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Alternate waiting list strategies for heart transplantation maximize donor organ utilization
Jonathan M Chen1, Mark J Russo, Kim M Hammond
1Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA. jmc23@columbia.edu
Insights
Alternate waiting lists for heart transplantation offer comparable survival to standard lists but show increased risks. This suggests current donor criteria may be too restrictive, potentially impacting patient access to life-saving procedures.
Area of Science:
- Cardiology
- Transplantation Medicine
- Surgical Outcomes
Background:
- Alternate waiting list (AL) strategies aim to expand access to heart transplantation.
- Evaluating the outcomes of AL candidates is crucial for optimizing organ allocation.
Purpose of the Study:
- To assess the safety and efficacy of heart transplantation in AL candidates.
- To compare post-transplant outcomes between AL and standard list (SL) recipients.
Main Methods:
- Retrospective analysis of adult heart transplant recipients from January 2001 to April 2004.
- Patients not meeting standard listing criteria were placed on an alternate list.
- Primary outcomes included short-term (30-day, 90-day) and long-term mortality, and perioperative morbidity.
Main Results:
- 37 patients (14.3%) were listed as AL candidates due to contraindications like advanced age or comorbidities.
- No significant difference in post-transplant survival was observed between AL and SL recipients.
- AL recipients experienced longer ventilatory support times (5.7 vs. 2.3 days) and higher rates of sternal wound infections (16.2% vs. 5.9%).
Conclusions:
- Heart transplantation in AL candidates yields comparable survival to SL candidates.
- AL recipients face increased risks of prolonged ventilation and sternal wound infections.
- Findings suggest current donor selection criteria may be overly stringent, potentially limiting organ availability.
Background:
Alternate waiting list strategies have been promoted as a means to offer the benefit of heart transplantation to a greater number of candidates. We undertook the current study to evaluate our experience with transplantation in alternate list (AL) candidates.
Methods:
Adults undergoing heart transplantation from January 1, 2001, through April 15, 2004, were evaluated. Selected patients who did not meet criteria for standard listing for heart transplantation were offered alternate listing. Primary posttransplant outcomes included 30-day, 90-day, and more than 90-day mortality, and determinants of perioperative morbidity.
Results:
Thirty-seven patients (14.3%) met alternate list criteria. Among these alternate list patients, contraindications to standard listing included age greater than 65 years, amyloidosis, severe diabetes mellitus and peripheral vascular disease, human immunodeficiency virus, and high-risk retransplant. The average age of alternate list donors was 41.2 +/- 13.9 years. Survival analysis revealed no posttransplant survival advantage for standard list recipients However, mean ventilatory support time was significantly (p < 0.001) longer in the alternate list group (5.7 +/- 9.3 days) compared with the standard group (2.3 +/- 4.2 days), and significantly more sternal wound infections (p = 0.03) were observed in the alternate list group (6 [16.2%]) compared with the standard group (13 [5.9%]).
Conclusions:
The alternate list patients demonstrated comparable survival with standard list patients, but did exhibit more ventilatory dependence and sternal wound infections. More than half of alternate list donor organs in the future could be considered for standard list candidates as well. Use of the alternate list reinforces the assertion that, even today, our donor criteria remain too stringent.
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