Reassessing Recipient Mortality Under the New Heart Allocation System

Jawitz, Oliver K.; Fudim, Marat; Raman, Vignesh; Bryner, Benjamin S.; DeVore, Adam D.; Mentz, Robert J.; Milano, Carmelo A.; Patel, Chetan B.; Schroder, Jacob N.; Rogers, Joseph G.

doi:10.1016/j.jchf.2020.03.010

Cited by 87 publications

(110 citation statements)

References 16 publications

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“…The comparison of donor characteristics were similar between the two cohorts, with the exception that in the old system the most likely cause of death was head trauma, while in the new system the most likely cause was anoxia. 88 Unadjusted Kaplan-Meier survival analysis performed by the authors established a minimal decrease in 90 and 180-day survival with 93.0% and 90.6%, respectively, under the new allocation system as compared with 94.4% and 93.3% under the old system. 88 However, after adjusted analysis was performed to determine independent association between the new allocation system and survival, there was no significant decrease in survival between the old and new systems.…”

Section: Update On the New Heart Allocation Systemmentioning

confidence: 95%

“…88 Unadjusted Kaplan-Meier survival analysis performed by the authors established a minimal decrease in 90 and 180-day survival with 93.0% and 90.6%, respectively, under the new allocation system as compared with 94.4% and 93.3% under the old system. 88 However, after adjusted analysis was performed to determine independent association between the new allocation system and survival, there was no significant decrease in survival between the old and new systems. Independently identified factors associated with decrease in survival included increasing donor and recipient age, pre-transplant extracorporeal membrane oxygenation utilization, previous cardiac surgery, and prolonged graft ischemic time.…”

Section: Update On the New Heart Allocation Systemmentioning

confidence: 95%

“…87 Jawitz and colleagues sought to build on these preliminary data and determine survival under the new system. 88 Performing a registry update allowed the authors to include a total of 7,119 recipients, with a split of 6,004 under the old system as compared to 1,115 under the new allocation system. 88 Recipients transplanted under the new system were more likely to be bridged to transplant with temporary MCS devices, have shorter waitlist times, and longer graft ischemic times.…”

Section: Update On the New Heart Allocation Systemmentioning

confidence: 99%

“…88 Performing a registry update allowed the authors to include a total of 7,119 recipients, with a split of 6,004 under the old system as compared to 1,115 under the new allocation system. 88 Recipients transplanted under the new system were more likely to be bridged to transplant with temporary MCS devices, have shorter waitlist times, and longer graft ischemic times. They were less likely to have durable left ventricular assist devices, diabetes, and ischemic cardiomyopathy.…”

Section: Update On the New Heart Allocation Systemmentioning

confidence: 99%

“…Independently identified factors associated with decrease in survival included increasing donor and recipient age, pre-transplant extracorporeal membrane oxygenation utilization, previous cardiac surgery, and prolonged graft ischemic time. 88…”

Section: Update On the New Heart Allocation Systemmentioning

confidence: 99%

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The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2020

Martin

Weiner

Feinman

et al. 2021

Journal of Cardiothoracic and Vascular Anesthesia

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This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Section: Update On the New Heart Allocation Systemmentioning

confidence: 95%

Section: Update On the New Heart Allocation Systemmentioning

confidence: 95%

Section: Update On the New Heart Allocation Systemmentioning

confidence: 99%

Section: Update On the New Heart Allocation Systemmentioning

confidence: 99%

Section: Update On the New Heart Allocation Systemmentioning

confidence: 99%

See 3 more Smart Citations

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2020

Martin

Weiner

Feinman

et al. 2021

Journal of Cardiothoracic and Vascular Anesthesia

View full text Add to dashboard Cite

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Organ Acceptance and Outcomes—A Surgeon’s Perspective—Reply

2021

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To the Editor We read with great interest the analysis of US National Transplant Registry data by Choi et al. 1 This sophisticated analysis showed higher facility-level organ offer acceptance rates were associated with lower waitlist mortality, which is not surprising since the logical result of a high acceptance rate is fewer people waiting on the waitlist. Additionally, posttransplant mortality was equivalent among firstrank vs lower-rank offers, indicating, they concluded, that outcomes would be the same regardless of who accepted the organ. The findings are timely considering current revisions in United Network for Organ Sharing allocation and provide an avenue for further efforts to reduce waitlist mortality and improve overall transplant outcomes.Nonetheless, there are issues that ought to be further explored as we interpret these findings. First, higher surgical volumes generally result in better outcomes. 2 Importantly, hospital structural factors may influence this observed association more than simply individual surgeon volume. Logically, transplant programs with high organ acceptance rates would have more organs to transplant and therefore higher volumes compared with programs with similar number of offers but a lower acceptance rate. How does the volume-outcomes relationship contribute to the findings by Choi et al 1 ; are lower acceptance rates perhaps a consequence of those same structural factors that foster the volume-outcome relationship (fewer available surgeons; limited availability of resources, such as dedicated beds and procuring teams; or risk-averse multidisciplinary teams)?Second, since this retrospective analysis shows association but not necessarily causation, it is possible that centers with higher recent transplant mortality rates have become more selective to improve their publicly reported transplant outcomes. They may reject organs looking for the perfect donor to theoretically increase the odds of a better outcome in the immediate future.Third, did the authors consider immortal time bias, accounting for time alive on the waitlist? Without a timedependent analysis to account for this bias, Choi et al 1 may have falsely overestimated the survival penalty of the varying acceptance rates. For instance, centers with lower offers could have sicker patients who ultimately do not undergo a transplant. Finally, considering new allocation systems as organs are offered from distant centers with higher travel time and changing recipient characteristics, a follow-up study to evaluate organ offer and acceptance would be timely.Again, a well-done, important study that may result in policy and structural changes for organ offer evaluation, reimbursement for transplant centers, or potentially universal guidelines for organ acceptability in the current era of public scrutiny.

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