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Prolonged Ischemia Times for Heart Transplantation: Impact of the 2018 Allocation Change
Jennie H Kwon1, Lauren V Huckaby2, Brandon Sloan1
1Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina.
Insights
Prolonged organ ischemia time after heart transplant increases 1-year mortality risk. This risk persists despite policy changes and technological advances, emphasizing its importance in donor-recipient matching for heart transplantation.
Area of Science:
- Cardiology
- Transplantation Medicine
- Public Health Policy
Background:
- Organ ischemia time is a critical factor in heart transplant outcomes.
- Recent policy changes by the United Network for Organ Sharing (UNOS) in 2006 and 2018 may have impacted ischemia times.
Purpose of the Study:
- To evaluate the impact of organ ischemia time on 1-year mortality following heart transplantation.
- To assess this impact in the context of evolving UNOS allocation policies.
Main Methods:
- Analysis of adult heart transplant recipients from the UNOS registry (2000-2020).
- Stratification by UNOS allocation policy eras and ischemia time (normal ≤4 hours vs. prolonged >4 hours).
- Kaplan-Meier survival analysis and Cox regression for risk-adjusted mortality.
Main Results:
- Over 40,000 heart transplants were analyzed; 18.64% experienced prolonged ischemia times.
- The frequency of prolonged ischemia times increased across policy eras, notably after the 2018 policy change.
- Prolonged ischemia time was independently associated with increased 1-year mortality (HR 1.20/hour in the current era, P=.004).
Conclusions:
- Despite advancements, prolonged organ ischemia time remains a significant independent risk factor for 1-year mortality after heart transplantation.
- The increasing frequency of prolonged ischemia times warrants continued attention in donor-recipient matching protocols.
Background:
In 2018, the United Network for Organ Sharing implemented a change in heart allocation policy resulting in increased organ ischemia times in early analyses. This study evaluated the effect of ischemia time on 1-year mortality in the context of allocation policy changes implemented in 2006 and 2018.
Methods:
The United Network for Organ Sharing registry was used to identify adults undergoing heart transplantation from 2000 to 2020. Patients were stratified by the allocation policy era in which they received a transplant (2000-June 2006, July 2006-October 2018, October 2018-2020) and by ischemia time, defined as normal (≤4 hours) and prolonged (>4 hours). One-year survival was estimated using Kaplan-Meier analysis. Cox regression was used to determine risk-adjusted hazards for ischemia time on 1-year mortality.
Results:
There were 40 052 patients included for analysis. Ischemia times were normal in 32 585 (81.36%) and prolonged in 7467 (18.64%) patients. The proportion of transplantations with prolonged ischemia times increased with each subsequent policy era. After the 2018 policy change, 1-year survival was 90.92% with normal ischemia times vs 87.52% with prolonged ischemia times (P < .001). Ischemia time independently predicted 1-year mortality in each era with a hazard ratio of 1.20 per hour (P = .004) in the current era.
Conclusions:
Prolonged ischemia times occur in a minority of cases but are increasing in frequency. The independent risk of prolonged ischemia time on 1-year mortality persists despite advances in storage technology and should remain a consideration in donor-recipient matching.
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