Changes in multiorgan heart transplants following the 2018 allocation policy change

BACKGROUND

This study evaluated the impact of the heart allocation policy change in 2018 on the characteristics and outcomes of multiorgan transplants involving heart allografts.

METHODS

Adults undergoing multiorgan heart transplantation from 2010 to 2020 were identified from the United Network for Organ Sharing (UNOS) registry. Transplants were stratified into occurring before versus after the October 2018 heart allocation change. The primary outcome was 1-year survival following transplantation. A Cox proportional hazards model was used to evaluate the risk-adjusted effect of the allocation policy change on outcomes between cohorts.

RESULTS

A total of 1832 patients underwent multiorgan heart transplantation during the study period with 245 (13.37%) undergoing heart-lung transplantation, 244 (13.32%) undergoing heart-liver transplantation, and 1343 (73.31%) undergoing heart-kidney transplantation. There was a higher utilization of temporary MCSDs as well as longer ischemic times for all three types of transplantation following the policy change. Heart-lung and heart-liver recipients had a similar 1-year survival before and after the policy change (each p > .05). Renal failure requiring dialysis (29.5% vs. 39.4%, p = .001) as well as 1-year survival (88% vs. 82%; log-rank p = .01) were worse in the heart-kidney cohort after the organ allocation system modification.

CONCLUSIONS

This study demonstrates similar trends in multiorgan transplants as has been observed in isolated heart transplants following the allocation change, including more frequent utilization of temporary mechanical support and longer ischemic times. Although outcomes have remained comparable in the new allocation era with heart-lung and heart-liver transplants, heart-kidney recipients have a worse 1-year survival following the change.

Very Early Discharge After Coronary Artery Bypass Grafting Does Not Affect Readmission or Survival

BACKGROUND

This study evaluated the impact of very early hospital discharge after coronary artery bypass grafting (CABG) on subsequent readmission and survival.

METHODS

Adults undergoing isolated CABG from 2011 to 2018 at a single institution were included. Patients were stratified on the basis of their postoperative length of hospital stay: short stay (≤4 days) and nonshort stay (>4 days). The primary outcomes were longitudinal survival and freedom from hospital readmission. Secondary outcomes included rates of postoperative complications. Propensity score matching with a 1:1 ratio was performed to generate cohorts with comparable baseline characteristics.

RESULTS

A total of 6327 patients underwent CABG during the study period, and a matched cohort of 2286 patients was identified. In matched analysis, the average Society of Thoracic Surgeons predicted risk of operative mortality was low in both groups (average, 0.7%). Rates of postoperative complications were low and several complication rates were even lower in the short-stay cohort: stroke (1.14% vs 0.26%; P = .01), renal failure (0.87% vs 0.09%; P = .007), reoperations (1.84% vs 0.26%; P < .001), and new-onset atrial fibrillation (34.21% vs 13.04%; P < .001). Survival was similar between the matched groups at 30 days (99.56% vs 99.21%), 1 year (97.73% vs 97.46%), and 5 years (91.15% vs 92.48%) (all P > .05). Readmission rates were also comparable at all time intervals, and there were no differences in cardiac-related or heart failure-specific readmissions (all P > .05). Risk-adjusted analyses confirmed these findings.

CONCLUSIONS

This study demonstrates that very early discharge within 4 days of isolated CABG is safe and has no substantial impact on subsequent mortality or readmission risk.