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Impact of "increased-risk" donor hearts on transplant outcomes: A propensity-matched analysis
Yasuhiro Shudo1, Jeffrey E Cohen1, Bharathi Lingala1
1Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif.
Insights
Increased risk (IR) donor hearts, categorized by the Centers for Disease Control and Prevention (CDC), do not significantly impact adult heart transplant survival. Utilizing these grafts may help alleviate donor organ shortages and reduce waitlist times.
Area of Science:
- Cardiology
- Transplantation Medicine
- Public Health
Background:
- Orthotopic heart transplantation (OHT) is the standard treatment for advanced heart failure.
- Increased risk (IR) donor criteria are defined by the Centers for Disease Control and Prevention (CDC).
- The impact of CDC IR donor hearts on adult OHT outcomes is not well-established.
Purpose of the Study:
- To compare the outcomes of adult OHT recipients using CDC IR versus non-IR donor grafts.
- To evaluate the effect of CDC IR donor hearts on post-transplant survival and complications.
Main Methods:
- Utilized data from the United Network for Organ Sharing Database (2004-2016).
- Included 24,751 adult OHT recipients; propensity score matching was used for 6,304 transplants (3,152 in CDC IR and non-IR groups).
- Cox-proportional hazards models and survival analyses assessed 30-day and overall mortality, and post-transplant events.
Main Results:
- No significant difference in 30-day or overall mortality between CDC IR and non-IR donor groups (HR 0.97 and 0.94, respectively).
- Higher incidence of post-transplant acute myocardial rejection in the CDC IR group (11.4% vs 9.6%, P=.03).
- Fewer pacemaker placements in the CDC IR group (2.6% vs 3.5%, P=.020); no significant difference in overall survival.
Conclusions:
- CDC IR donor status does not significantly affect adult OHT recipient survival.
- Increased utilization of CDC IR donor grafts can help mitigate donor organ shortages and shorten transplant waitlist times.
Objectives:
Orthotopic heart transplantation (OHT) remains the gold standard for advanced heart failure. Increased risk (IR) donors were categorized by the United Network for Organ Sharing Database (UNOS) according to the Centers for Disease Control and Prevention (CDC) criteria. However, the impact of CDC IR donor hearts on the outcome of adult OHT recipients remains unclear. The aim of this study was to compare the outcome of adult OHT recipients between CDC IR and non-CDC IR donor grafts.
Methods:
Data were obtained from the United Network for Organ Sharing Databas. All adult patients (age ≥18 years) undergoing OHT from 2004 through 2016 were included (n = 24,751). Propensity scores for CDC IR donors were calculated by estimating probabilities of CDC IR donor graft use using a nonparsimonious multivariable logistic regression model. Patients were matched 1:1 using a greedy matching algorithm based on the propensity score of each patient. The impact of CDC IR donors on the post-transplant outcomes, such as 30-day and overall mortalities, was investigated using Cox-proportional hazards. Overall survival probability analyses were performed.
Results:
Of 24,751 primary heart transplants from 2004 to 2016 with 3584 (14.5%) as IR donors, 6304 transplants were successfully matched (n = 3152 in CDC IR group and non-IR group). There were no significant differences in baseline characteristics in recipients and donors. In the Cox-proportional hazards model for matched subjects, the use of CDC IR grafts was not associated with 30-day (hazard ratio of IR group vs non-IR group 0.97; 95% confidence interval, 0.87-1.08; P = .57) and overall mortalities (hazard ratio, 0.94; 95% confidence interval, 0.73-1.21; P = .62). Interestingly, post-transplant acute myocardial rejection episodes during hospital stays were found more often in the CDC-IR group, compared with the non-CDC IR group (CDC IR, n = 358 [11.4%]; non-CDC IR, n = 304 [9.6%] P = .03), whereas post-transplant pacemaker placements were performed less frequently in the CDC IR group (CDC IR, n = 80 [2.6%]; non-CDC IR, n = 111 [3.5%] P = .020). Importantly, there was no significant difference in the overall survival probability between CDC IR and non-IR groups in both unadjusted and adjusted survival analyses.
Conclusions:
CDC IR status does not have a significant impact on adult OHT recipient survival probability. Increased use of CDC IR donor grafts can potentially alleviate the persistent and worsening shortage of available donor organs and shorten the waitlist time for heart transplantation.