Network For Organ Sharing Database Research Articles

An analysis of the number of liver and kidney transplantations during COVID-19 pandemic in Korea.

BackgroundThe severity of the coronavirus disease 2019 (COVID-19) pandemic has discouraged organ donation. However, the prevalence of COVID-19 in Korea was much lower in comparison to Western countries. With this, the authors decided to determine the real-world impact of COVID-19 on organ donation and transplantation in Korea.MethodsThe number of kidney transplantations (KTs) and liver transplantations (LTs) performed in 2020 were compared with those in 2019 using the Korean Network for Organ Sharing database and Asan Medical Center (AMC) database.ResultsThe annual number of deceased donors (DDs) was 450 in 2019 compared to 478 in 2020. Monthly DD number was 37.5±5.9 in 2019 and 39.8±4.4 in 2020 (P=0.284). Annual number of DD kidney transplant (DDKT) was 794 in 2019 and 848 in 2020, and monthly number was 66.1±10.4 in 2019 and 70.7±9.8 in 2020 (P=0.285). The annual number of DDLT was 391 in 2019 and 395 in 2020, and the monthly number was 32.6±5.7, 2019 and 32.9±4.7 in 2020 (P=0.877). The annual number of living donor (LD) KT was 2,293 in 2019 and 1,432 in 2020, and the monthly number was 191.1±19.5 in 2019 and 119.3±11.7 in 2020 (P<0.001). Annual number of living donor LDLT was 1,577 in 2019 and 1,146 in 2020, and monthly number was 131.4±18.1 in 2019 and 95.5±8.0 in 2020 (P<0.001). In the AMC, not all types of KT and LT changed significantly.ConclusionsThe results of this study indicate that the number of DD organ transplantations remained stable in Korea in 2020, but the number of LD organ transplantations was significantly reduced. However, the number of organ transplantations did not change in the AMC.

MILESTONE: More Than 1,200 Children Bridged to Heart Transplantation with Mechanical Circulatory Support.

Pediatric mechanical circulatory support (MCS) has been successfully used to bridge numerous children to transplantation who otherwise would have been unlikely to survive on the waitlist and, in many cases, make them better transplant candidates. The purpose of this study was to analyze what the pediatric heart failure community has achieved over the last 15 years in reaching 1,200 cases of bridging children to heart transplantation. The United Network for Organ Sharing database was used to identify MCS patients ages 0-18 at the time of listing for heart transplantation between 2005 and 2019, divided into three eras: first (2005-2009), second (2010-2014), and third (2015-2019). From 2005 to 2019, 1,289 pediatric cases were identified. More patients were successfully bridged to transplantation with MCS in the third-era (28%) [vs. first-era (16%), second-era (24%), p ≤ 0.004]. The proportion of discharges on ventricular assist device has increased as well from 3% to 22% (p < 0.001). Post-transplant survival was significantly better in the third era (1-year survival: 96%; 3-year survival: 89%) compared to the two previous eras (p = 0.006). On MCS, renal dysfunction, ventilator dependence, inotrope use, and functional status improved from the time of listing to transplantation (p < 0.01). Hepatic dysfunction (p < 0.001), renal dysfunction (p = 0.004), congenital heart disease (p = 0.023), and infant age (p = 0.002) were risk factors for post-transplant mortality. Over the last 15 years, pediatric MCS has become an accepted and increasingly used strategy for bridging children to transplantation. MCS therapy is associated with improved end-organ function at the time of transplantation, perhaps contributing to the increasing post-transplantation survival of patients bridged with MCS.

Lung transplantation for chronic obstructive pulmonary disease: A call to modify the lung allocation score to decrease waitlist mortality

ObjectiveApproximately 40% of lung transplants for chronic obstructive pulmonary disease (COPD) in the lung allocation score era are single lung transplantations (SLTs). We hypothesized that double lung transplantation (DLT) results in superior survival, but that mortality on the waitlist may compel clinicians to perform SLT. We investigated both waitlist mortality in COPD patients with restricted versus unrestricted listing preferences and posttransplant survival in SLT versus DLT to identify key predictors of mortality. MethodsA retrospective analysis of waitlist mortality and posttransplant survival in patients with COPD was conducted using post-lung allocation score data from the United Network for Organ Sharing database between 2005 and 2018. ResultsOf 6740 patients with COPD on the waitlist, 328 (4.87%) died and 320 (4.75%) were removed due to clinical deterioration. Median survival on the waitlist was significantly worse in patients listed as restricted for DLT (4.39 vs 6.09 years; P = .002) compared with patients listed as unrestricted (hazard ratio, 1.34; 95% CI, 1.13-1.57). Factors that increase waitlist mortality include female sex, increased pulmonary artery pressure, and increased wait time. Median posttransplant survival was 5.3 years in SLT versus 6.5 years in DLT (P < .001). DLT recipients are younger, male patients with a higher lung allocation score. The survival advantage of DLT persisted in adjusted analysis (hazard ratio, 0.819; 95% CI, 0.741-0.905). ConclusionsRestricted listing preference is associated with increased waitlist mortality, but DLT recipients have superior posttransplant survival. Because the lung allocation score does not prioritize COPD, concern for increased waitlist mortality with restricted listing preference may drive continued use of SLT despite better posttransplant survival in DLT.

Race/Ethnicity Is Not Independently Associated with Risk of Adverse Waitlist Removal among Patients with HCC Exception Points.

(1) Background: Since 2015, exception points have been awarded to appropriate candidates after six months of waitlist time to allow more equitable access to liver transplants regardless of hepatocellular carcinoma status. However, it remains unknown whether racial disparities in outcomes among waitlisted patients remain after the introduction of a 6-month waiting period for exception points. (2) Methods: Using the United Network for Organ Sharing database, we identified 2311 patients diagnosed with hepatocellular carcinoma listed for liver transplant who received exception points from 2015 to 2019. The outcome of interest was waitlist survival defined as the composite outcome of death or removal for clinical deterioration. Competing risk analysis was used to identify factors associated with death or removal for clinical deterioration. The final model adjusted for age, sex, race/ethnicity, blood type, diabetes, obesity, laboratory MELD score, tumor size, AFP, locoregional therapies, UNOS region, and college education. (3) Results: No difference was found in the risk of adverse waitlist removal among ethnic/racial groups.

Utilization and effectiveness of the organ procurement and transplantation network “safety-net” policy

BackgroundLiver transplant recipients with persistent renal dysfunction may be prioritized on the kidney transplant waitlist based on the Organ Procurement and Transplantation Network “safety-net” policy implemented in 2017. The aim of this study was to evaluate the utilization of kidney transplant and posttransplant outcomes, of liver transplant recipients with persistent renal dysfunction before and after implementation of the Organ Procurement and Transplantation Network kidney safety-net policy and standardization of simultaneous liver-kidney requirements. MethodsUsing the United Network for Organ Sharing database from January 2015 to March 2019, outcomes of liver transplant recipients listed for kidney transplant and the subset who received kidney after liver transplants were compared before and after policy implementation. ResultsLiver transplant recipients listed for kidney transplant increased from 58 to 200, and kidney after liver transplants increased from 29.3% to 42.5% after safety-net policy implementation. Post-policy kidney after liver transplants received more local organs (91.8% vs 70.6%, P = .03) and trended toward shorter waitlist time (47 [17–123] vs 84 [37–226] days, P = .051). The pre- and post-policy cohorts had similar (P > .05) kidney donor profile index (0.43 [0.27–0.69] vs 0.42 [0.28–0.58]) and delayed graft function (11.8% vs 14.1%). Patient, kidney graft, and liver graft survival were similar (P > .05) between pre and post-policy cohorts. Patient and kidney graft survival were similar between kidney after liver transplants and propensity score–matched kidney transplant alone recipients. Patient, kidney, and liver graft survival were similar between kidney after liver transplants and propensity score–matched simultaneous liver-kidney transplant recipients. ConclusionThis study demonstrates that after Organ Procurement and Transplantation Network “safety-net” policy implementation, there has been an increase in liver transplant recipients with renal dysfunction who are listed for and undergo kidney transplant with excellent short-term results.

Impact of Obesity on Heart Transplantation Outcomes.

BackgroundPatients with obesity and advanced heart failure face unique challenges on the path to heart transplantation. There are limited data on waitlist and transplantation outcomes in this population. We aimed to evaluate the impact of obesity on heart transplantation outcomes, and to investigate the effects of the new organ procurement and transplantation network allocation system in this population.Methods and ResultsThis cohort study of adult patients listed for heart transplant used the United Network for Organ Sharing database from January 2006 to June 2020. Patients were stratified by body mass index (BMI) (18.5–24.9, 25–29.9, 30–34.9, 35–39.9, and 40–55 kg/m2). Recipient characteristics and donor characteristics were analyzed. Outcomes analyzed included transplantation, waitlist death, and posttransplant death. BMI 18.5 to 24.9 kg/m2 was used as the reference compared with progressive BMI categories. There were 46 645 patients listed for transplantation. Patients in higher BMI categories were less likely to be transplanted. The lowest likelihood of transplantation was in the highest BMI category, 40 to 55 kg/m2 (hazard ratio [HR], 0.19 [0.05–0.76]; P=0.02). Patients within the 2 highest BMI categories had higher risk of posttransplantation death (HR, 1.29; P<0.001 and HR, 1.65; P<0.001, respectively). Left ventricular assist devices among patients in obese BMI categories decreased after the allocation system change (P<0.001, all). After the change, patients with obesity were more likely to undergo transplantation (BMI 30–35 kg/m2: HR, 1.31 [1.18–1.46], P<0.001; BMI 35–55 kg/m2: HR, 1.29 [1.06–1.58]; P=0.01).ConclusionsThere was an inverse relationship between BMI and likelihood of heart transplantation. Higher BMI was associated with increased risk of posttransplant mortality. Patients with obesity were more likely to undergo transplantation under the revised allocation system.

Abstract 11786: Heart Transplant in Congenital Heart Disease: Trends in Mortality With Ventricular Assist Devices

Introduction: Patients with congenital heart disease (CHD) may require cardiac transplantation for either primary management or failed surgical palliation. This study describes 1-year mortality of patients with CHD listed for transplant, trends in 1-year mortality over three decades, and use of mechanical support in this population. Methods: The United Network for Organ Sharing database was queried to identify patients aged 0-30 years with CHD listed for transplant from 1990 to 2019. VAD status at listing and 1-year mortality after listing were examined using the Cochran-Armitage trend test. Results: Overall, 9327 patients with CHD aged 0-30 years were listed for transplant between 1990 and 2019 with a total 1-year mortality rate of 26% (n=2466). For non-survivors to 1-year after listing, 66% (n=1619) died before transplant and 34% (n=847) after transplant. Patients &lt;1 year of age were the most frequent age group listed for transplant (n=3678, 39%) and experienced the highest 1-year mortality after listing (n=1264, 34%). The 1-year overall mortality decreased over the study period (1990-1999: 33% vs 2000-2009: 30% vs 2010-2019: 19%, p&lt;0.0001), including in infants &lt;1 year of age (1990-1999: 41% vs 2000-2009: 37% vs 2010-2019: 26%, p&lt;0.0001). Overall, few patients were supported with VAD at listing (3.1%). However, VAD use increased (1990-1999: 1.0% vs 2000-2009: 2.8% vs 2010-2019: 5.0%, p&lt; 0.0001) and the 1-year mortality for patients with VAD at listing decreased over time (1990-1999: 57% vs 2000-2009: 35% vs 2010-2019: 20%, p&lt;0.0001). Conclusions: Survival after listing for heart transplant is improving, however mortality amongst infants remains high. While there has been &gt;50% improvement in survival in patients of all ages with CHD supported with a VAD at listing, VADs are used rarely in patients with CHD. Further study is needed to understand which patients may benefit from mechanical circulatory support, especially among infants.

Abstract 12292: Trends and Outcomes of Cardiac Transplantation in the Lowest Urgency Candidates

Introduction: Due to discrepancies between donor supply and recipient demand, the cardiac transplantation process aims to prioritize the most medically urgent patients. It remains unknown how recipients with the lowest medical urgency compare to others in the allocation process. Methods: We performed a retrospective analysis of the United Network for Organ Sharing database. Patients listed for cardiac transplantation between January 2011 to May 2020 were stratified according to status at time of transplantation. Baseline recipient and donor characteristics, waitlist survival, and post-transplantation outcomes were compared between lower urgency listing and higher urgency listing in the years before and after the 2018 allocation system change. Results: Lower urgency patients in the old system were older (58.5 vs. 56 years) and more likely female (54.4% vs. 23.8%) compared to the highest urgency patients, and these trends persisted in the new system for the lowest urgency patients (59 vs. 55 years; 47.0% vs. 23.9% female; p&lt;0.001, all). Donors for the lowest urgency patients were more likely older, female, or have a history of CMV, hepatitis C, or diabetes (p&lt;0.01, all). The lowest urgency patients had longer waitlist times, and under the new allocation system these patients received organs from shorter distances and with decreased ischemic times (178 vs. 269 miles, 3.1 vs 3.5 hours; p&lt;0,001, all). There was no difference in post-transplantation survival (p&lt;0.01, all). Conclusions: Cardiac transplantation for lower urgency patients has not been well characterized. Our analysis demonstrates that, over the last decade, these patients receive hearts from donors with additional comorbidities compared to higher urgency patients but that outcomes are similar at one year. Our results may support the utility of early listing and less stringent thresholds for organ acceptance to increase access to cardiac transplantation.

Abstract 12426: Influence of Body Mass Index in Donor Recipient Size Mismatch in Pediatric Heart Transplantation

Introduction: Body weight has been the traditional metric for matching donor and recipient size for pediatric heart transplantation (pHT). However, the impact of such mismatch is not well established. We hypothesized that mismatch in compound measures such as body mass index (BMI) or body surface area (BSA) rather than weight, may impact outcomes of pHT and therefore should be used for donor-recipient size matching. Methods: Analysis of the United Network for Organ Sharing database limited to pHT recipients was performed. Donor and recipient mismatch tertiles were created for weight, BMI, and BSA ratios. Differences in recipient characteristics between each tertile were studied using univariate analysis. Multivariable analysis was used to assess the impact of each mismatch on one-year survival. Kaplan Meier analysis was used to assess overall survival. Results: A total of 4,465 pHT patients were available and included in the analysis of which 43% had congenital heart disease (CHD). Overall, those with low donor-recipient ratio for BMI were more likely to be younger recipients, less likely to be Caucasian and be on ECMO (all p&lt;0.01). In both CHD and non-CHD cohorts, multivariable regression analysis showed that use of ECMO (CHD OR 3.97; non-CHD OR 3.24), presence of liver dysfunction (CHD OR 1.10; non-CHD OR 1.11), and low donor to recipient BMI ratio (compared to normal) (CHD OR 1.70; non-CHD OR 2.28) were the only predictors of one-year mortality (all p &lt;0.001). Low BMI ratio was also associated with worse long-term survival in non-CHD groups, but not in the CHD cohort. This finding probably reflects inferior overall outcomes in the CHD cohort. Weight and BSA ratio did not predict one year or long-term survival. Conclusions: Traditional matching practice using weight may be inadequate and use of BMI matching may provide improved donor-recipient matching. Use of low BMI donors compared to recipients may predict poor early and long-term survival and therefore should be avoided in pediatric heart transplantation. Further refinement of matching may be needed in specific recipient populations.

Impact of the 2018 change in US allocation policy on adults with congenital heart disease

The US adult heart allocation policy was changed on October 18, 2018. This study aims to evaluate its impact on orthotopic heart transplantation (OHT) for adults with congenital heart disease (ACHD).The United Network for Organ Sharing database was used to perform 2 comparisons: waitlist outcomes among listed ACHD candidates, and post-transplant outcomes in those transplanted. Waitlisted candidates were stratified by date of waitlisting: Period 1: 2010 to 2013; Period 2: 2014 to October 17, 2018 and Period 3: October 18, 2018 to March 20, 2020. Transplanted ACHD patients were similarly stratified but by date of transplantation. Competing risk regression for waitlist outcomes was performed. Post-transplant survival was analyzed using the Kaplan-Meier method and multivariable Cox regression.Nine hundred and seventy-six patients with ACHD were waitlisted for OHT in our study: 343(35.1%), 466(47.8%), and 167(17.1%) in periods 1, 2, and 3. Post-policy change, 1-year cumulative incidence of waitlist mortality or deterioration decreased (p = 0.02). Six hundred and forty-eight patients were transplanted: 221(34.1%), 329(50.8%) and 98(15.1%) respectively. In those transplanted, post-policy median waitlist time (174, 161 and 38 days, p < 0.001) decreased and the use of intra-aortic balloon pumps increased (1.4%, 4.9% and 19.4%, p < 0.001). Compared to periods 1 and 2, risk-adjusted post-transplant 1-year mortality was similar to period 3 (HR 1.10, 95% CI 0.52-2.32; p = 0.81) (HR 1.19, 95% CI 0.58-2.46, p = 0.63).The recent US allocation policy change may have resulted in reduced waitlist times and 1-year waitlist mortality for OHTs in ACHD patients. Early post-transplant outcomes appear comparable post-policy change.

A Risk Assessment Model for Stroke in the Early Post-Transplant Period in Adult Cardiac Allograft Recipients: A UNOS Database Analysis

Stroke risk in adult cardiac allograft recipients in the early postoperative period remains less defined. This study attempts to develop a risk assessment model in this population. Patients (≥18 years of age) between 2005 and 2015 who underwent cardiac transplantation were selected from the United Network for Organ Sharing database. The final study cohort had 20,915 patients. Risk factors were identified and multivariate logistic regression was used to test associations. SAS software was used for analyses. Male recipients had a lower risk (odds ratio [OR] 0.7 [0.6-0.92]; P < .05) for stroke. Prolonged ischemic time (OR 1.2 [1.1-1.3), mechanical ventilation (OR 1.6 [1.2-1.9]), left ventricular assist device support (OR 1.8 [1.4-2.3]), black or Hispanic ethnicity (OR 1.33 [1.04-1.7]), days in status 1A (OR 1.05 [1.01-1.1]), recipient creatinine (OR 1.2 [1.02-1.4]), and type 2 diabetes (OR 1.4 [1.1-1.7]) were significant risk factors. A risk score was generated. Patients with a score of 8 had a 5-fold increase in event rate as compared with those with a score of 0. The c-statistic for this model was 0.65. For the first time, a weighted risk score GIMVECH (female gender, ischemic time, mechanical ventilation, left ventricular assist device support, ethnicity, clinical history) was generated to assess stroke in the early post-transplant period.

Trends and Outcomes of Cardiac Transplantation in the Lowest Urgency Candidates.

BackgroundBecause of discrepancies between donor supply and recipient demand, the cardiac transplantation process aims to prioritize the most medically urgent patients. It remains unknown how recipients with the lowest medical urgency compare to others in the allocation process. We aimed to examine differences in clinical characteristics, organ allocation patterns, and outcomes between cardiac transplantation candidates with the lowest and highest medical urgency.Methods and ResultsWe performed a retrospective analysis of the United Network for Organ Sharing database. Patients listed for cardiac transplantation between January 2011 and May 2020 were stratified according to status at time of transplantation. Baseline recipient and donor characteristics, waitlist survival, and posttransplantation outcomes were compared in the years before and after the 2018 allocation system change. Lower urgency patients in the old system were older (58.5 versus 56 years) and more likely female (54.4% versus 23.8%) compared with the highest urgency patients, and these trends persisted in the new system (P<0.001, all). Donors for the lowest urgency patients were more likely older, female, or have a history of cytomegalovirus, hepatitis C, or diabetes (P<0.01, all). The lowest urgency patients had longer waitlist times and under the new allocation system received organs from shorter distances with decreased ischemic times (178 miles versus 269 miles, 3.1 versus 3.5 hours; P<0.001, all). There was no difference in posttransplantation survival (P<0.01, all).ConclusionsPatients transplanted as lower urgency receive hearts from donors with additional comorbidities compared with higher urgency patients, but outcomes are similar at 1 year.

Contemporary outcomes of durable ventricular assist devices in adults with congenital heart disease as a bridge to heart transplantation.

This study aimed to compare the clinical characteristics, risk factors, and overall survival outcomes in adults with congenital heart disease (ACHD) bridged to transplantation with a ventricular assist device (VAD) versus no-VAD. The study included 894 ACHD patients aged ≥18years listed for primary heart transplantation between 2010 and 2019 from the United Network for Organ Sharing database. Primary outcomes were waitlist and 1-year post-transplant mortality between VAD and no-VAD ACHD patients. Of 894 ACHD patients included in the study, 91(10.1%) had VAD support at the time of listing. Patients who needed VAD support were mostly males, heavier, and had higher pulmonary artery pressure than the no-VAD group at the listing. The overall waitlist mortality was 38% in the VAD group than 17% in the no-VAD group (p<0.01). ECMO use was associated with significantly higher mortality than either group. There was no significant difference in 1-year post-transplant mortality between VAD versus no-VAD at the time of transplant (15% vs. 17%; p=0.66). Multivariate regression analysis found that BMI <20kg/m2 (hazard ratio (HR) 1.1; p=0.01), bilirubin >2mg/dl (HR 1.1; p=0.03), creatinine >2mg/dl (HR 1.3; p=0.04) and ECMO at transplant (HR 1.4; p=0.03) increased early post-transplant mortality. The one-year post-transplant mortality rate was no different for ACHD patients that received VAD versus no-VAD. These findings suggest that a VAD should be considered an option to support ACHD patients as a bridge to heart transplantation.

Prevalence, Clinical Characteristics, and Outcomes Among Lung Transplant Recipients of Donors With Cocaine Use

There is limited data regarding lung transplant (LT) outcomes among recipients of donors with a history of cocaine use. We sought to assess the burden of cocaine abuse among LT donors, describe their characteristics, and evaluate the association with post-transplant outcomes. From the United Network for Organ Sharing database, we included adult patients (age ≥18 years) who underwent LT between 1996 and 2014 (N=20,106; mean age 53.7 ± 13 years; male: 57%). Study groups were divided based on the donor history of recent cocaine abuse (last 6 months). Donor and recipient characteristics were compared between the 2 groups. With 1-year survival as the primary endpoint, multivariate logistic regression analysis was conducted to assess for an independent association with the donor history of cocaine use. The overall frequency of donors with any history of cocaine use was 10.9% (n=2189), although less than half were current users (n=1001, 4.98%). Unadjusted 1-year survival was worse among recipients of donors with current cocaine use, although it did not achieve statistical significance (84.4% vs 82.2%; odds ratio 1.17, 95% confidence interval 0.99-1.38; P=.07). After adjusting for potential confounders, the current use of cocaine was not associated with 1-year survival (adjusted OR 1.06, 95% CI 0.95-1.18; P=.29). A significant proportion of lung donors have a history of cocaine abuse. Although unadjusted early outcomes appear to worsen among recipients of active cocaine users, an independent association was not seen with 1-year survival. The current analysis supports the continued use of donors with a history of cocaine abuse, assuming they meet other criteria for organ quality.

Short and long term outcomes of cardiac amyloidosis patients listed for heart transplantation in the united states: a propensity-matched analysis

Abstract Background Heart transplantation (HT) in cardiac amyloidosis (CA) patients has been historically controversial due to the risk of amyloid recurrence. However, recent single-center experiences suggest good outcomes in carefully selected patients. We sought to evaluate contemporary outcomes of CA patients listed for HT in the U.S. and evaluate predictors of survival Methods Using data from the United Network for Organ Sharing database on adult patients listed for a donor heart in the U.S. between 2010 and 2019, we identified 3 cohorts of patients, namely CA, dilated cardiomyopathy (DCM), and non-CA restrictive cardiomyopathy (RCM). Propensity-match analysis was used to compare primary outcomes of waitlist mortality and post-transplant graft survival between CA and DCM. Results Over the study period, 411 CA patients (mean age 62.7 years, 16.1% female) were added to the waitlist. In the propensity-matched cohorts, the rates of waitlist mortality were 33.7, 15.8, and 15.6 per 100 person-years for CA, DCM, and non-CA RCM, respectively. Compared to DCM, there was significantly higher waitlist mortality for CA (HR=1.75, 95% CI=1.16–2.65). Over the study period, 330 CA patients were transplanted with donor hearts. The 1-year graft survival rates for CA, DCM, and non-CA RCM were 89%, 92%, and 86%, respectively; and 5-year graft survival rates were 78%, 82%, and 76%, respectively. Graft survival for CA was significantly worse than DCM (HR=1.46, 1.03–2.08), and the two most significant risk factors for poor graft survival among CA patients were renal failure requiring dialysis while on the waitlist (HR=5.4, 1.6–17) and prior history of malignancy (HR=1.7, 1.0–29). CA patients with neither of the risk factor had 1- and 5-year graft survival that is comparable to those of DCM (HR=1.18, 0.81–1.74). On the other hand, CA patients with either of the risk factor had 1- and 5-year graft survival of 81% and 65%, respectively, (HR=2.33, 1.40–3.87, compared to DCM). Conclusion CA patients experience higher waitlist mortality and worse post-transplant graft survival compared to DCM. However, we identified two risk factors that can be used for further risk-stratification in these patients to achieve comparable graft survival as DCM. Funding Acknowledgement Type of funding sources: None.

Better together: a reappraisal of heterotopic heart transplantation.

Heterotopic heart transplantation (HHT) is rare in the modern era. When used as a biologic left ventricular assist, HHT provides pulsatile flow, supports the left ventricle with a physiologic cardiac output, responds to humoral stimuli, and with modern immunosuppression may offer long-term untethered survival. This study was undertaken to compare survival of HHT with orthotopic heart transplantation (OHT) to assess its viability in the modern era. In the United Network for Organ Sharing database, from January 1999 to December 2020, there were 27691 bicaval OHT, 13836 biatrial OHT, 1271 total OHT, and 51 HHT with sufficient follow-up. Survival was analyzed using restricted mean survival time (RMST) through 4 years as the outcome. In the first 4 years after transplant, compared with HHT, differences in RMST were 0.1 years (99% CI: -0.4 to 0.5 years) for bicaval OHT, 0.0 years (99% CI: -0.4 to 0.5 years) for biatrial OHT, and 0.0 years (99% CI: -0.5 to 0.4 years) for total OHT. In this cohort, survival was indistinguishable between HHT and OHT recipients in the first four years. Thus, HHT might be a viable alternative to durable mechanical circulatory assist particularly with size mismatched grafts or for patients with refractory pulmonary hypertension.

PH-ILD: Identification, Evaluation, and Monitoring: A Diagnostic View From Both Sides

PH-ILD: Identification, Evaluation, and Monitoring: A Diagnostic View From Both Sides

Postoperative Outcomes in Infants Undergoing ABO-incompatible Heart Transplantation in the United States

BackgroundABO-incompatible heart transplant is a method to increase the infant donor pool. However data on long-term survival and rejection after ABO-incompatible heart transplant in recent era are limited. MethodsThe United Network for Organ Sharing database was queried for infant heart transplants performed from January 2008 to March 2020. Patient demographics and known risk factors for posttransplant mortality were collected. Statistical analysis using Bayesian additive regression trees was performed to evaluate the association of ABO incompatibility and overall survival, graft survival, acute rejection episodes, and length of stay. ResultsOf 1368 included infants (age < 1 year), 280 (20.47%) were ABO incompatible. ABO incompatibility was not associated with increased all-cause mortality, acute rejection episodes, or length of stay, whereas extracorporeal membrane oxygenation and intubation status of the recipient at the time of transplantation were associated with increased all-cause mortality and graft failure. Idiopathic cardiomyopathy was associated with a decreased likelihood of posttransplant all-cause mortality. One-, 5-, and 10-year survival rates among compatible vs incompatible transplants were estimated to be 90% vs 88%, 82% vs 79%, and 77% vs 73%, respectively. ConclusionsABO-incompatible infant heart transplant does not affect posttransplant survival, incidence of rejection, or postoperative length of stay. Therefore it remains a viable and important strategy to increase the infant donor pool.

Epstein-Barr Virus Predicts Malignancy After Pediatric Heart Transplant, Induction Therapy and Tacrolimus Don’t

BackgroundPatients after heart transplantation are at increased risk for malignancy secondary to immunosuppression and oncogenic viral infections. Most common among children is posttransplant lymphoproliferative disorder (PTLD), occurring in 5% to 10% of patients. We used a national database to examine the incidence and risk factors for posttransplant malignancy. MethodsThe United Network for Organ Sharing database was queried for pediatric (<18 years) heart transplant recipients from October 1987 through November 2019. Freedom from malignancy after transplant was assessed with Kaplan-Meier analysis. Cox regression was performed to generate hazard ratios (HRs) and 95% CIs for risk of malignancy development. ResultsOf 8581 pediatric heart transplant recipients, malignancy developed in 8.1% over median follow-up time of 6.3 years, with PTLD compromising 86.4% of the diagnosed cancers. The incidence of PTLD development was 1.3% at 1 year and 4.5% at 5 years. Older age at the time of transplant was protective against the development of malignancy (HR, 0.98; 95% CI, 0.96-0.99; P < .001), whereas a history of previous malignancy (HR, 1.9; 95% CI, 1.2-3.0; P = .007) and Ebstein-Barr virus (EBV) recipient-donor mismatch (HR, 1.7; 95% CI, 1.3-2.2; P < .001) increased the risk. Induction therapy, used in 78.9% of the cohort, did not increase malignancy risk (P = .355) nor did use of maintenance tacrolimus (P = .912). ConclusionsPTLD occurred after 7% of pediatric heart transplants, with risk increased by younger age and EBV mismatch, highlighting the importance of PTLD monitoring in EBV-seronegative recipients. Induction therapy, used in most of the pediatric heart transplants, does not seem to increase posttransplant malignancy nor does tacrolimus, the most commonly used calcineurin inhibitor.

Evaluation of Racial and Ethnic Disparities in Cardiac Transplantation.

BackgroundRacial and ethnic disparities contribute to differences in access and outcomes for patients undergoing heart transplantation. We evaluated contemporary outcomes for heart transplantation stratified by race and ethnicity as well as the new 2018 allocation system.Methods and ResultsAdult heart recipients from 2011 to 2020 were identified in the United Network for Organ Sharing database and stratified into 3 groups: Black, Hispanic, and White. We analyzed recipient and donor characteristics, and outcomes. Among 32 353 patients (25% Black, 9% Hispanic, 66% White), Black and Hispanic patients were younger, more likely to be women and have diabetes mellitus or renal disease (all, P<0.05). Over the study period, the proportion of Black and Hispanic patients listed for transplant increased: 21.7% to 28.2% (P=0.003) and 7.7% to 9.0% (P=0.002), respectively. Compared with White patients, Black patients were less likely to undergo transplantation (adjusted hazard ratio [aHR], 0.87; CI, 0.84–0.90; P<0.001), but had a higher risk of post‐transplant death (aHR, 1.14; CI, 1.04–1.24; P=0.004). There were no differences in transplantation likelihood or post‐transplant mortality between Hispanic and White patients. Following the allocation system change, transplantation rates increased for all groups (P<0.05). However, Black patients still had a lower likelihood of transplantation than White patients (aHR, 0.90; CI, 0.79–0.99; P=0.024).ConclusionsAlthough the proportion of Black and Hispanic patients listed for cardiac transplantation have increased, significant disparities remain. Compared with White patients, Black patients were less likely to be transplanted, even with the new allocation system, and had a higher risk of post‐transplantation death.