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A Pre-Clinical Porcine Model of Orthotopic Heart Transplantation
Published on: April 27, 2019
Reevaluating Heart Transplant Compatibility: A Retrospective Analysis Using Echocardiographic Left Ventricular Mass
Anthony Altobelli1, Laura Parker1, Deepa Iyer1
1Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA.
Insights
The choice of metric and threshold significantly impacts donor heart acceptance in transplantation. Different methods show operational discordance, particularly by donor sex, highlighting the need for outcome-based validation.
Area of Science:
- Cardiology
- Transplantation Surgery
- Medical Informatics
Background:
- Accurate donor-recipient size matching is critical for adult heart transplantation success.
- The optimal metric for assessing donor heart size acceptability remains debated.
- Current metrics may not fully capture the nuances of size matching.
Purpose of the Study:
- To compare the predicted heart mass ratio (PHMr) with the measured donor left ventricular mass to predicted recipient left ventricular mass (mLVM:pLVM) ratio.
- To evaluate how these metrics classify donor heart size acceptability.
- To identify potential disparities in classification based on donor characteristics.
Main Methods:
- Retrospective analysis of 594 adult donor offers evaluated at a single center.
- Classification of offers using bilateral windows and lower-bound-only thresholds for PHMr and mLVM:pLVM.
- Statistical analysis using recipient-clustered models, generalized estimating equations, and linear mixed models.
Main Results:
- PHMr classified more offers as acceptable than mLVM:pLVM under bilateral windows (46.3% vs. 40.1%), though not always significantly.
- Low agreement (Cohen's κ 0.12–0.24) was observed between the two metrics.
- Classification differences varied significantly by donor sex, with PHMr favoring male donors and mLVM:pLVM favoring female donors.
Conclusions:
- The selection of metric and threshold influences donor heart offer classification.
- Observed differences indicate operational discordance rather than inherent clinical superiority.
- Further validation of these metrics against transplant outcomes is warranted.
Abstract:
Background/Objectives: Accurate size-matching between donor and recipient is central to adult heart transplantation, yet the optimal operational metric remains unsettled. We compared the predicted heart mass ratio (PHMr) with a ratio pairing measured donor left ventricular mass and predicted recipient left ventricular mass (mLVM:pLVM) to determine how each classifies the size acceptability of donor offers. Methods: In a retrospective single-center cohort of 594 adult donor offers evaluated for 22 recipients during 2023, offers were classified as acceptable under bilateral windows (PHMr 0.86 to 1.14, mLVM:pLVM 0.80 to 1.20) and under lower-bound-only thresholds. Recipient-clustered models with cluster-robust standard errors were the primary analysis, with a generalized estimating equation and a linear mixed model as sensitivity analyses. Prespecified subgroups were defined by sex and body mass index. Results: Under bilateral windows, PHMr classified more offers as acceptable than mLVM:pLVM (46.3% versus 40.1%), but the overall difference was not significant in the primary analysis (cluster-robust risk difference 6.2 percentage points, 95% CI -0.5 to 13.0, p = 0.068) and reached significance only in sensitivity analyses. Agreement was low (Cohen's κ 0.12 to 0.24). The between-method difference varied by donor sex, confirmed by interaction testing: PHMr classified more male donor offers as acceptable, whereas mLVM:pLVM classified more female donor offers as acceptable. Under lower-bound-only thresholds, significant differences were confined to donor sex. Conclusions: Metric and threshold choice changed which offers were classified as acceptable. These differences reflect operational discordance rather than clinical superiority and warrant validation linked to outcomes.
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