Related Experiment Video
Updated: Aug 1, 2025
Author Spotlight: Enhancing Graft Viability Assessment Through Quantitative Metrics and Innovative Reservoir Systems
Published on: August 2, 2024
Textbook outcomes in heart transplantation: A quality metric for the modern era
Syed Shahyan Bakhtiyar1, Sara Sakowitz2, Konmal Ali2
1Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO.
Insights
Textbook outcomes, a comprehensive measure for heart transplantation, identify patients with superior long-term survival and graft function. This metric offers a better way to compare transplant center performance than traditional survival rates.
Area of Science:
- Cardiology
- Transplantation Medicine
- Outcomes Research
Background:
- Traditional metrics like one-year survival are insufficient for assessing complex solid organ transplantation outcomes.
- The textbook outcome offers a more comprehensive evaluation but is not well-defined for heart transplantation.
Purpose of the Study:
- To define and evaluate the textbook outcome in heart transplantation.
- To assess the association between textbook outcome and long-term patient and graft survival.
- To compare the variability of textbook outcome rates across transplant centers.
Main Methods:
- Utilized the Organ Procurement and Transplantation Network database (2011-2022) for 26,885 heart transplant recipients.
- Defined textbook outcome by criteria including absence of major complications, short length of stay, no rejection/PGF, no readmission/re-transplant within one year, and high ejection fraction at one year.
- Employed statistical modeling to analyze mortality, graft survival, and inter-hospital outcome variations.
Main Results:
- 37% of heart transplant recipients achieved a textbook outcome.
- Textbook outcome was significantly associated with reduced mortality (HR 0.71 at 5 years, 0.73 at 10 years) and improved graft survival (HR 0.69 at 5 years, 0.72 at 10 years).
- Hospital-specific textbook outcome rates varied widely (39%-91%), with 9% of variation attributable to inter-hospital differences, contrasting with narrow one-year survival rates (97%-99%).
Conclusions:
- Textbook outcomes provide a more nuanced and composite assessment of heart transplantation results.
- This metric is a valuable alternative to one-year survival for evaluating transplant program performance.
- The significant variation in textbook outcomes highlights opportunities for quality improvement across transplant centers.
Background:
Traditional quality metrics like one-year survival do not fully encapsulate the multifaceted nature of solid organ transplantation in contemporary practice. Therefore, investigators have proposed using a more comprehensive measure, the textbook outcome. However, the textbook outcome remains ill-defined in the setting of heart transplantation.
Methods:
Within the Organ Procurement and Transplantation Network database, the textbook outcome was defined as having: (1) No postoperative stroke, pacemaker insertion, or dialysis, (2) no extracorporeal membrane oxygenation requirement within 72 hours of transplantation, (3) index length of stay <21 days, (4) no acute rejection or primary graft dysfunction, (5) no readmission for rejection or infection, or re-transplantation within one year, and (6) an ejection fraction >50% at one year.
Results:
Of 26,885 heart transplantation recipients between 2011 to 2022, 9,841 (37%) achieved a textbook outcome. Following adjustment, textbook outcome patients demonstrated significantly reduced hazard of mortality at 5- (hazard ratio 0.71, 95% CI 0.65-0.78; P < .001) and 10-years (hazard ratio 0.73, CI 0.68-0.79; P < .001), and significantly greater likelihood of graft survival at 5- (hazard ratio 0.69, CI 0.63-0.75; P < .001) and 10-years (hazard ratio 0.72, CI 0.67-0.77; P < .001). Following estimation of random effects, hospital-specific, risk-adjusted rates of textbook outcome ranged from 39% to 91%, compared to a range of 97% to 99% for one-year patient survival. Multi-level modeling of post-transplantation rates of textbook outcomes revealed that 9% of the variation between transplant programs was attributable to inter-hospital differences.
Conclusion:
Textbook outcomes offer a nuanced, composite alternative to using one-year survival when evaluating heart transplantation outcomes and comparing transplant program performance.
