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Optimization of the Cuff Technique for Murine Heart Transplantation
Published on: June 26, 2020
Pretransplant survival of patients with end-stage heart failure under competing risks
Kevin B Smith1, Tseeye Odugba Potters2, Gabriel Lopez Zenarosa1
1Systems Engineering and Engineering Management, University of North Carolina at Charlotte, Charlotte, North Carolina, United States of America.
Insights
The current heart transplant allocation policy may create disparities. Lower priority patients have reduced survival rates, indicating a need to consider clinical characteristics for better prioritization.
Area of Science:
- Cardiology
- Transplant Surgery
- Health Policy
Background:
- Heart transplantation is the standard treatment for end-stage heart failure.
- Donor hearts are scarce, and the current allocation policy (implemented 2018) has not resolved disparities.
- The number of heart transplant candidates increased significantly, while transplant rates decreased.
Purpose of the Study:
- To analyze survival rates of heart transplant candidates considering competing risks of transplantation and mechanical circulatory assist device (MCSD) implantation.
- To evaluate the effectiveness of the current heart transplant allocation policy in addressing patient disparities.
- To determine if clinical characteristics should be prioritized in allocation decisions.
Main Methods:
- Survival analyses were performed on adult patients (age ≥ 16) listed for heart transplantation between 2005 and 2014 without prior MCSD.
- Cause-specific and subdistribution hazards models were used for multivariate regression analyses of competing events.
- A cohort of 23,373 patients was analyzed.
Main Results:
- Patients listed as low priority were less likely to require MCSD implantation but had lower survival rates after 1,000 days compared to higher priority patients.
- Pretransplant mortality rates declined, particularly for patients with MCSDs.
- The current policy, focusing on MCSD stratification, does not adequately address disparities.
Conclusions:
- The existing heart transplant allocation policy may lead to survival disparities based on priority status.
- Clinical characteristics, not just MCSD type, should be considered in patient prioritization for heart transplantation.
- Revisions to the allocation policy are needed to ensure equitable outcomes for all heart failure patients awaiting transplant.
Abstract:
Heart transplantation is the gold standard of care for end-stage heart failure in the United States. Donor hearts are a scarce resource, however the current allocation policy-proposed in 2016 and implemented in 2018-has not addressed certain disparities. Between 2005 and 2016, the number of active candidates increased 127%, whereas transplant rates decreased 27.8%. Pretransplant mortality rates declined steadily for that period from 14.6 to 9.7, especially for candidates with mechanical circulatory assistive devices (MCSDs). This study reports survival analyses of candidates for heart transplantation list under competing events of transplantation and MCSD implantation. We queried the transplant data for a cohort of adult patients (age ≥ 16) without MCSDs prior to listing for transplantation between 2005 and 2014 (n = 23,373). We used cause-specific and subdistribution hazards models as multivariate regressions for all competing events. Patients listed as low priority for transplantation are less likely to require implantation but less likely to survive after 1,000 days of listing than patients listed at higher priorities. The current policy does not address this disparity as it focuses on stratifying patients with different types of MCSD. Clinical characteristics must be considered in prioritization.
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