Background:
Limited donor availability and evolution in procurement techniques have renewed interest in heart transplantation (HT) with donation after circulatory death (DCD). The aim of this study is to evaluate outcomes of HT using DCD in the United States.
Methods:
The United Network for Organ Sharing registry was used to identify adult HT recipients from 2019 to 2021. Recipients were stratified between DCD and donation after brain death. Propensity-score matching was performed. Cox proportional hazards was used to identify independent predictors of 1-year mortality. Kaplan-Meier analysis was used to estimate 1-year survival.
Results:
Of 7496 HTs, 229 DCD and 7267 donation after brain death recipients were analyzed. The frequency of DCD HT increased from 0.2% of all HT in 2019 to 6.4% in 2021 (
P
<0.001), and the number of centers performing DCD HT increased from 3 of 120 centers to 20 of 121 centers (
P
<0.001). DCD donors were more likely to be younger, male, and White. After propensity matching, 1-year survival was 92.5% for DCD versus 90.3% for donation after brain death (hazard ratio, 0.80 [95% CI, 0.44–1.43];
P
=0.44). Among DCD HTs, increasing recipient age and waitlist time predicted 1-year mortality on univariable analysis.
Conclusions:
Rates of DCD HT in the United States are increasing. This practice appears safe and feasible as mortality outcomes are comparable to donation after brain death. Although this study represents early adopting centers, outcomes of the experience for DCD HT in the United States is consistent with existing international data and encourages broader utilization of this practice.
Background
Heart‐lung transplantation (HLTx) is relatively uncommon, and there is a paucity of literature to suggest an age at which older recipients may be exposed to excess risk for mortality. This analysis aimed to identify a threshold of age that predicts adverse outcomes after HLTx.
Methods
The United Network of Organ Sharing registry was used to identify adult patients undergoing HLTx from 2005 to 2021. The primary outcome was 1‐year mortality. Threshold regression was used to identify the threshold at which age impacts 1‐year mortality. Kaplan−Meier analysis was used to model survival, and Cox proportional hazards modeling was used for risk‐adjustment.
Results
We identified 453 patients undergoing HLTx. Threshold analysis identified that the risk for 1‐year mortality was significantly elevated beyond an age of 58 years, and 47 (10.38%) patients were older than this threshold. On Kaplan−Meier analysis, 1‐year survival was significantly lower in patients > 58 years compared to younger recipients (64.7% vs. 82.0%, p = .007). After risk adjustment, the hazard ratio for 1‐year mortality in recipients older than 58 years was 2.27 (95% confidence interval [1.21−4.28], p = .011).
Conclusion
A threshold for recipient age of 58 years of age may avoid excess 1‐year mortality after HLTx. However, patients older than this threshold demonstrate acceptable early and midterm survival, and the majority survive to 1 year. Advanced age should be considered in patient selection for HLTx, but may not be a contraindication for candidacy particularly in the absence of other risk factors.
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 competingrisks 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.
Background: Impella devices are increasingly utilized as a bridge to heart transplantation (BTT) and are now prioritized as Status 2 under the current heart allocation policy. This study evaluated waitlist and post-transplant outcomes of patients supported with Impella 5.0/5.5 devices.
Methods:The United Network of Organ Sharing registry was used to identify adults waitlisted or transplanted with Impella 5.0 or 5.5 devices from 2010 to 2021.Separate analyses were performed for waitlist and transplantation outcomes for patients supported by Impella 5.0/5.5 devices. Competing outcomes for the waitlist analysis included rates of transplantation, recovery, and death or clinical deterioration. Among patients undergoing transplantation, the primary outcome was 1-year survival. Secondary outcomes included rates of rejection, new postoperative dialysis, stroke, and pacemaker implantation after transplantation.Results: There were 344 patients waitlisted and 394 patients transplanted with an Impella 5.0 (n = 212 and 251) or 5.5 (n = 132 and 143) device. Competing risk regression demonstrated similar likelihood of transplant (subhazard ratio [SHR], 1.33 (0.98-1.81, p = 0.067)) and similar likelihood of death or clinical deterioration (SHR, 0.67 [0.27-1.69, p = 0.400]) for Impella 5.5 patients. In the transplanted cohort, unadjusted 1-year post-transplant survival was comparable at 91.3% versus 94.6% (log-rank p = 0.661) for patients supported by Impella 5.0 or 5.5 device, respectively, a finding that persisted after risk-adjustment (HR 1.22, p = 0.699). Post-transplant complication rates were also comparable between 5.0 and 5.5 patients.Conclusions: Impella devices can be used as a BTT with excellent survival and minimal post-transplant morbidity. Outcomes were comparable for Impella 5.0 and 5.5 devices.
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