Strategic Changes and Heart Transplant Volume

Sep 21, 2020
Font Size
A
A
A
Authors:
Mori M, Wilson L, Ali A, et al.
Citation:
Evaluation of Case Volumes of a Heart Transplant Program and Short-term Outcomes After Changes in the United Network for Organ Sharing Donor Heart Allocation System. JAMA Netw Open 2020;3:e2017513.
Summary By:
Monica M. Colvin, MD

Quick Takes

  • A strategic and multi-faceted approach to organ acceptance and candidate management improved transplant center volumes without compromising outcomes.
  • Increased use of temporary devices and less use of LVAD prior to transplant occurred after change in surgical direction.
  • Increased ICU length of stay may be a negative consequence of the more aggressive strategy.

Study Questions:

How do strategic changes in recipient and donor selection impact center-level heart transplant outcomes?

Methods:

A retrospective analysis was performed to compare characteristics and outcomes of patients who underwent heart transplant before (n = 49) and after (n = 58) restructuring of an advanced heart failure program in September 2018, which also coincided with the United Network for Organ Sharing (UNOS) heart allocation policy change. Key changes in the program included change in surgical directorship, patient-centered approach to donor heart selection, support for a dedicated procurement surgeon, and increased surgical attending involvement at transplant meetings.

Results:

Following infrastructural changes, the transplant center volume increased from an average of 12.25 over the prior 4 years to 58 during the year following the change. The organ acceptance rate increased from 6.4% to 20.5% (p < 0.001), mean donor age increased from 30 years to 40 years (p < 0.001), and left ventricular assist device (LVAD) use prior to transplant decreased from 63.3% to 20.7% (p < 0.001), while use of extracorporeal membrane oxygen and intra-aortic balloon pump increased significantly from 0 to 6.9% and 17.2%, respectively. Time on the wait list decreased from a median of 242 days to 41 days (p < 0.001) and intensive care unit (ICU) length of stay increased from 7 to 10 days (p < 0.001) following the change. There was no difference between the pre- and post-change eras in waitlist mortality or transplant recipient survival at 180 days, 87.8% and 89.7%, respectively.

Conclusions:

Strategic changes in donor heart selection and recipient selection and management may increase transplant volume without negatively impacting short-term outcomes.

Perspective:

Strategically aggressive organ acceptance practices may increase organ utilization, decrease wait times, and increase transplant volume; however, the long-term impact on outcomes is unclear.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support

Keywords: Cardiac Surgical Procedures, Extracorporeal Membrane Oxygenation, Graft Survival, Heart Failure, Heart Transplantation, Heart-Assist Devices, Intensive Care Units, Intra-Aortic Balloon Pumping, Length of Stay, Patient-Centered Care, Tissue Donors, Transplantation


< Back to Listings