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Oversizing Donors - Is It Necessary for ACHD Patients?: An Analysis of the United Network for Organ Sharing Registry
S160
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
ourselves to accept organs sooner for patients who are waiting for a heart transplant.
373 analysis showed that donor T4 therapy was independently associated with a significant >5-fold increased risk for PGD (OR=5.38, 95%CI 1.7917.78; Fig). These results remained consistent after propensity score analysis. Conclusion: Donor hormonal thyroid therapy is independently associated with increased risk of PGD. Hypothesizing a “withdrawal effect” as the cause, administration of thyroid hormonal therapy to the recipient at time of reperfusion may oppose this negative effect. Further prospective studies are needed to validate this hypothesis-generating study.
372 Matchmaking Just Got Easier: Impact of Phenotypic Donor-Recipient Likeness in Open Heart Transplantation B.D. Lo, A. Suarez-Pierre, X. Zhou, C. Lui, M.F. Hunt, G.J. Whitman, C.W. Choi and A. Kilic. Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD. Purpose: Phenotypic matching in heart transplantation, where donors and recipients are matched based on physical characteristics, has been previously limited to only analyzing gender, BMI, and age. This study examines the effects of phenotypic matching utilizing multiple factors. Methods: Adult patients undergoing heart transplantation between 2006 and 2016 were identified from the Organ Procurement and Transplantation Network (OPTN) database. Phenotypic matching was defined based on six factors: Body mass index (BMI) difference >30%, age difference >30%, height difference >7%, non-identical ABO blood grouping, ethnicity, and gender. A value between 0-1 mismatched characteristics was considered phenotypically like matching, while 2-6 mismatches was considered phenotypically unlike matching. The primary study endpoint was one-year survival. Risk-adjusted mortality was examined with multivariable Cox regression models after controlling for donor and recipient covariates. Results: During the study period, 20,052 adult patients underwent heart transplantation, of which 9,595 (47.9%) were phenotypically like matched and 10,457 (52.1%) were phenotypically unlike matched. No differences in 1-year survival were seen between like and unlike matched patients (risk-adjusted OR 1.05, 95% CI 0.96-1.15, p=0.305) after controlling for clinically relevant covariates (Figure.) Subgroup analyses did not demonstrate survival differences after stratification based on hospital volume and initial waitlist status. Phenotypically like matched patients had longer waiting times compared to unlike matched patients both overall (225 days versus 192 days, p<0.001) and within each subgroup. Conclusion: Waiting for a phenotypically matched heart provides no survival benefit and exposes patients to prolonged waitlist times. This challenges the belief that a perfect donor heart exists, and we should challenge
Oversizing Donors - Is It Necessary for ACHD Patients?: An Analysis of the United Network for Organ Sharing Registry D.E. Clark,1 R.D. Byrne,2 D.S. Burnstein,3 M.R. Danter,4 R. Fowler,1 B.P. Frischhertz,1 J. Lindenfeld,1 J.A. Mazurek,5 B.A. Mettler,6 A. Opotowsky,7 T.L. Richardson,2 E.M. Sandhuas,1 K.H. Schlendorf,1 J. Schmeckpeper,1 A.S. Shah,4 A.J. Weingarten,8 S. Zalawadiya,1 and J.N. Menachem.1 1Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN; 2Internal Medicine-Pediatrics, Vanderbilt University Medical Center, Nashville, TN; 3Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA; 4Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN; 5Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA; 6Pediatric Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN; 7Cardiology, Harvard Medical School, Boston, MA; and the 8Cardiovascular Medicine, Vanderbilt University, Nashville, TN. Purpose: Orthotopic heart transplantation (OHT) among adult congenital heart disease (ACHD) patients triggers debate as to optimal donor sizing. Outcomes related to donor-to-recipient size ratios have never been analyzed in the ACHD population. Methods: We conducted a retrospective cohort analysis of adults with ACHD undergoing OHT in the USA from January 1, 2000 to June 30, 2017 using the United Network for Organ Sharing (UNOS) registry. Univariate and multivariate analyses were performed to compare survivors versus those deceased at last follow-up. Chi-squared and Wilcoxon rank sum tests were used for categorical and continuous variables, respectively. Cox proportional hazard modeling was performed for time to death, cardiac graft failure, and post-OHT dialysis to assess the effects of donor-torecipient ratios of height, weight, BMI, and LV mass ratios using a priori selected covariates. Results: 827 patients met inclusion criteria and were analyzed. At a median follow-up of 1,462 days, there were 279 (33.7%) deceased ACHD OHT recipients. Renal dysfunction, ischemic time, and gender mismatch were all significantly associated with death and graft dysfunction using multivariate survival analysis. However, donor-to-recipient ratios of height, weight, BMI, and LV mass were not associated with the outcomes of interest. Conclusion: This study is the first to show that ACHD patients undergoing OHT do not have differential survival based on donor sizing. Survival and freedom from graft dysfunction among ACHD patients undergoing OHT is similar to the non-ACHD population and is associated with reduced ischemic times, a lack of gender mismatch, and a lack of pre- and post-operative renal dysfunction. Our findings demonstrate that intentional donor oversizing in the ACHD population as a protective measure against post-operative right ventricular dysfunction does not reduce mortality, decrease risk of graft dysfunction or post-OHT need for dialysis.
Abstracts
S161 375 Time to death and graft failure Death
Height ratio Weight ratio BMI ratio LV mass ratio
Graft Failure
Odds ratio
95% CI
P-value
Odds ratio
95% CI
P-value
1.08 0.94 0.93 1.00
0.90-1.29 0.81-1.10 0.81-1.08 0.85-1.18
0.44 0.45 0.33 0.98
1.08 0.95 0.93 1.01
0.90-1.29 0.82-1.10 0.81-1.08 0.85-1.19
0.41 0.47 0.34 0.95
374 Mitigating the Impact of Gender Mismatch in Heart Transplantation Using BMI and BSA Ratios Y.D. Barac, O. Jawitz, V. Raman, M. Hartwig, J. Klapper, J. Schroder, M. Daneshmand, C. Patel and C. Milano. Duke University Medical Center, Durham, NC. Purpose: Heart transplantation is limited by the supply of donor organs. Previous studies have associated donor/recipient gender mismatch with decreased post-transplant survival and increased rates of primary graft dysfunction. We evaluate whether this risk can be mitigated. Methods: We performed a retrospective analysis of the OPTN/UNOS registry encompassing years 1987 to 2018 for all male adult recipients (>18 years) who underwent isolated heart transplantation with grafts from female donors. Comparison was made to transplants from male donors. Recipients were primarily stratified into two groups, those with BMI less than or greater than donor BMI. Patients were stratified by BSA on secondary analysis. Kaplan-Meier analysis was used to estimate survival post-transplant. Cox Proportional Hazards modeling was performed to identify independent predictors of survival. Results: A total of 8,232 candidates met inclusion criteria. Male recipients receiving hearts from higher BMI female donors were more likely to be in the ICU pre-transplant (39.5% vs 36.6%, p = 0.001), on IV inotropes at listing (35.7% vs 33.0%, p = 0.013), and were less likely to have a history of diabetes (21.4% vs 23.9%, p = 0.012). On Kaplan-Meier analysis, recipients transplanted with hearts from higher BMI female donors had improved overall survival. When stratified by BSA (Figure 1), male recipients transplanted with hearts from higher BSA female donors had similar post-transplant survival as male recipients who received hearts from male donors. On Cox Proportional Hazards analysis, increased donor BMI/BSA relative to recipient BMI/ BSA remained an independent predictor of improved survival (p < 0.05). Conclusion: Prior studies have associated transplanting hearts from female donors into male recipients with decreased post-transplant survival. In this study we have demonstrated that this may be mitigated by matching grafts from female donors to male recipients with lower BMI and especially BSA.
Characteristics and Short-Term Outcomes of Hepatitis C Antibody Positive Organs for Heart Transplantation: UNOS Analysis E.M. DeFilippis, R.C. Givens, A.R. Garan, F. Latif, S.W. Restaino, Y. Naka, K. Takeda, H. Takayama, P.C. Colombo, M.A. Farr and V.K. Topkara. Columbia University Medical Center, New York, NY. Purpose: Heart transplant centers are increasingly utilizing organs from donors infected with Hepatitis C virus (HCV). Aside from single-center experiences, there is little existing data regarding the characteristics of recipients of HCV Antibody (Ab)+ organs as well as short-term outcomes and graft survival. Methods: We analyzed the United Network for Organ Sharing registry from January 2016 and March 2018 to include adults ≥18 who had undergone heart transplantation with a HCV Ab+ donor. Information regarding nucleic acid amplification testing (NAT) was also available. Results: Between January 2016 and March 2018, 159 recipients underwent heart transplantation with HCV Ab+ donors. When comparing recipients of HCV+ to HCV- hearts, there were no differences between recipient age (53.4 vs 53.6 years, p =0.86), donor age (33.2 vs 31.9 years, p =0.055), female donor (26.0 vs 27.7%, p =0.64), body mass index (27.3 vs 27.6, p =0.47), and serum creatinine at transplant (1.4 vs 1.4, p = 0.36). There were no differences in the use of ventricular assist devices at time of transplant between groups. Recipients of HCV+ organs were more likely to be Blood Type O (55.3% vs 38.9%, p <0.001) and spent significantly fewer days as Status 1A (25.8 vs 42.6, p <0.001). Recipients of HCV+ organs had longer ischemic times (3.6 vs 3.0 hours, p <0.001) with associated longer distances from the donor hospital to the transplant center (323 vs 146 miles, p<0.001). Kaplan-Meier survival curves showed a trend towards decreased survival in the HCV+ group when compared to the HCV- group (p =0.06). Among recipients of HCV+ organs, there was no difference in survival between recipients of NAT+ and NAT- donors (Figure). Conclusion: While recipient baseline characteristics were similar between those receiving HCV+ and HCV- transplants, recipients of HCV+ organs had significantly longer ischemic times with longer distances from the donor hospital to the transplant center. Short-term survival appears similar between groups.
376 Heart Transplant Recipient and Donor Age: Should the Younger Recipient Be Matched with the Younger Donor? Y. Ravi,1 N. Srikanth,2 I.W. Paul,3 B.A. Whitson,4 S. Emani,5 and C.B. SaiSudhakar.1 1Cardiac Surgery, Scott & White, Texas A&M, Temple, TX; 2 Medical Student, Saveetha Institute of Medical Sciences, Chennai, India; 3 Medical Student, Sree Mookambika Institute of Medical Sciences, Kulasekaram, India; 4Cardiac Surgery, The Ohio State University, Columbus, OH; and the 5Internal Medicine, The Ohio State University, Columbus, OH. Purpose: With the shortage of donor hearts, older donors are being increasingly evaluated for potential recipients. Currently it is unknown if the younger recipients is affected by donor age. We sought to evaluate the outcomes in younger heart transplant recipients from younger and older donors and conversely, the older heart transplant recipients from younger and older donors. Methods: We analyzed The United Network for Organ Sharing data registry for all adult heart transplant recipients (HTR) from 2008 to 2017. HTR with right or bi-ventricular support or TAH were excluded. Patients were stratified based on recipient age (R) 18-29, 20-39, 40-49 and >50 years old
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
ourselves to accept organs sooner for patients who are waiting for a heart transplant.
373 analysis showed that donor T4 therapy was independently associated with a significant >5-fold increased risk for PGD (OR=5.38, 95%CI 1.7917.78; Fig). These results remained consistent after propensity score analysis. Conclusion: Donor hormonal thyroid therapy is independently associated with increased risk of PGD. Hypothesizing a “withdrawal effect” as the cause, administration of thyroid hormonal therapy to the recipient at time of reperfusion may oppose this negative effect. Further prospective studies are needed to validate this hypothesis-generating study.
372 Matchmaking Just Got Easier: Impact of Phenotypic Donor-Recipient Likeness in Open Heart Transplantation B.D. Lo, A. Suarez-Pierre, X. Zhou, C. Lui, M.F. Hunt, G.J. Whitman, C.W. Choi and A. Kilic. Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD. Purpose: Phenotypic matching in heart transplantation, where donors and recipients are matched based on physical characteristics, has been previously limited to only analyzing gender, BMI, and age. This study examines the effects of phenotypic matching utilizing multiple factors. Methods: Adult patients undergoing heart transplantation between 2006 and 2016 were identified from the Organ Procurement and Transplantation Network (OPTN) database. Phenotypic matching was defined based on six factors: Body mass index (BMI) difference >30%, age difference >30%, height difference >7%, non-identical ABO blood grouping, ethnicity, and gender. A value between 0-1 mismatched characteristics was considered phenotypically like matching, while 2-6 mismatches was considered phenotypically unlike matching. The primary study endpoint was one-year survival. Risk-adjusted mortality was examined with multivariable Cox regression models after controlling for donor and recipient covariates. Results: During the study period, 20,052 adult patients underwent heart transplantation, of which 9,595 (47.9%) were phenotypically like matched and 10,457 (52.1%) were phenotypically unlike matched. No differences in 1-year survival were seen between like and unlike matched patients (risk-adjusted OR 1.05, 95% CI 0.96-1.15, p=0.305) after controlling for clinically relevant covariates (Figure.) Subgroup analyses did not demonstrate survival differences after stratification based on hospital volume and initial waitlist status. Phenotypically like matched patients had longer waiting times compared to unlike matched patients both overall (225 days versus 192 days, p<0.001) and within each subgroup. Conclusion: Waiting for a phenotypically matched heart provides no survival benefit and exposes patients to prolonged waitlist times. This challenges the belief that a perfect donor heart exists, and we should challenge
Oversizing Donors - Is It Necessary for ACHD Patients?: An Analysis of the United Network for Organ Sharing Registry D.E. Clark,1 R.D. Byrne,2 D.S. Burnstein,3 M.R. Danter,4 R. Fowler,1 B.P. Frischhertz,1 J. Lindenfeld,1 J.A. Mazurek,5 B.A. Mettler,6 A. Opotowsky,7 T.L. Richardson,2 E.M. Sandhuas,1 K.H. Schlendorf,1 J. Schmeckpeper,1 A.S. Shah,4 A.J. Weingarten,8 S. Zalawadiya,1 and J.N. Menachem.1 1Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN; 2Internal Medicine-Pediatrics, Vanderbilt University Medical Center, Nashville, TN; 3Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA; 4Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN; 5Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA; 6Pediatric Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN; 7Cardiology, Harvard Medical School, Boston, MA; and the 8Cardiovascular Medicine, Vanderbilt University, Nashville, TN. Purpose: Orthotopic heart transplantation (OHT) among adult congenital heart disease (ACHD) patients triggers debate as to optimal donor sizing. Outcomes related to donor-to-recipient size ratios have never been analyzed in the ACHD population. Methods: We conducted a retrospective cohort analysis of adults with ACHD undergoing OHT in the USA from January 1, 2000 to June 30, 2017 using the United Network for Organ Sharing (UNOS) registry. Univariate and multivariate analyses were performed to compare survivors versus those deceased at last follow-up. Chi-squared and Wilcoxon rank sum tests were used for categorical and continuous variables, respectively. Cox proportional hazard modeling was performed for time to death, cardiac graft failure, and post-OHT dialysis to assess the effects of donor-torecipient ratios of height, weight, BMI, and LV mass ratios using a priori selected covariates. Results: 827 patients met inclusion criteria and were analyzed. At a median follow-up of 1,462 days, there were 279 (33.7%) deceased ACHD OHT recipients. Renal dysfunction, ischemic time, and gender mismatch were all significantly associated with death and graft dysfunction using multivariate survival analysis. However, donor-to-recipient ratios of height, weight, BMI, and LV mass were not associated with the outcomes of interest. Conclusion: This study is the first to show that ACHD patients undergoing OHT do not have differential survival based on donor sizing. Survival and freedom from graft dysfunction among ACHD patients undergoing OHT is similar to the non-ACHD population and is associated with reduced ischemic times, a lack of gender mismatch, and a lack of pre- and post-operative renal dysfunction. Our findings demonstrate that intentional donor oversizing in the ACHD population as a protective measure against post-operative right ventricular dysfunction does not reduce mortality, decrease risk of graft dysfunction or post-OHT need for dialysis.
Abstracts
S161 375 Time to death and graft failure Death
Height ratio Weight ratio BMI ratio LV mass ratio
Graft Failure
Odds ratio
95% CI
P-value
Odds ratio
95% CI
P-value
1.08 0.94 0.93 1.00
0.90-1.29 0.81-1.10 0.81-1.08 0.85-1.18
0.44 0.45 0.33 0.98
1.08 0.95 0.93 1.01
0.90-1.29 0.82-1.10 0.81-1.08 0.85-1.19
0.41 0.47 0.34 0.95
374 Mitigating the Impact of Gender Mismatch in Heart Transplantation Using BMI and BSA Ratios Y.D. Barac, O. Jawitz, V. Raman, M. Hartwig, J. Klapper, J. Schroder, M. Daneshmand, C. Patel and C. Milano. Duke University Medical Center, Durham, NC. Purpose: Heart transplantation is limited by the supply of donor organs. Previous studies have associated donor/recipient gender mismatch with decreased post-transplant survival and increased rates of primary graft dysfunction. We evaluate whether this risk can be mitigated. Methods: We performed a retrospective analysis of the OPTN/UNOS registry encompassing years 1987 to 2018 for all male adult recipients (>18 years) who underwent isolated heart transplantation with grafts from female donors. Comparison was made to transplants from male donors. Recipients were primarily stratified into two groups, those with BMI less than or greater than donor BMI. Patients were stratified by BSA on secondary analysis. Kaplan-Meier analysis was used to estimate survival post-transplant. Cox Proportional Hazards modeling was performed to identify independent predictors of survival. Results: A total of 8,232 candidates met inclusion criteria. Male recipients receiving hearts from higher BMI female donors were more likely to be in the ICU pre-transplant (39.5% vs 36.6%, p = 0.001), on IV inotropes at listing (35.7% vs 33.0%, p = 0.013), and were less likely to have a history of diabetes (21.4% vs 23.9%, p = 0.012). On Kaplan-Meier analysis, recipients transplanted with hearts from higher BMI female donors had improved overall survival. When stratified by BSA (Figure 1), male recipients transplanted with hearts from higher BSA female donors had similar post-transplant survival as male recipients who received hearts from male donors. On Cox Proportional Hazards analysis, increased donor BMI/BSA relative to recipient BMI/ BSA remained an independent predictor of improved survival (p < 0.05). Conclusion: Prior studies have associated transplanting hearts from female donors into male recipients with decreased post-transplant survival. In this study we have demonstrated that this may be mitigated by matching grafts from female donors to male recipients with lower BMI and especially BSA.
Characteristics and Short-Term Outcomes of Hepatitis C Antibody Positive Organs for Heart Transplantation: UNOS Analysis E.M. DeFilippis, R.C. Givens, A.R. Garan, F. Latif, S.W. Restaino, Y. Naka, K. Takeda, H. Takayama, P.C. Colombo, M.A. Farr and V.K. Topkara. Columbia University Medical Center, New York, NY. Purpose: Heart transplant centers are increasingly utilizing organs from donors infected with Hepatitis C virus (HCV). Aside from single-center experiences, there is little existing data regarding the characteristics of recipients of HCV Antibody (Ab)+ organs as well as short-term outcomes and graft survival. Methods: We analyzed the United Network for Organ Sharing registry from January 2016 and March 2018 to include adults ≥18 who had undergone heart transplantation with a HCV Ab+ donor. Information regarding nucleic acid amplification testing (NAT) was also available. Results: Between January 2016 and March 2018, 159 recipients underwent heart transplantation with HCV Ab+ donors. When comparing recipients of HCV+ to HCV- hearts, there were no differences between recipient age (53.4 vs 53.6 years, p =0.86), donor age (33.2 vs 31.9 years, p =0.055), female donor (26.0 vs 27.7%, p =0.64), body mass index (27.3 vs 27.6, p =0.47), and serum creatinine at transplant (1.4 vs 1.4, p = 0.36). There were no differences in the use of ventricular assist devices at time of transplant between groups. Recipients of HCV+ organs were more likely to be Blood Type O (55.3% vs 38.9%, p <0.001) and spent significantly fewer days as Status 1A (25.8 vs 42.6, p <0.001). Recipients of HCV+ organs had longer ischemic times (3.6 vs 3.0 hours, p <0.001) with associated longer distances from the donor hospital to the transplant center (323 vs 146 miles, p<0.001). Kaplan-Meier survival curves showed a trend towards decreased survival in the HCV+ group when compared to the HCV- group (p =0.06). Among recipients of HCV+ organs, there was no difference in survival between recipients of NAT+ and NAT- donors (Figure). Conclusion: While recipient baseline characteristics were similar between those receiving HCV+ and HCV- transplants, recipients of HCV+ organs had significantly longer ischemic times with longer distances from the donor hospital to the transplant center. Short-term survival appears similar between groups.
376 Heart Transplant Recipient and Donor Age: Should the Younger Recipient Be Matched with the Younger Donor? Y. Ravi,1 N. Srikanth,2 I.W. Paul,3 B.A. Whitson,4 S. Emani,5 and C.B. SaiSudhakar.1 1Cardiac Surgery, Scott & White, Texas A&M, Temple, TX; 2 Medical Student, Saveetha Institute of Medical Sciences, Chennai, India; 3 Medical Student, Sree Mookambika Institute of Medical Sciences, Kulasekaram, India; 4Cardiac Surgery, The Ohio State University, Columbus, OH; and the 5Internal Medicine, The Ohio State University, Columbus, OH. Purpose: With the shortage of donor hearts, older donors are being increasingly evaluated for potential recipients. Currently it is unknown if the younger recipients is affected by donor age. We sought to evaluate the outcomes in younger heart transplant recipients from younger and older donors and conversely, the older heart transplant recipients from younger and older donors. Methods: We analyzed The United Network for Organ Sharing data registry for all adult heart transplant recipients (HTR) from 2008 to 2017. HTR with right or bi-ventricular support or TAH were excluded. Patients were stratified based on recipient age (R) 18-29, 20-39, 40-49 and >50 years old