Elsevier

Transplantation Proceedings

Volume 53, Issue 1, January–February 2021, Pages 353-357
Transplantation Proceedings

Advances in Transplantation
Cardiac Transplantation
Acceptable Post–Heart Transplant Outcomes Support Temporary MCS Prioritization in the New OPTN|UNOS Heart Allocation Policy

https://doi.org/10.1016/j.transproceed.2020.04.1819Get rights and content

Highlights

  • Heart allocation changes prioritize temporary mechanical circulatory support.

  • Temporary mechanical circulatory support is frequently used in patients with greater severity of illness.

  • The impact of prioritizing this sicker cohort on post-transplant outcomes is not well understood.

Abstract

Background

Temporary mechanical circulatory support (MCS) devices are generally used short term to maintain adequate organ perfusion in patients with advanced heart failure and cardiogenic shock. Unacceptably high waitlist mortality in this cohort motivated changes to heart allocation policy, which recognized the severity of illness by prioritization for temporary MCS and broader sharing in the new U.S. donor heart allocation policy. We evaluated the post–heart transplant outcomes for patients bridged with temporary MCS, a control population not bridged with MCS, and a cohort bridged with durable MCS.

Methods

The heart transplant research database was queried to identify patients bridged with temporary MCS and bridged with durable MCS who went directly to heart transplant in our center. Temporary MCS included Impella, intra-aortic balloon pump, and extracorporeal membrane oxygenation. Post-transplant endpoints were assessed at 30 days, 6 months, and 1 year.

Results

From 2010 to 2017, a total of 23 patients were bridged to heart transplant with temporary MCS and 548 were transplanted without MCS bridge. Patients bridged with temporary MCS had younger age, lower body mass index, and higher frequencies of prior blood transfusion and Status 1 (1A/1B) listing at transplant compared to patients not bridged with MCS (all P < .001). Despite the severity of illness in patients bridged with temporary MCS, post-transplant outcomes were indistinguishable from those in patients transplanted without MCS bridge, with no difference in 30-day, 6-month, or 1-year survival or 1-year freedom from cardiac allograft vasculopathy, nonfatal major adverse cardiac events, any-treated rejection, acute cellular rejection, or antibody-mediated rejection (P = .23-.97). Similarly, compared to 157 patients bridged with durable MCS, no differences in post-transplant outcomes were identified for the temporary MCS cohort (P = .15-.94).

Conclusion

Temporary MCS as a bridge to transplant achieves similar post-transplant outcomes at 1 year compared to no MCS and durable MCS. These encouraging findings support recent changes in the Organ Procurement and Transplantation Network | United Network Organ Sharing (OPTN|UNOS) adult heart allocation policy.

Section snippets

Patient Population

During the years 2010 to 2017, a total of 728 heart transplants were performed in our institution and entered into a prospectively maintained heart transplant research database. The population was divided into 3 groups who went directly to heart transplant: patients bridged to transplant with temporary MCS, patients without MCS bridge, and patients bridged with durable MCS. The temporary MCS cohort included patients bridged to transplant with ECMO, percutaneous endovascular MCS, and/or IABP.

Results

Twenty-three patients were bridged to heart transplant using temporary MCS from 2010 to 2017 in our center. The temporary MCS pathways included Impella 5.0 (ABIOMED, Danvers, Mass, United States) (n = 5), intra-aortic balloon pump (n = 14), and venoarterial extracorporeal circulatory support (n = 4) (Table 2). Indications for temporary MCS were cardiogenic shock in the setting of multiorgan dysfunction or on mechanical ventilation to allow successful optimization of clinical status and

Discussion

In the 2018 International Society of Heart and Lung Transplantation registry report, a significant increase in patients bridged to heart transplant with MCS, predominantly as a result of an increase in left ventricular assist devices (LVADs), was identified, from 23.0% in years 2005 to 2008 to 43.9% in 2009 to 6/2017 (P < .001). In the 2009 to 6/2016 cohort of 30,824 registry patients, 1-year survival was 85.4%. MCS bridge to transplant did not adversely affect post-transplant survival, except

Conclusion

Bridging with temporary MCS devices achieves acceptable outcomes after heart transplant compared to 2 cohorts who now have lower priority in allocation: those not bridged with MCS and those bridged with durable MCS. These encouraging findings support increased priority and broader sharing for patients with temporary MCS in the new OPTN|UNOS adult heart allocation policy.

Cited by (15)

  • Commentary: Mechanical bridge over troubled waters

    2023, Journal of Thoracic and Cardiovascular Surgery
  • Long-term preservation of functional capacity and quality of life in advanced heart failure patients with bridge to transplant therapy: A report from Japanese nationwide multicenter registry

    2022, International Journal of Cardiology
    Citation Excerpt :

    Although the prioritization process of LVAD patients on the waiting list for HTx differs among countries, BTT patients without severe complications are facing an extremely long expected waiting time. Under the revised heart allocation system in the United States in October 2018, there has been a dramatic change in the bridging strategy, resulting in more patients being bridged with temporary devices, which places them in a high urgency waitlist [16,17]. As a result of this allocation policy change, BTT patients have a longer waitlist period to receive a donor heart, as they are now placed in a less urgent waitlist.

View all citing articles on Scopus
View full text