Journal article
Three-year outcomes after bridge to transplantation ECMO—pre- and post-2018 UNOS revised heart allocation system
The Journal of heart and lung transplantation, v 43(11), pp 1838-1845
Nov 2024
PMID: 39122220
Featured in Collection : UN Sustainable Development Goals @ Drexel
Abstract
Utilization of temporary mechanical circulatory support, including veno-arterial extra-corporeal membrane oxygenation as a bridge to heart transplantation (HT) has increased significantly under the revised United Network for Organ Sharing (UNOS) donor heart allocation system. The revised heart allocation system aimed to lower waitlist times and mortality for the most critically ill patients requiring biventricular, nondischargeable, mechanical circulatory support. While previous reports have shown improved 1-year post-HT survival in the current era, 3-year survival and factors associated with mortality among bridge-to-transplant (BTT) extra-corporeal membrane oxygenation (ECMO) patients are not well described.
We queried the UNOS database for all adult (age ≥ 18 years) heart-only transplants performed between 2010 and 2019. Patients were stratified as either pre- (January 2010-September 2018; era 1) or post-allocation change (November 2018-December 2019; era 2) cohort based on their HT date. Baseline recipient characteristics and post-transplant outcomes were compared. A Cox regression analysis was performed to explore risk factors for 3-year mortality among BTT-ECMO patients in era 2. For each era, 3-year mortality was also compared between BTT ECMO patients and those transplanted without ECMO support.
During the study period, 116 patients were BTT ECMO during era 1 and 154 patients during era 2. Baseline recipient characteristics were similar in both groups. Median age was 48 (36-58 interquartile range (IQR)) years in era 2, while it was 51 (27-58 IQR) years in era 1. The majority of BTT-ECMO patients were males in both era 2 and era 1 (77.7% vs 71.5%, p = 0.28). Median ECMO run times while listed for HT were significantly shorter (4 days vs 7 days, p < 0.001) in era 2. Waitlist mortality among BTT ECMO patients was also significantly lower in era 2 (6.3% vs 19.3%, p < 0.001). Post-HT survival at 6 months (94.2% vs 75.9%, p < 0.001), 1 year (90.3% vs 74.2%, p < 0.001), and 3 years (87% vs 66.4%, p < 0.001) was significantly improved in era 2 as compared to era 1. Graft failure at 1 year (10.3% vs 25.8%, p = 0.0006) and 3 years (13.6% vs 33.6%, p = 0.0001) was also significantly lower in era 2 compared to era 1. Three-year survival among BTT ECMO patients in era 2 was similar to that of patients transplanted in era 2 without ECMO support (87% vs 85.7%, p = 0.75). In multivariable analysis of BTT-ECMO patients in era 2, every 1 kg/m2 increase in body mass index was associated with higher mortality at 3 years (hazard ratio (HR) 1.09, 95% CI 1.02-1.15, p = 0.006). Similarly, both post-HT stroke (HR 5.58, 95% CI 2.57-12.14, p < 0.001) and post-HT renal failure requiring hemodialysis (HR 4.36, 95% CI 2.43-7.82, p < 0.001) were also associated with 3-year mortality.
Three years post-HT survival in patients bridged with ECMO has significantly improved under the revised donor heart allocation system compared to prior system. BTT ECMO recipients under the revised system have significantly shorter ECMO waitlist run times, lower waitlist mortality and 3-year survival similar to those not bridged with ECMO. Overall, the revised allocation system has allowed more rapid transplantation of the sickest patients without a higher post-HT mortality.
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Details
- Title
- Three-year outcomes after bridge to transplantation ECMO—pre- and post-2018 UNOS revised heart allocation system
- Creators
- Het Patel - Willis-Knighton Cancer CenterLeonie Dupuis - Vanderbilt University Medical CenterMatthew Bacchetta - Vanderbilt University Medical CenterAntonio Hernandez - Vanderbilt University Medical CenterManreet K. Kanwar - Allegheny Health NetworkJoAnn Lindenfeld - Vanderbilt University Medical CenterZubair Shah - University of Kansas Medical CenterHasan K. Siddiqi - Vanderbilt University Medical CenterShashank S. Sinha - Inova Fairfax HospitalAshish S. Shah - Vanderbilt University Medical CenterKelly H. Schlendorf - Vanderbilt University Medical CenterAniket S. Rali - Vanderbilt University Medical Center
- Publication Details
- The Journal of heart and lung transplantation, v 43(11), pp 1838-1845
- Publisher
- Elsevier; NEW YORK
- Number of pages
- 8
- Resource Type
- Journal article
- Language
- English
- Academic Unit
- Cardiology
- Web of Science ID
- WOS:001345216600001
- Scopus ID
- 2-s2.0-85201594309
- Other Identifier
- 991021932106504721
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InCites Highlights
Data related to this publication, from InCites Benchmarking & Analytics tool:
- Collaboration types
- Domestic collaboration
- Web of Science research areas
- Cardiac & Cardiovascular Systems
- Respiratory System
- Surgery
- Transplantation