Abstract
Institution-level strategic changes may be associated with heart transplant volume and outcomes. To describe changes in practice that markedly increased heart transplant volume at a single center, as well as associated patient characteristics and outcomes. A pre-post cohort study was conducted of 107 patients who underwent heart transplant between September 1, 2014, and August 31, 2019, at Yale New Haven Hospital before (September 1, 2014, to August 31, 2018; prechange era) and after (September 1, 2018, to August 31, 2019; postchange era) a strategic change in patient selection by the heart transplant program. Strategic change in donor and recipient selection at Yale New Haven Hospital that occurred in August 2018. Outcome measures were transplant case volume, donor and recipient characteristics, and 180-day survival. A total of 49 patients (12.3 per year; 20 women [40.8%]; median age, 57 years [interquartile range {IQR}, 50-63 years]) received heart transplants in the 4 years of the prechange era and 58 patients (58 per year; 19 women [32.8%]; median age, 57 years [IQR, 52-64 years]) received heart transplants in the 1 year of the postchange era. Organ offers were more readily accepted in the postchange era, with an offer acceptance rate of 20.5% (58 of 283) compared with 6.4% (49 of 768) in the prechange era (P < .001). In the postchange era, donor hearts were accepted with a higher median number of prior refusals by other centers than in the prechange era (16.5 [IQR, 6-38] vs 3 [IQR, 1-6]; P < .001). Hearts accepted in the postchange era were from older donors than in the prechange era (median age, 40 years [IQR, 29-48 years] vs 30 years [IQR, 24-42 years]; P < .001). Recipients had a significantly shorter time on the waiting list in the postchange era compared with prechange era (median, 41 days [IQR, 12-289 days] vs 242 days [IQR, 135-428 days]; P < .001). More patients were supported on temporary circulatory assist devices preoperatively in the postchange era than the prechange era (14 [24.1%] vs 0; P < .001). Survival rates at 180 days were not significantly different (43 [87.8%] in the prechange era vs 52 [89.7%] in the postchange era). Mortality while on the waiting list was similar (2.8 deaths per year in the prechange era vs 3 deaths per year in the postchange era). During the comparable time period, 4 other regional centers had volume change ranging from -10% to 68%, while this center's volume increased by 374%. This study suggests that strategic changes in donor heart and recipient selection may significantly increase the number of heart transplants while maintaining short-term outcomes comparable with more conservative patient selection. Such an approach may augment the allocation of currently unused donor hearts.
Highlights
In heart transplantation, there is uncertainty about who is eligible to receive donor hearts and which hearts are acceptable.1,2 For example, donor sequence number dictates how likely it is that the heart will be used, but donor sequence number correlates poorly with posttransplant outcomes.3 In addition, donor hearts traditionally perceived as high risk, including those from hepatitis C virus– positive donors4 and those with donation after circulatory death status,5 are being considered as potentially suitable donor hearts
Donor hearts were accepted with a higher median number of prior refusals by other centers than in the prechange era (16.5 [interquartile range (IQR), 6-38] vs 3 [IQR, 1-6]; P < .001)
This study suggests that strategic changes in donor heart and recipient selection may significantly increase the number of heart transplants while maintaining short-term outcomes comparable with more conservative patient selection
Summary
There is uncertainty about who is eligible to receive donor hearts and which hearts are acceptable. For example, donor sequence number dictates how likely it is that the heart will be used, but donor sequence number correlates poorly with posttransplant outcomes. In addition, donor hearts traditionally perceived as high risk, including those from hepatitis C virus– positive donors and those with donation after circulatory death status, are being considered as potentially suitable donor hearts. The evolving perception of acceptable donor hearts may lead centers to apply a more inclusive set of criteria for accepting hearts. It remains unknown how such multifaceted expansion for donor heart selection may be associated with transplant case volume and outcomes. Our hospital (Yale New Haven Hospital) experienced a 5-fold increase in heart transplant volume after restructuring of the heart failure service, change in surgical leadership, and adoption of a more aggressive philosophy on donor heart selection, accepting higher-risk donor hearts that coincided with implementation of the new United Network for Organ Sharing (UNOS) donor heart allocation system in the United States, which was implemented in 2018.6 In this study, we investigated the changes in donor and recipient characteristics that occurred during the case volume increase. Our goal is to provide accountability and insight regarding the increase in volume and to extract lessons for other centers contemplating a change in practice
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