non-ECLS counterparts.
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Affiliation(s)
- Iris Feng
- Division of Cardiac Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Paul A Kurlansky
- Division of Cardiac Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York; Center of Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York
| | - Yanling Zhao
- Division of Cardiac Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Krushang Patel
- Division of Cardiac Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Morgan K Moroi
- Division of Cardiac Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Alice V Vinogradsky
- Division of Cardiac Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Farhana Latif
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Gabriel Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiac Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiac Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York.
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Seadler BD, Karra H, Zelten J, Rein LE, Durham LA, Joyce LD, Kohmoto T, Joyce DL. Risk and Reward: Nationwide Analysis of Cardiac Transplant Center Variation in Organ Travel Distance and the Effects on Outcomes. Clin Transplant 2024; 38:e15456. [PMID: 39229694 DOI: 10.1111/ctr.15456] [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: 06/07/2024] [Revised: 08/11/2024] [Accepted: 08/26/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND The 2018 UNOS allocation policy change deprioritized geographic boundaries to organ distribution, and the effects of this change have been widespread. The aim of this investigation was to analyze changes in donor transplant center distance for organ travel and corresponding outcomes before and after the allocation policy change. METHODS The UNOS database was utilized to identify all adult patients waitlisted for heart transplants from 2016 to 2021. Transplant centers were grouped by average donor heart travel distance based on whether they received more or less than 50% of organs from >250 miles away. Descriptive statistics were provided for waitlisted and transplanted patients. Regression analyses modeled waitlist mortality, incidence of transplant, overall survival, and graft survival. RESULTS Centers with a longer average travel distance had a higher mean annual transplant volume with a reduction in total days on a waitlist (86.6 vs. 149.2 days), an increased cold ischemic time (3.6 vs. 3.2 h), with no significant difference in post-transplant overall survival or graft survival. CONCLUSIONS The benefits of reducing waitlist time while preserving post-transplant outcomes extend broadly. The trends observed in this investigation will be useful as we revise organ transplant policy in the era of new organ procurement and preservation techniques.
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Affiliation(s)
- Benjamin D Seadler
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Hamsitha Karra
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - James Zelten
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lisa E Rein
- Institute for Health & Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lucian A Durham
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lyle D Joyce
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Takushi Kohmoto
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David L Joyce
- Cardiothoracic Surgery, Eastern Idaho Regional Medical Center, Idaho Falls, Idaho, USA
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Deshpande SR, Das B, Kumar A, Sinha P, Alsoufi B, Trivedi J. Impact of new allocation policy on waitlist and transplant outcomes of adult congenital heart patients supported with ECMO. Artif Organs 2024; 48:912-920. [PMID: 38483147 DOI: 10.1111/aor.14738] [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: 06/21/2023] [Revised: 02/01/2024] [Accepted: 02/22/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND The use of ECMO as a bridge to heart transplantation has been growing rapidly in all heart transplant recipients since the implementation of the new UNOS allocation policy; however, the impact on adult congenital heart disease (ACHD) patients is not known. METHODS We analyzed the UNOS data (2015-2021) for ACHD patients supported with extracorporeal membrane oxygenation (ECMO) during the waitlist, before and after October 2018, to assess the impact on the waitlist and posttransplant outcomes. We compared the characteristics and outcomes of ACHD patients with or without ECMO use during the waitlist and pre- and postpolicy changes. RESULTS A total of 23 821 patients underwent heart transplantation, and only 918 (4%) had ACHD. Out of all ACHD patients undergoing heart transplants, 6% of patients in the prepolicy era and 7.6% in the postpolicy era were on ECMO at the time of listing. Those on ECMO were younger and sicker compared to the rest of the ACHD cohort. Those on ECMO had similar profiles pre- and postpolicy change; however, there was a very significant decrease in the waitlist time [136 days (IQR 29-384) vs. 38 days (IQR 11-108), p = 0.01]. There was no difference in waitlist mortality; however, competing risk analyses showed a higher likelihood of transplantation (51% vs. 29%) and a lower likelihood of death or deterioration (31% vs. 42%) postpolicy change. Long-term outcomes posttransplant for those supported with ECMO compared to the non-ECMO cohort are similar for ACHD patients, although there was higher attrition in the first year for the ECMO cohort. CONCLUSION The new allocation policy has resulted in shorter waitlist times and a higher likelihood of transplantation for ACHD patients supported by ECMO. However, the appropriate use of ECMO and the underuse of durable circulatory support devices in this population need further exploration.
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Affiliation(s)
- Shriprasad R Deshpande
- Pediatric Cardiology Division, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Bibhuti Das
- Pediatric Cardiology, Baylor College of Medicine-Temple, Temple, Texas, USA
| | - Akshay Kumar
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pranava Sinha
- Department of Pediatric Cardiovascular Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, Norton Children's Hospital, University of Louisville, Louisville, Kentucky, USA
| | - Jaimin Trivedi
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky, USA
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Butts RJ, Toombs L, Kirklin JK, Schumacher KR, Conway J, West SC, Auerbach S, Bansal N, Zhao H, Cantor RS, Nandi D, Peng DM. Waitlist Outcomes for Pediatric Heart Transplantation in the Current Era: An Analysis of the Pediatric Heart Transplant Society Database. Circulation 2024; 150:362-373. [PMID: 38939965 DOI: 10.1161/circulationaha.123.068189] [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: 11/28/2023] [Accepted: 05/22/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Waitlist mortality (WM) remains elevated in pediatric heart transplantation. Allocation policy is a potential tool to help improve WM. This study aims to identify patients at highest risk for WM to potentially inform future allocation policy changes. METHODS The Pediatric Heart Transplant Society database was queried for patients <18 years of age indicated for heart transplantation between January 1, 2010 to December 31, 2021. Waitlist mortality was defined as death while awaiting transplant or removal from the waitlist due to clinical deterioration. Because WM is low after the first year, analysis was limited to the first 12 months on the heart transplant list. Kaplan-Meier analysis and log-rank testing was conducted to compare unadjusted survival between groups. Cox proportional hazard models were created to determine risk factors for WM. Subgroup analysis was performed for status 1A patients based on body surface area (BSA) at time of listing, cardiac diagnosis, and presence of mechanical circulatory support. RESULTS In total 5974 children met study criteria of which 3928 were status 1A, 1012 were status 1B, 963 were listed status 2, and 65 were listed status 7. Because of the significant burden of WM experienced by 1A patients, further analysis was performed in only patients indicated as 1A. Within that group of patients, those with smaller size and lower eGFR had higher WM, whereas those patients without congenital heart disease or support from a ventricular assist device (VAD) at time of listing had decreased WM. In the smallest size cohort, cardiac diagnoses other than dilated cardiomyopathy were risk factors for WM. Previous cardiac surgery was a risk factor in the 0.3 to 0.7 m2 and >0.7 m2 BSA groups. VAD support was associated with lower WM other than in the single ventricle cohort, where VAD was associated with higher WM. Extracorporeal membrane oxygenation and mechanical ventilation were associated with increased risk of WM in all cohorts. CONCLUSIONS There is significant variability in WM among status-1A patients. Potential refinements to current allocation system should factor in the increased WM risk we identified in patients supported by extracorporeal membrane oxygenation or mechanical ventilation, single ventricle congenital heart disease on VAD support and small children with congenital heart disease, restrictive cardiomyopathy, or hypertrophic cardiomyopathy.
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Affiliation(s)
- Ryan J Butts
- University of Texas Southwestern, Department of Pediatrics, Division of Cardiology, Dallas (R.J.B.)
| | - Leah Toombs
- Children's Medical Center of Dallas, TX (L.T.)
| | | | - Kurt R Schumacher
- University of Michigan, Department of Pediatrics, Division of Cardiology, Ann Arbor (K.R.S., D.M.P.)
| | - Jennifer Conway
- Stollery Childrens, Department of Pediatrics, Division of Cardiology, Edmonton, Alberta, Canada (J.C.)
| | - Shawn C West
- Children's Hospital of Pittsburgh, Department of Pediatrics, Division of Cardiology, PA (S.C.W.)
| | - Scott Auerbach
- Children's Hospital of Colorado, Department of Pediatrics, Division of Cardiology, Aurora (S.A.)
| | - Neha Bansal
- Mount Sinai Kravis Children's Hospital, Department of Pediatrics, Division of Cardiology, New York (N.B.)
| | - Hong Zhao
- Kirklin Solutions, Hoover, AL (J.K.K., H.Z., R.S.C.)
| | - Ryan S Cantor
- Kirklin Solutions, Hoover, AL (J.K.K., H.Z., R.S.C.)
| | - Deipanjan Nandi
- Nationwide Children's Hospital, Department of Pediatrics, Division of Cardiology, Columbus, OH (D.N.)
| | - David M Peng
- University of Michigan, Department of Pediatrics, Division of Cardiology, Ann Arbor (K.R.S., D.M.P.)
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D'Alessandro D, Schroder J, Meyer DM, Vidic A, Shudo Y, Silvestry S, Leacche M, Sciortino CM, Rodrigo ME, Pham SM, Copeland H, Jacobs JP, Kawabori M, Takeda K, Zuckermann A. Impact of controlled hypothermic preservation on outcomes following heart transplantation. J Heart Lung Transplant 2024; 43:1153-1161. [PMID: 38503386 DOI: 10.1016/j.healun.2024.03.010] [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: 09/28/2023] [Revised: 02/09/2024] [Accepted: 03/14/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Severe primary graft dysfunction (PGD) is a major cause of early mortality after heart transplant, but the impact of donor organ preservation conditions on severity of PGD and survival has not been well characterized. METHODS Data from US adult heart-transplant recipients in the Global Utilization and Registry Database for Improved Heart Preservation-Heart Registry (NCT04141605) were analyzed to quantify PGD severity, mortality, and associated risk factors. The independent contributions of organ preservation method (traditional ice storage vs controlled hypothermic preservation) and ischemic time were analyzed using propensity matching and logistic regression. RESULTS Among 1,061 US adult heart transplants performed between October 2015 and December 2022, controlled hypothermic preservation was associated with a significant reduction in the incidence of severe PGD compared to ice (6.6% [37/559] vs 10.4% [47/452], p = 0.039). Following propensity matching, severe PGD was reduced by 50% (6.0% [17/281] vs 12.1% [34/281], respectively; p = 0.018). The Kaplan-Meier terminal probability of 1-year mortality was 4.2% for recipients without PGD, 7.2% for mild or moderate PGD, and 32.1%, for severe PGD (p < 0.001). The probability of severe PGD increased for both cohorts with longer ischemic time, but donor hearts stored on ice were more likely to develop severe PGD at all ischemic times compared to controlled hypothermic preservation. CONCLUSIONS Severe PGD is the deadliest complication of heart transplantation and is associated with a 7.8-fold increase in probability of 1-year mortality. Controlled hypothermic preservation significantly attenuates the risk of severe PGD and is a simple yet highly effective tool for mitigating post-transplant morbidity.
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Affiliation(s)
- David D'Alessandro
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
| | - Jacob Schroder
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Dan M Meyer
- Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas
| | - Andrija Vidic
- Department of Cardiovascular Medicine University of Kansas Health System, Kansas City, Kansas
| | - Yasuhiro Shudo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Scott Silvestry
- Department of Cardiothoracic Surgery, AdventHealth Transplant Institute, Orlando, Florida
| | - Marzia Leacche
- Division of Cardiothoracic Surgery, Corewell Health (formerly Spectrum Health), Grand Rapids, Michigan
| | | | - Maria E Rodrigo
- Department of Cardiology, MedStar Health, Washington, District of Columbia
| | - Si M Pham
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Hannah Copeland
- Department of Cardiothoracic Surgery, Lutheran Health, Fort Wayne, Indiana
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Congenital Heart Center, UF Health Shands Hospital, Gainesville, Florida
| | - Masashi Kawabori
- Department of Surgery, Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Koji Takeda
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University, New York, New York
| | - Andreas Zuckermann
- Department for Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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6
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Sollie ZW, Kwon JH, Usry B, Shorbaji K, Welch BA, Hashmi ZA, Witer L, Pope N, Tedford RJ, Kilic A. Changes in heart transplant outcomes of elderly patients in the new allocation era. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00269-1. [PMID: 38519014 DOI: 10.1016/j.jtcvs.2024.03.015] [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: 05/04/2023] [Revised: 02/16/2024] [Accepted: 03/08/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE Studies demonstrate that heart transplantation can be performed safely in septuagenarians. We evaluate the outcomes of septuagenarians undergoing heart transplantation after the US heart allocation change in 2018. METHODS The United Network for Organ Sharing registry was used to identify heart transplant recipients aged 70 years or more between 2010 and 2021. Primary outcomes were 90-day and 1-year mortality. Kaplan-Meier, multivariable Cox proportional hazards, and accelerated failure time models were used for unadjusted and risk-adjusted analyses. RESULTS A total of 27,403 patients underwent heart transplantation, with 1059 (3.9%) aged 70 years or more. Patients aged 70 years or more increased from 3.7% before 2018 to 4.5% after 2018 (P = .003). Patients aged 70 years or more before 2018 had comparable 90-day and 1-year survivals relative to patients aged less than 70 years (90 days: 93.8% vs 94.2%, log-rank P = .650; 1 year: 89.4% vs 91.1%, log-rank P = .130). After 2018, septuagenarians had lower 90-day and 1-year survivals (90 days: 91.4% vs 95.0%, log-rank P = .021; 1 year: 86.5% vs 90.9%, log-rank P = .018). Risk-adjusted analysis showed comparable 90-day mortality (hazard ratio, 1.29; 0.94-1.76, P = .110) but worse 1-year mortality (hazard ratio, 1.32; 1.03-1.68, P = .028) before policy change. After policy change, both 90-day and 1-year mortalities were higher (90 days: HR, 1.99; 1.23-3.22, P = .005; 1 year: hazard ratio, 1.71; 1.14-2.56, P = .010). An accelerated failure time model showed comparable 90-day (0.42; 0.16-1.44; P = .088) and 1-year (0.48; 0.18-1.26; P = .133) survival postallocation change. CONCLUSIONS Septuagenarians comprise a greater proportion of heart transplant recipients after the allocation change, and their post-transplant outcomes relative to younger recipients have worsened.
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Affiliation(s)
- Zachary W Sollie
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Jennie H Kwon
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Benjamin Usry
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Brett A Welch
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Zubair A Hashmi
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Va
| | - Lucas Witer
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Nicolas Pope
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Ryan J Tedford
- Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC.
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Kwon JH, Skidmore SH, Bhandari K, Carnicelli AP, Yourshaw JP, Shorbaji K, Kilic A. Waitlist and transplant outcomes in heart transplant candidates bridged with temporary endovascular right ventricular assist devices. J Heart Lung Transplant 2024; 43:369-378. [PMID: 37951321 DOI: 10.1016/j.healun.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 10/20/2023] [Accepted: 11/06/2023] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Advances in mechanical circulatory support and changes in allocation policy have shifted waitlisting practices for heart transplantation (HT) in the United States. This analysis reports waitlist and transplant outcomes among HT candidates bridged with temporary endovascular right ventricular assist devices (tRVADs). METHODS Patients awaiting HT from 2008 to 2022 in the United Network of Organ Sharing registry were grouped by the presence of tRVAD while waitlisted and propensity matched. Waitlist outcomes were HT and a competing outcome of death/deterioration requiring waitlist inactivation. Competing-risks regression was used to model waitlist outcomes. Subanalyses were performed to compare waitlist outcomes among patients with durable and temporary left ventricular assist devices (LVADs) with and without concomitant tRVADs. One-year posttransplant mortality was estimated using Kaplan-Meier analysis. RESULTS Of 41,507 HT candidates, 133 (0.3%) had tRVADs. After propensity matching, patients with tRVAD had a similar likelihood of HT and an elevated hazard for death/deterioration (hazard ratio 2.2, 95% confidence interval 1.4-3.2, p < 0.001) compared to those without tRVAD. Most patients with tRVAD (84%) had concomitant LVADs. tRVAD was associated with an elevated risk for deterioration/death among those with temporary LVADs but not durable LVADs. For patients undergoing HT, tRVAD was associated with an increased risk for 1-year mortality compared to propensity-matched recipients. CONCLUSIONS Bridging with tRVAD is uncommon and primarily used in patients requiring biventricular support. tRVADs are associated with waitlist inactivation or death, particularly with concomitant temporary LVAD support. As temporary devices are increasingly used as a bridge to HT, outcomes of patients with tRVADs should inform future allocation policy, particularly for candidates with biventricular failure.
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Affiliation(s)
- Jennie H Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Savannah H Skidmore
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Krishna Bhandari
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Anthony P Carnicelli
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Jeffrey P Yourshaw
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina.
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Abstract
Heart transplantation (HT) remains the best treatment of patients with severe heart failure who are deemed to be transplant candidates. The authors discuss postoperative management of the HT recipient by system, emphasizing areas where care might differ from other cardiac surgery patients. Working together, critical care physicians, heart transplant surgeons and cardiologists, advanced practice providers, pharmacists, transplant coordinators, nursing staff, physical therapists, occupational therapists, rehabilitation specialists, nutritionists, health psychologists, social workers, and the patient and their loved ones partner to increase the likelihood of a successful outcome.
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Affiliation(s)
- Gozde Demiralp
- Division of Critical Care Medicine, Department of Anesthesiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI 53792, USA
| | - Robert T Arrigo
- Division of Critical Care Medicine, Department of Anesthesiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Mail Code 3272, Madison, WI 53792, USA; Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Mail Code 3272, Madison, WI 53792, USA
| | - Christopher Cassara
- Division of Critical Care Medicine, Department of Anesthesiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Mail Code 3272, Madison, WI 53792, USA; Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, Mail Code 3272, Madison, WI 53792, USA
| | - Maryl R Johnson
- Heart Failure and Transplant Cardiology, University of Wisconsin School of Medicine & Public Health, 600 Highland Avenue, E5/582 CSC, Mail Code 5710, Madison, WI 53792, USA.
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9
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Shin M, Iyengar A, Helmers MR, Weingarten N, Patrick WL, Rekhtman D, Song C, Kelly JJ, Cevasco M. Decreased survival of simultaneous heart-kidney transplant recipients in the new heart allocation era. J Heart Lung Transplant 2023; 42:1725-1734. [PMID: 37579829 DOI: 10.1016/j.healun.2023.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/16/2023] [Accepted: 08/04/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND In 2018, the United Network for Organ Sharing (UNOS) modified their heart allocation policy to reduce waitlist mortality. The rates of simultaneous heart-kidney transplant (SHKT) have dramatically increased in recent years, despite increased rates of posttransplant renal failure in the new policy era. This study sought to investigate the impact of the new allocation system on waitlist and posttransplant outcomes of simultaneous heart-kidney transplantation. METHODS Adult patients listed for SHKT between 2012 and 2021 were included. Patients were cross-validated across both Thoracic and Kidney UNOS databases to confirm accurate listing and transplant data. Patients were stratified according to listing era. The Fine and Gray model was used to assess waitlist outcomes and posttransplant renal graft function. Kaplan-Meier analysis and Cox regression were used to compare posttransplant survival. RESULTS A total of 2,588 patients were included, of whom 1,406 (54.1%) were listed between 2012 and 2018 (era 1) and 1,182 (45.9%) between 2019 and 2021 (era 2). Era 2 was associated with increased likelihood of transplant (adjusted Sub-hazard ratios (aSHR): 1.52; p < 0.01) and decreased waitlist mortality (aSHR: 0.63; p < 0.01). Posttransplant survival at 2 years was decreased in era 2 (78.8% vs 86.9%; p < 0.01). Undersized hearts (hazard ratio [HR]: 2.02; p < 0.01), use of extracorporeal membrane oxygenation (HR: 2.67; p < 0.1), and transplants performed following the policy change (HR: 1.45; p = 0.03) were associated with increased mortality. Actuarial survival (combined waitlist and posttransplant) was significantly lower in the modern era (71.6% vs 62.2%; p = 0.02). CONCLUSIONS The allocation policy change has improved waitlist outcomes in patients listed for SHKT but potentially at the cost of worsened posttransplant outcomes.
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Affiliation(s)
- Max Shin
- Perelman School of Medicine, Philadelphia, PA, USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - William L Patrick
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Cindy Song
- Perelman School of Medicine, Philadelphia, PA, USA
| | - John J Kelly
- Perelman School of Medicine, Philadelphia, PA, USA; Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
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Doulamis IP, Gemelli M, Rempakos A, Tzani A, Oh NA, Kampaktsis P, Guariento A, Kuno T, Alvarez P, Briasoulis A. Impact of new allocation system on length of stay following heart transplantation in the United States. Clin Transplant 2023; 37:e15114. [PMID: 37641567 DOI: 10.1111/ctr.15114] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/22/2023] [Accepted: 08/23/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND United Network for Organ Sharing (UNOS) allocation criteria changed in 2018 to accommodate the increased prevalence of ventricular assist device use as a bridge to heart transplant, which consequently prioritized sicker patients. We aimed to assess the impact of this new allocation policy on the length of stay following heart transplantation. Secondary outcomes include other risk factors for prolonged hospitalization and its effect on mortality and postoperative complications. METHODS The UNOS Registry was queried to identify patients who underwent isolated heart transplants in the United States between 2001 and 2023. Patients were divided into quartiles according to their respective length of stay. RESULTS A total of 57 020 patients were included, 15 357 of which were allocated with the new system. The median hospital length of stay was 15 days (mean 22.7 days). Length of stay was longer in the new allocation era (25 ± 30 vs. 22 ± 27 days, p < .001). The longer length of stay was associated with increased 5-year mortality in the new allocation system (aHR: 1.18; 95% CI: 1.15, 1.20; p-value: < .001). CONCLUSION Longer hospital stays and associated observed increased risk for mortality in the era after the allocation criteria change reflect the rationale of this shift which was to prioritize heart transplants for sicker patients. Further studies are needed to track the progress of surgical and perioperative management of these studies over time.
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Affiliation(s)
- Ilias P Doulamis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Marco Gemelli
- Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Athanasios Rempakos
- Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Aspasia Tzani
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas A Oh
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Polydoros Kampaktsis
- Division of Cardiology, Columbia University Irving Medical Center, New York City, New York, USA
| | - Alvise Guariento
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, New York, USA
| | - Paulino Alvarez
- Division of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Alexandros Briasoulis
- Medical School of Athens, National and Kapodistrian University of Athens, Athens, Greece
- Division of Cardiovascular Medicine, Section of Heart Failure and Transplantation, University of Iowa, Iowa City, Iowa, USA
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11
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Ambardekar AV, Hoffman JRH. Newton's laws of heart transplant allocation. J Heart Lung Transplant 2023; 42:206-208. [PMID: 36456407 DOI: 10.1016/j.healun.2022.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Amrut V Ambardekar
- Department of Medicine, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Jordan R H Hoffman
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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