Friday, September 20, 2024: 5:00 PM - 6:30 PM
Omni King Edward Hotel
Objective: In an effort to prioritize the most critically ill patients with heart failure and decrease overall waitlist mortality, the 2018 UNOS allocation policy change transitioned from a 3-tiered system, where Status 1A was composed of a heterogeneous group of qualifications, to a more stratified 6-tiered system. One concern was that overall transplant survival might decrease due to the increased acuity of the new Status 1 cohort, comprised primarily of those on ECMO support, who historically have experienced poor post-transplant survival. We aimed to evaluate our own institution's post-transplant survival in patients listed as Status 1 in the new era.
Methods: A single-center retrospective review of all adult heart transplant recipients with biventricular failure listed as Status 1 was conducted between 4/2019 and 4/2024. Patients who were listed as Status 1 by exception request for other causes were excluded. Demographic variables analyzed included age, gender, race, BMI, and etiology of heart failure. Waitlist variables included waitlist duration and mechanical circulatory support devices implanted during the waitlist period, including ECMO, Impella, IABP, RVAD, and durable LVAD. Intraoperative transplant variables analyzed included organs transplanted, cardiopulmonary bypass time, cold ischemia time, total operative time, and intraoperative blood products received. The primary outcome was 1-year mortality. Secondary outcomes focused on morbidity, and included prolonged intubation, tracheostomy, pneumonia, stroke, dialysis, reoperation for any cause, and ICU and postoperative lengths of stay.
Results: A total of 34 heart transplant recipients with biventricular failure who were listed as Status 1 were included over the study period. Median age of the cohort was 51 years, with a male predominance (82%). The majority of patients presented with non-ischemic cardiomyopathy (74%). All patients were bridged to transplant on mechanical circulatory support, half of whom required ECMO support (50%) for a median duration of 7 days. Those who were able to be weaned from ECMO support commonly required a combination of Impella and percutaneous RVAD support, with a median duration of 15 days. One patient was bridged to transplant with a total artificial heart that was implanted for 107 days prior to transplant. Median waitlist duration for the entire cohort was 9 days. While the majority of patients (62%) underwent isolated heart transplant, 21% received simultaneous heart/lung transplants, and 18% received heart/kidney transplants. Median cardiopulmonary bypass time was 139 minutes with a median cold ischemic time of 207 minutes. Total operative time ranged between 5 and 7 hours. Regarding the primary outcome, there were no 1-year mortalities at a mean follow up of 436 days. Postoperatively, 44% of patients experienced prolonged intubation. Nine patients underwent delayed chest closure, and seven patients required postoperative mechanical circulatory support. Median ICU length of stay was 9 days, with a median postoperative length of stay of 20 days.
Conclusions: The 2018 UNOS allocation policy change aimed to prioritize the highest acuity patients by awarding them Status 1 listing, raising concerns over post-transplant survival. We report our institutional experience with 34 patients with biventricular failure listed as Status 1 and successfully transplanted with no mortalities within 1 year.
Authors
Michael Dorsey (1), Jeffrey Park (1), Katherine Phillips (1), Alex Reyentovich (1), Randal Goldberg (1), Nader Moazami (1), Deane Smith (1)
Institutions
(1) NYU Langone Health, New York, NY