Abstract 12663: Impact of Increased Utilization of Expanded Criteria Donors at a High-Volume Heart Transplant Center: A Quasi-Experimental Analysis

Abstract

Introduction: Increased use of expanded criteria donors (ECDs) could alleviate the donor shortage in heart transplantation (HT), but whether ECDs confer acceptable outcomes remains unclear. We utilized a “natural experiment” to assess the impact of ECD utilization on outcomes. Methods: We evaluated outcomes before (2011-15; “pre-intervention”) and after (2016-18; “post-intervention”) the adoption of an aggressive ECD utilization strategy at our high-volume HT program. We compared pre- vs. post- intervention changes in outcomes at our program with those occurring concurrently at other programs in the United States. We defined an ECD as a donor with age > 50 years, left ventricular ejection fraction < 50%, and/or coronary artery disease. Results: ECD utilization at our program increased from 10.9% of all HTs pre-intervention to 28.0% post-intervention (p < 0.0001), with a concurrent decrease in ECD utilization nationwide (12.5% to 11.7%; p = 0.08). There was no concurrent change at our program in recipient mix by priority status at listing, blood type, demographics, or comorbidities. Our program experienced significant decreases (pre- vs. post- intervention) in median wait times (67 to 42 days; p = 0.05) and the proportions with prolonged (> 10 days) hospitalization (25.0% to 17.1%; p = 0.04) and any MCS or inotrope requirement (79.4% to 70.6%; p = 0.03) prior to transplant. Nationwide, median wait times were unchanged (p = 0.18) and prolonged pre-transplant hospitalization (p = 0.0009) and MCS/inotrope utilization (p < 0.0001) were increasingly common. At our program, there was no significant change in a composite of death or graft failure at 30 days (2.8% to 1.9%; p = 0.32) or 1 year (6.9% to 8.1%; p = 0.21) post-HT. Concurrently, there were modest changes nationwide in this composite outcome at 30 days (4.3% to 3.7%; p = 0.05) and 1 year (9.9% to 8.6%; p = 0.003). Conclusions: A “natural experiment” employing increased ECD utilization at a high-volume HT program was associated with decreases in wait times, duration of hospitalization, and MCS or inotrope requirement prior to transplant, with no accompanying change in recipient mix or post-transplant outcomes. Broader ECD utilization is likely a safe and resource-saving strategy to alleviate the donor shortage in HT.