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Heart Transplant Candidates Perceptions of the Newly Implemented United Network for Organ Sharing Heart Allocation System: An Eye Opener
S270
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
Recipients transplanted with donors <60 years were significantly younger compared to the other two Groups (mean age 55 § 11.1 vs 59 § 11.1 vs 61.1 § 12.8 years old, p < 0,01); otherwise, no difference has been reported comparing the Group B vs the Group C (p=0.72). Furthermore, recipients from donors of Group A had more previous cardiac surgery (52% vs 31% vs 29%, p < 0.001); but no difference has been reported comparing the Group B vs the Group C (p=0.49). No differences have been reported in the aetiology of the cardiomyopathy or total ischemia time (194.5§58.8 min vs 187.1 §62.5 min, p=0.4).Considering the donor < 60 years group, 22 HTx patients (4%) died in the first month after HTx; conversely 7 patients (13%) died early from the Group B and 2 HTx patients (20%) from the Group C. In a mean follow up of 216 § 48 months, a total of 503 patients (81%) was alive after the first year from the Group A, compared to 38 (76%) from the Group B and 8 (80%) from the Group C. Conclusion: In the older donor groups, the incidence mortality is highest in the first month from HTx; conversely, it appears similar at 1-year between donor < 60 and ≥60 years old, even if when ≥65 years old have been considered. It could be reliable to expand the cardiac donor pool by accepting allografts from donors ≥ 60 years of age in selected cases.
mismatch relative to male donors. We try to compensate for this size mismatch by using obese female donors into male recipients. However, there have been recent concerns with obese donors, in the sense that there are commonly large fat deposits on the donor heart. It is not known whether short and obese female donors (weight oversizing) results in acceptable outcome after HTx. We sought to assess for this possibility in our large single center. Methods: Between 2010 and 2017 we assessed 799 HTx patients and divided them into those male recipients who received female donors (n=246) that were short (≤ 66 inches) and obese (BMI≥30) (n=61) and short and non-obese (BMI<30) recipients (n=128). In addition, we compared both groups to a male donor cohort inclusive of similar heights and weights. All patients were reviewed for 1-year outcomes including survival, freedom from CAV (as defined by stenosis ≥ 30% by angiography), freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), and freedom from any-treated rejection, acute cellular rejection, and antibody-mediated rejection. Results: There is no significant difference in 1-year outcomes between short and obese female donors, short and non-obese female donors, and male donors of similar heights and weights (see tables). Conclusion: Short and stout female donors appear to be acceptable for HTx which increases the donor pool.
Female Donors
Endpoints 1-Year Survival 1-Year Freedom from CAV 1-Freedom from NFMACE 1-Freedom from AnyTreated Rejection 1-Year Freedom from Acute Cellular Rejection 1-Year Freedom from Antibody-Mediated Rejection
Male Donors
Short Short and Short and and Obese Non-Obese Short and Non-Obese (n=61) (n=128) Obese (n=24) (n=68) P-Value 86.9% 96.7%
92.1% 96.9%
91.7% 91.7%
94.1% 91.2%
0.453 0.290
80.3%
85.0%
87.5%
85.3%
0.742
83.6%
83.5%
79.2%
86.8%
0.851
91.8%
92.1%
91.7%
94.1%
0.938
95.1%
92.9%
95.8%
95.6%
0.825
663 Heart Transplant Candidates Perceptions of the Newly Implemented United Network for Organ Sharing Heart Allocation System: An Eye Opener N.T. Rivera, B. Bednar, O. Wu, M. Loebe and A. Badiye. Miami Transplant Institute, Jackson Health System in affiliation with University of Miami Health System, Miami, FL.
662 Short and Stout Female Donors in Heart Transplantation: Do They Make a Difference? D.H. Chang, M. Kittleson, J. Patel, D. Geft, R. Levine, S. Dimbil, K. Nishihara, T. Kao, L. Czer, A. Trento and J.A. Kobashigawa. Cedars-Sinai Smidt Heart Institute, Los Angeles, CA. Purpose: Certain donor characteristics after heart transplantation (HTx) may have less optimal outcome post-HTx. One factors leading to worse outcome is female donors to male recipient possibly due to size (height and weight)
Purpose: In October 2018, United Network for Organ Sharing (UNOS) implemented a new allocation system for heart transplantation. The purpose was to better stratify the most medically urgent heart transplant candidates and address geographic disparities in donor access. In this survey of listed patients at our center, we investigate the candidate’s perspective on the new changes to the heart allocation system. Methods: A standardized scale-response survey was designed and delivered to heart transplant candidates currently listed at the Miami Transplant Institute. Results: Thirty-six out of 39 (92%) of heart transplant candidates responded to the standardized survey questionnaire. Despite one on one patient education, provision of education material, one-third of candidates felt that they had no understanding of the changes and only half had some understanding. Even while maintaining a higher status in the new allocation system, the higher the candidates’ listing status was with the original allocation system, the stronger it correlated with unsatisfactory responses. We observed that 100% of status 1A, 50% of status 1B, and 25% of status 2 candidates felt that their new statuses moved their priority lower on the list. The candidates’ perception about the ability of the new system to provide the most critically ill candidates a broader range of donor hearts also demonstrated a similar trend. The largest disagreement and unhappiness was found among the status 1A (100%) and status 1B (28%) groups, while no disagreement was found
Abstracts
S271
among statuses 2 (0%) and 7 (0%). Candidates were further asked about changes in their perceived wait times under the new system. 100% of status 1A, 56% of status 1B, and 50% of status 2 candidates felt that their wait time would be longer. As expected, this correlated to unhappiness in 100% of status 1A, 33.3% of status 1B, and 25% of status 2 candidates. Conclusion: Overall there was limited understanding and a sense of dis-satisfaction amongst the majority of the listed patients with regards to the new heart allocation system. A less favorable perception was observed in the patients who were listed in the higher priority statuses in the former system. Therefore, we propose that more candidate education is needed to improve their understanding and satisfaction regarding the new allocation system. 664 Coronary Angiography and Intravascular Ultrasound in an Ex-Vivo Perfused Heart Using the Organ Care System (OCS) D. Schibilsky,1 Q. Zhou,2 T. Wengenmayer,2 S. Maier,1 C. Benk,1 M. Berchtold-Herz,3 F. Beyersdorf,1 and M. Siepe.1 1Department Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Faculty of Medicine, Albert-Ludwigs-University Freiburg, Germany, Freiburg, Germany; 2Department of Cardiology, University Heart Center Freiburg Bad Krozingen, Faculty of Medicine, AlbertLudwigs-University Freiburg, Germany, Freiburg, Germany; and the 3 Department Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen; Freiburg, Germany Faculty of Medicine, Albert-LudwigsUniversity Freiburg, Germany, Freiburg, Germany. Purpose: To describe technical aspects of angiography and intravascular ultrasound (IVUS) in ex-vivo perfused hearts using the Organ Care System (OCS, TransMedics, Andover, MA USA). Methods: During ex-vivo perfusion of a pig heart a moderate stenosis of the mid left anterior descending coronary artery (LAD) was created in order to test the sensitivity of angiography and IVUS. The operating table was removed and the OCS was lifted by 45 cm to achieve an AP position of the heart within the X-ray system. As tilted or rotated projections are limited by radiopaque materials within the OCS, the heart had to be rotated to facilitate different views. Results: The standard heart position in the OCS revealed good visualization of the right coronary artery(RCA) using a 5 Fr. JR catheter (Fig 1). Using a JL catheter the left coronary artery(LCA) ostium could be intubated easily, however, visualization was suboptimal. Therefore the heart was rotated 90˚clockwise, which led to good LAD and suboptimal circumflex artery(RCx) visualization. 135˚-anticlockwise-rotation(-45˚ from standard position) led to good LAD and RCx projection(Fig 2). The LAD stenosis could be visualized in the angiography and confirmed by IVUS. Conclusion: Coronary angiogram of hearts during ex-vivo perfusion is feasible. As the OCS allows only AP fluoroscopy, the heart needs to be rotated to achieve sufficient views for coronary diagnostics. IVUS can be implemented to extend the diagnostic value.
665 Successful Use of Female Donors in Heart Transplantation: A Single Center Experience N. Rajagopalan, D.R. Dennis, J. Akhtarekhavari and M.E. Sekela. University of Kentucky, Lexington, KY. Purpose: Female donors are underutilized in heart transplantation, primarily due to data showing that using female donors for male recipients leads to increased mortality. Starting in 2015, our program utilized a more liberal donor policy including greater acceptance of female donors in an attempt to increase transplant volume. Our purpose was to assess the characteristics of female donors and resulting 1-year survival in heart transplant recipients. Methods: We retrospectively identified 125 patients (80% male) who underwent heart transplantation at our institution from January 2015 to September 2017. Recipients were divided into 2 groups based on whether they received a female donor or male donor. Baseline characteristics for both donors and recipients were recorded. The primary endpoint was 1-year survival. Results: Female donors were used in 53 heart transplant recipients (42% of total population). Clinical characteristics and results are shown in the table (*p < 0.05 female versus male donor). Female donor hearts were much less likely to be used in patients supported with durable mechanical circulatory support (MCS). Donor body mass index (BMI) was significantly greater in the female donor group. Female donors were oversized by weight compared to recipient on average by 16% compared to male donors that were oversized by 3% (p < 0.01). Female donors were located significantly further from the transplant hospital than male donors with greater donor sequence number and ischemic time. Primary graft dysfunction requiring extracorporeal membrane oxygenation was 8% in both groups. One-year survival was 98% in the female donor group compared to 92% in male donors. Conclusion: Female donors were used successfully in heart transplant recipients with excellent 1-year survival. Using larger and oversized female donors may have been one factor in mitigating the possible increased risk of using these donors, particularly in male recipients.
Recipient age (yrs) Male recipient Pre-transplant MCS Donor age (yrs) Donor BMI (kg/m2) Donor/recipient weight ratio Donor distance (miles) Ischemic time (min) Donor sequence no. 1-year survival
Female donor (n=53)
Male donor (n=72)
55 § 12 64% 17%* 37 § 13 34 § 10* 1.2 § 0.3* 357 § 207* 236 § 69* 71 § 94* 98%
53 § 11 93% 57% 34 § 12 28 § 6 1.0 § 0.2 189 § 217 199 § 66 23 § 43 92%
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
Recipients transplanted with donors <60 years were significantly younger compared to the other two Groups (mean age 55 § 11.1 vs 59 § 11.1 vs 61.1 § 12.8 years old, p < 0,01); otherwise, no difference has been reported comparing the Group B vs the Group C (p=0.72). Furthermore, recipients from donors of Group A had more previous cardiac surgery (52% vs 31% vs 29%, p < 0.001); but no difference has been reported comparing the Group B vs the Group C (p=0.49). No differences have been reported in the aetiology of the cardiomyopathy or total ischemia time (194.5§58.8 min vs 187.1 §62.5 min, p=0.4).Considering the donor < 60 years group, 22 HTx patients (4%) died in the first month after HTx; conversely 7 patients (13%) died early from the Group B and 2 HTx patients (20%) from the Group C. In a mean follow up of 216 § 48 months, a total of 503 patients (81%) was alive after the first year from the Group A, compared to 38 (76%) from the Group B and 8 (80%) from the Group C. Conclusion: In the older donor groups, the incidence mortality is highest in the first month from HTx; conversely, it appears similar at 1-year between donor < 60 and ≥60 years old, even if when ≥65 years old have been considered. It could be reliable to expand the cardiac donor pool by accepting allografts from donors ≥ 60 years of age in selected cases.
mismatch relative to male donors. We try to compensate for this size mismatch by using obese female donors into male recipients. However, there have been recent concerns with obese donors, in the sense that there are commonly large fat deposits on the donor heart. It is not known whether short and obese female donors (weight oversizing) results in acceptable outcome after HTx. We sought to assess for this possibility in our large single center. Methods: Between 2010 and 2017 we assessed 799 HTx patients and divided them into those male recipients who received female donors (n=246) that were short (≤ 66 inches) and obese (BMI≥30) (n=61) and short and non-obese (BMI<30) recipients (n=128). In addition, we compared both groups to a male donor cohort inclusive of similar heights and weights. All patients were reviewed for 1-year outcomes including survival, freedom from CAV (as defined by stenosis ≥ 30% by angiography), freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), and freedom from any-treated rejection, acute cellular rejection, and antibody-mediated rejection. Results: There is no significant difference in 1-year outcomes between short and obese female donors, short and non-obese female donors, and male donors of similar heights and weights (see tables). Conclusion: Short and stout female donors appear to be acceptable for HTx which increases the donor pool.
Female Donors
Endpoints 1-Year Survival 1-Year Freedom from CAV 1-Freedom from NFMACE 1-Freedom from AnyTreated Rejection 1-Year Freedom from Acute Cellular Rejection 1-Year Freedom from Antibody-Mediated Rejection
Male Donors
Short Short and Short and and Obese Non-Obese Short and Non-Obese (n=61) (n=128) Obese (n=24) (n=68) P-Value 86.9% 96.7%
92.1% 96.9%
91.7% 91.7%
94.1% 91.2%
0.453 0.290
80.3%
85.0%
87.5%
85.3%
0.742
83.6%
83.5%
79.2%
86.8%
0.851
91.8%
92.1%
91.7%
94.1%
0.938
95.1%
92.9%
95.8%
95.6%
0.825
663 Heart Transplant Candidates Perceptions of the Newly Implemented United Network for Organ Sharing Heart Allocation System: An Eye Opener N.T. Rivera, B. Bednar, O. Wu, M. Loebe and A. Badiye. Miami Transplant Institute, Jackson Health System in affiliation with University of Miami Health System, Miami, FL.
662 Short and Stout Female Donors in Heart Transplantation: Do They Make a Difference? D.H. Chang, M. Kittleson, J. Patel, D. Geft, R. Levine, S. Dimbil, K. Nishihara, T. Kao, L. Czer, A. Trento and J.A. Kobashigawa. Cedars-Sinai Smidt Heart Institute, Los Angeles, CA. Purpose: Certain donor characteristics after heart transplantation (HTx) may have less optimal outcome post-HTx. One factors leading to worse outcome is female donors to male recipient possibly due to size (height and weight)
Purpose: In October 2018, United Network for Organ Sharing (UNOS) implemented a new allocation system for heart transplantation. The purpose was to better stratify the most medically urgent heart transplant candidates and address geographic disparities in donor access. In this survey of listed patients at our center, we investigate the candidate’s perspective on the new changes to the heart allocation system. Methods: A standardized scale-response survey was designed and delivered to heart transplant candidates currently listed at the Miami Transplant Institute. Results: Thirty-six out of 39 (92%) of heart transplant candidates responded to the standardized survey questionnaire. Despite one on one patient education, provision of education material, one-third of candidates felt that they had no understanding of the changes and only half had some understanding. Even while maintaining a higher status in the new allocation system, the higher the candidates’ listing status was with the original allocation system, the stronger it correlated with unsatisfactory responses. We observed that 100% of status 1A, 50% of status 1B, and 25% of status 2 candidates felt that their new statuses moved their priority lower on the list. The candidates’ perception about the ability of the new system to provide the most critically ill candidates a broader range of donor hearts also demonstrated a similar trend. The largest disagreement and unhappiness was found among the status 1A (100%) and status 1B (28%) groups, while no disagreement was found
Abstracts
S271
among statuses 2 (0%) and 7 (0%). Candidates were further asked about changes in their perceived wait times under the new system. 100% of status 1A, 56% of status 1B, and 50% of status 2 candidates felt that their wait time would be longer. As expected, this correlated to unhappiness in 100% of status 1A, 33.3% of status 1B, and 25% of status 2 candidates. Conclusion: Overall there was limited understanding and a sense of dis-satisfaction amongst the majority of the listed patients with regards to the new heart allocation system. A less favorable perception was observed in the patients who were listed in the higher priority statuses in the former system. Therefore, we propose that more candidate education is needed to improve their understanding and satisfaction regarding the new allocation system. 664 Coronary Angiography and Intravascular Ultrasound in an Ex-Vivo Perfused Heart Using the Organ Care System (OCS) D. Schibilsky,1 Q. Zhou,2 T. Wengenmayer,2 S. Maier,1 C. Benk,1 M. Berchtold-Herz,3 F. Beyersdorf,1 and M. Siepe.1 1Department Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Faculty of Medicine, Albert-Ludwigs-University Freiburg, Germany, Freiburg, Germany; 2Department of Cardiology, University Heart Center Freiburg Bad Krozingen, Faculty of Medicine, AlbertLudwigs-University Freiburg, Germany, Freiburg, Germany; and the 3 Department Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen; Freiburg, Germany Faculty of Medicine, Albert-LudwigsUniversity Freiburg, Germany, Freiburg, Germany. Purpose: To describe technical aspects of angiography and intravascular ultrasound (IVUS) in ex-vivo perfused hearts using the Organ Care System (OCS, TransMedics, Andover, MA USA). Methods: During ex-vivo perfusion of a pig heart a moderate stenosis of the mid left anterior descending coronary artery (LAD) was created in order to test the sensitivity of angiography and IVUS. The operating table was removed and the OCS was lifted by 45 cm to achieve an AP position of the heart within the X-ray system. As tilted or rotated projections are limited by radiopaque materials within the OCS, the heart had to be rotated to facilitate different views. Results: The standard heart position in the OCS revealed good visualization of the right coronary artery(RCA) using a 5 Fr. JR catheter (Fig 1). Using a JL catheter the left coronary artery(LCA) ostium could be intubated easily, however, visualization was suboptimal. Therefore the heart was rotated 90˚clockwise, which led to good LAD and suboptimal circumflex artery(RCx) visualization. 135˚-anticlockwise-rotation(-45˚ from standard position) led to good LAD and RCx projection(Fig 2). The LAD stenosis could be visualized in the angiography and confirmed by IVUS. Conclusion: Coronary angiogram of hearts during ex-vivo perfusion is feasible. As the OCS allows only AP fluoroscopy, the heart needs to be rotated to achieve sufficient views for coronary diagnostics. IVUS can be implemented to extend the diagnostic value.
665 Successful Use of Female Donors in Heart Transplantation: A Single Center Experience N. Rajagopalan, D.R. Dennis, J. Akhtarekhavari and M.E. Sekela. University of Kentucky, Lexington, KY. Purpose: Female donors are underutilized in heart transplantation, primarily due to data showing that using female donors for male recipients leads to increased mortality. Starting in 2015, our program utilized a more liberal donor policy including greater acceptance of female donors in an attempt to increase transplant volume. Our purpose was to assess the characteristics of female donors and resulting 1-year survival in heart transplant recipients. Methods: We retrospectively identified 125 patients (80% male) who underwent heart transplantation at our institution from January 2015 to September 2017. Recipients were divided into 2 groups based on whether they received a female donor or male donor. Baseline characteristics for both donors and recipients were recorded. The primary endpoint was 1-year survival. Results: Female donors were used in 53 heart transplant recipients (42% of total population). Clinical characteristics and results are shown in the table (*p < 0.05 female versus male donor). Female donor hearts were much less likely to be used in patients supported with durable mechanical circulatory support (MCS). Donor body mass index (BMI) was significantly greater in the female donor group. Female donors were oversized by weight compared to recipient on average by 16% compared to male donors that were oversized by 3% (p < 0.01). Female donors were located significantly further from the transplant hospital than male donors with greater donor sequence number and ischemic time. Primary graft dysfunction requiring extracorporeal membrane oxygenation was 8% in both groups. One-year survival was 98% in the female donor group compared to 92% in male donors. Conclusion: Female donors were used successfully in heart transplant recipients with excellent 1-year survival. Using larger and oversized female donors may have been one factor in mitigating the possible increased risk of using these donors, particularly in male recipients.
Recipient age (yrs) Male recipient Pre-transplant MCS Donor age (yrs) Donor BMI (kg/m2) Donor/recipient weight ratio Donor distance (miles) Ischemic time (min) Donor sequence no. 1-year survival
Female donor (n=53)
Male donor (n=72)
55 § 12 64% 17%* 37 § 13 34 § 10* 1.2 § 0.3* 357 § 207* 236 § 69* 71 § 94* 98%
53 § 11 93% 57% 34 § 12 28 § 6 1.0 § 0.2 189 § 217 199 § 66 23 § 43 92%