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Attenuation of waiting time mortality with heterotopic heart transplantation
M E Sekela1, F W Smart, G P Noon
1Department of Surgery, Baylor College of Medicine, Methodist Hospital, Houston, Texas.
Insights
Heart transplant waiting times increased, especially for larger patients. Heterotopic transplants reduced wait times and mortality for large recipients without increasing risks.
Area of Science:
- Cardiology
- Transplant Surgery
- Medical Statistics
Background:
- Increasing heart transplant volume and programs have led to longer organ wait times.
- Recipient size is a critical factor influencing organ wait duration.
Purpose of the Study:
- To analyze heart transplant waiting times based on recipient size and transplantation era.
- To evaluate the impact of heterotopic versus orthotopic transplantation on wait times and outcomes.
Main Methods:
- Retrospective review of heart transplant recipient data.
- Analysis of waiting times stratified by recipient body surface area (large vs. small) and transplantation era (early, late, heterotopic).
Main Results:
- Waiting times significantly increased from the early era (35 days) to the late era (83 days).
- Large recipients experienced longer waits (130 days) in the late era compared to small recipients (60 days).
- Heterotopic transplantation in the late era significantly reduced wait times for large patients (67 days) versus orthotopic (166 days), with no change for small patients. Waiting time mortality decreased from 24% to 9%.
Conclusions:
- Heterotopic heart transplantation may expand the donor pool for large recipients.
- This approach can decrease waiting times and reduce mortality for high-risk patients.
- Heterotopic procedures do not appear to increase morbidity compared to orthotopic transplants.
Abstract:
As the number of heart transplants and the number of transplant programs has increased, so has the waiting time for a suitable organ. To more accurately assess the magnitude of this increase and the influence of recipient size, we reviewed waiting times for large (body surface area greater than or equal to 1.95 m2) and small (body surface area less than 1.95 m2) patients with respect to era of transplantation. Patients who underwent transplantation early (1984 to December 31, 1986) waited 35 +/- 47 days (mean +/- standard deviation), whereas patients who underwent transplantation in the late era (1987 to September 30, 1989) waited 83 +/- 102 days (p = 0.001). Large patients waited longer (130 +/- 142 days) in the late era than did small patients (60 +/- 67 days; p = 0.008). During the heterotopic era (October 1, 1989 to June 30, 1990), waiting times for large patients who received a heterotopic transplant (67 +/- 46 days) were significantly shorter than those for patients who received an orthotopic transplant (166 +/- 157 days; p = 0.05). Waiting times for small patients remained unchanged. In addition, waiting time mortality decreased from 24% to 9% (p less than 0.05). Comparison of orthotopic and heterotopic procedures performed during the same era revealed no significant differences in recipient age, preoperative status, graft ischemic time, donor age, early and midterm survival, or early postoperative functional status. Heterotopic heart transplantation may effectively increase the size of the donor pool, decrease the waiting time, and decrease waiting time mortality without increasing the morbidity of the procedure.