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Published on: July 18, 2014
University of Arizona, Cardiac Transplantation: changing patterns in selection and outcomes
1Department of Surgery, Section of Cardiovascular and Thoracic Surgery, University of Arizona Health Sciences Center, Tucson, Arizona, USA.
Insights
Bridge-to-transplant device patients now represent 50% of heart transplants, but have 10-15% lower survival rates. This suggests current UNOS status may not accurately identify high-risk transplant candidates.
Area of Science:
- Cardiology
- Transplantation Medicine
- Medical Devices
Background:
- The use of mechanical circulatory support devices as a bridge-to-transplant has significantly increased.
- Heart transplant recipients requiring pre-transplant mechanical support often face unique perioperative challenges.
Purpose of the Study:
- To evaluate the impact of pre-transplant mechanical support devices on heart transplant outcomes.
- To assess the adequacy of the current United Network for Organ Sharing (UNOS) status system in stratifying risk for these patients.
Main Methods:
- Retrospective analysis of 391 heart transplant recipients at the University of Arizona since 1990.
- Comparison of post-transplant survival rates between patients with and without pre-transplant devices.
- Evaluation of the UNOS status system's predictive accuracy for device patients.
Main Results:
- The proportion of bridge-to-transplant device patients increased from 6.7% to 50% since 1990.
- Patients bridged with devices had a 10-15% lower survival rate post-transplant compared to non-device patients.
- The current UNOS status system did not adequately identify the higher risk associated with device use.
Conclusions:
- Pre-transplant mechanical support devices identify a distinct high-risk group of heart transplant candidates.
- The UNOS status system may require revision to better stratify risk for device patients.
- Some high-risk device patients might be better served by mechanical support as a destination therapy rather than transplantation.
Abstract:
Among 391 patients who received heart transplants at the University of Arizona since 1990, the percentage of bridge-to-transplant device patients receiving donor hearts has increased from 6.7% to 50%. Survival after transplantation in this-bridge-to transplant group and has been consistently 10-15% lower than patients who do not require a device. The result has been that our overall survival rate is beginning to fall. We have come to 2 major conclusions based on these results: First, the current UNOS system ranking candidates as Status 1A, 1B, and 2 may not identify those who are at higher risk for transplantation. It has failed to do so in our program. Rather, by grouping the potential recipients into patients with a device, Status 1 nondevice patients, and Status 2 patients, we have found a significantly lower survival rate after transplantation in the device group. This suggests that the problems shared by device patients such as being anticoagulated, having a difficult reoperation at the time of transplantation, and having increased inflammation and decreased immunity clearly place these patients in a very different risk group than other potential recipients. Second, these results lead us to believe that some high-risk device patients may not be suitable for transplantation and might be better if treated with devices as alternatives to transplantation.
