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Association of Hemodynamic Variables with the Risk of Heart transplant Waitlist Death and Deterioration
Aaron M Wolfson1, Joel Ferrall2, Vincent Lam2
1Division of Cardiovascular Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California.
Insights
The 2018 heart transplant policy uses basic measures, but advanced hemodynamics like cardiac power output may better predict waitlist outcomes. Improved risk stratification is needed for heart allocation.
Area of Science:
- Cardiology
- Transplantation Medicine
- Medical Policy
Background:
- The 2018 United Network for Organ Sharing (UNOS) heart allocation policy uses specific hemodynamic cutoffs.
- While generally improving waitlist outcomes, concerns exist regarding post-transplant survival and increased exception requests.
Purpose of the Study:
- To evaluate the association between a broader range of hemodynamic variables and waitlist outcomes.
- To identify potential improvements for heart transplant candidate risk stratification and future allocation policies.
Main Methods:
- Analysis of 2393 adult heart transplant candidates (status 1-3) not on mechanical support.
- Utilized cause-specific Cox models with restricted cubic splines to assess hemodynamic variable associations with waitlist death or deterioration.
Main Results:
- Cardiac power output and pulmonary artery pulsatility index showed nonlinear associations with waitlist outcomes.
- Central venous pressure, mean pulmonary artery pressure, effective arterial elastance, and left ventricular stroke work index had linear associations.
- Systolic blood pressure and pulmonary capillary wedge pressure trended toward linear associations; cardiac index was not associated with risk.
Conclusions:
- Current hemodynamic cutoffs in heart allocation may not fully capture patient risk.
- Advanced hemodynamic variables offer potential for refining risk stratification in heart transplant candidates.
- Future allocation policies could benefit from incorporating a more comprehensive hemodynamic assessment.
Abstract:
The 2018 United Network for Organ Sharing heart allocation policy relies on discrete hemodynamic cutoffs for status stratification, evaluating systolic blood pressure, pulmonary capillary wedge pressure, and cardiac index. Although the policy change has generally resulted in improved overall waitlist outcomes, worsening post-transplant survival in certain groups and increased exception requests raise concern regarding its efficacy. We analyzed 2393 adult status 1-3 patients not on mechanical circulatory support at the time of hemodynamic assessment. We used cause-specific Cox models with restricted cubic splines to evaluate the association between an expanded panel of hemodynamic variables and waitlist death or deterioration. Cardiac power output of the left ventricle and the pulmonary artery pulsatility index displayed nonlinear associations with waitlist death or deterioration. In contrast, central venous pressure, mean pulmonary artery pressure, effective arterial elastance of the pulmonary artery, and left ventricular stroke work index showed linear associations with waitlist death or deterioration, whereas systolic blood pressure and pulmonary capillary wedge pressure trended toward linear associations. Cardiac index was not associated with the risk of waitlist death or deterioration. Our findings highlight possible areas for improvement in the risk stratification of heart transplant candidates and the use of advanced hemodynamic variables in future allocation policy iterations.
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