Original article
Adult cardiac
Matching High-Risk Recipients With Marginal Donor Hearts Is a Clinically Effective Strategy

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.
https://doi.org/10.1016/j.athoracsur.2008.12.020Get rights and content

Background

The purpose of this study is to determine the clinical outcomes associated with alternate listing transplantation, which utilizes “marginal” donor organs by transplanting them into high-risk recipients who fail to meet the standard criteria for transplantation.

Methods

The United Network for Organ Sharing provided de-identified patient-level data. Analysis focused on patients undergoing heart transplantation between January 1, 1999, and December 31, 2005 (n = 13,024). High-risk criteria included age more than 65 years old, retransplantation, hepatitis C-positive, human immunodeficiency virus-positive, creatinine clearance less than 30 mL/min, diabetes mellitus with peripheral vascular disease, and diabetes with creatinine clearance less than 40 mL/min. Marginal donor criteria included age more than 55 years, diabetes mellitus, hepatitis C-positive, human immunodeficiency virus-positive, ejection fraction less than 45%, and donor:recipient weight less than 0.7.

Results

Survival in the standard transplant group, defined as non–high-risk patients who received nonmarginal organs, was better than in all other groups (p ω 0.001). Alternate listing transplantation patients had the worst survival (p ω 0.001). The 5-year survival for the alternate listing transplantation group was 51.4%, compared with 75.1% in the standard transplant group; the standard transplant patients, with the lowest incidence of in-hospital infection (21.1%) and dialysis (7.1%), also had the best transplant hospitalization outcomes (p ω 0.001). In contrast, alternate listing transplantation patients had the highest incidence of in-hospital infection (35.4%; p ω 0.001). Length of stay during transplant hospitalization was also shortest in the standard transplant group (18.8 days; p ω 0.001).

Conclusions

Alternate listing transplantation is associated with greater morbidity and resource utilization compared with standard transplantation. However, this strategy offers a median survival of 5.2 years to patients who would otherwise be expected to live 1 year, and therefore, may be reasonably applied to expand the benefits of transplantation. Further studies examining the costs and quality of life related to this approach are needed.

Section snippets

Data Collection

This study has been approved by our university's Institutional Review Board (IRB-AAAB8495), and the use of these data is consistent with the UNOS data use agreement. The standard transplant analysis and research dataset was provided by UNOS (data source 021606-4) and is de-identified patient-level data. It contains information collected from the UNetsm forms, including the transplant candidate registration form, the transplant recipient registration form, and the transplant recipient follow-up

Study Population

Analysis included 13,024 (Table 1) recipients stratified by recipient and donor characteristics into four categories: STD (n = 9,642, 74.0%), SR:MD (n = 970, 7.5%), HR:SD (n = 2,065, 15.9%), and ALT (n = 347, 2.7%).

Survival

As expected, survival in the standard transplant group was better than in all other groups (p ω 0.001; Fig 1). Although 30-day survival was similar between all of the nonstandard groups (SR:MD, HR:SD, ALT), survival was worst in the ALT group by 1 year (p ω 0.001). Survival for the

Comment

The burden related to heart failure continues to grow. Unfortunately, treatment options remain limited. Medical management ameliorates symptoms and prolongs survival in mild to moderate heart failure, but it does not treat the underlying pathology; therefore, with medical therapy alone, disease remains progressive and typically leads to death [9, 10]. Left ventricular assist devices offer a promising alternative, but long-term survival remains limited and adverse events are substantial.

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