Friday, September 20, 2024: 5:00 PM - 6:30 PM
Omni King Edward Hotel
Objective: Organ recovery for heart transplantation (HT) has historically been performed by surgical fellows or attending cardiothoracic surgeons. In the era of machine perfusion, normothermic regional perfusion (NRP), and increasing utilization of expanded criteria and donation after cardiac death (DCD) donors, the need for highly skilled recovery surgeons has grown. Longer travel for heart recovery since the 2018 allocation change has increased strain on surgeons trying to balance clinical and other responsibilities, particularly at high volume centers. In an effort to alleviate this strain, our center incorporated an experienced and specially trained physician assistant (PA) as an integral lead surgeon for heart recoveries over the past two years. This strategy has mitigated the burden on cardiothoracic fellows and attendings while maintaining high quality allograft recovery. We sought to compare characteristics and outcomes of HT performed using this recovery strategy versus those in which heart recovery was performed only by physician surgeons.
Methods: We retrospectively reviewed all adult heart transplants between July 2022 and December 2023 at our institution. Patients undergoing multi-organ transplant and those with adult congenital heart disease were excluded. Patients were grouped based on the recovering team, either including a PA or exclusively faculty/fellow. We compared donor and recipient demographics, recovery characteristics such as procurement type (DBD, DCD), ischemic time, and recipient outcomes. Statistical comparisons were performed using Fisher's exact test for categorical variables and Wilcoxon signed-rank test for continuous variables.
Results: During the study period, 142 adult heart transplants met inclusion criteria. 92 recoveries (65%, 92/142) were performed by the PA and 50 recoveries (35%) were performed by surgical fellows/attendings. 63% (58/92) of the recoveries in the PA group were DCD compared to 24% (12/50) in the physician group (p<0.001). The average cold ischemic time was 210.5 ± 96.5 minutes in the PA group compared to 187.0 ± 66.8 minutes in the physician group (p=0.105). Among DCD-NRP recoveries, the rate of surgical complications resulting in organ turndown was lower in the PA group (0%, 0/58) compared to the physician group (16.6%, 2/12, p=0.027). All other donor characteristics and all recipient characteristics such as age, waitlist status, heart failure etiology, and lab values were similar between groups. Incidence of severe primary graft dysfunction (PGD) (8.7%, 8/92 v. 10.0%, 5/50, p>0.99) and one-year mortality were similar (2.2%, 2/92 v. 6.0%, 3/50, p=0.345) between groups.
Conclusions: In our experience, the utilization of an experienced surgical PA as opposed to cardiothoracic surgeons or fellows was associated with similar rates of severe PGD and 1-year survival among recipients, even in high-risk cases. As the number and complexity of heart recoveries increases, utilization of surgical PAs may afford cardiothoracic surgeons more bandwidth for other clinical and non-clinical responsibilities, while complementing the education of cardiothoracic surgical trainees.
Authors
Stephen DeVries (1), Swaroop Bommareddi (2), Mark Petrovic (2), Chen Chia Wang (2), Hasan Siddiqi (2), Kelly Schlendorf (2), Eric Quintana (2), Joseph Magliocca (2), Seth Karp (2), John Trahanas (2), Ashish Shah (2), Brian Lima (2)
Institutions
(1) Vanderbilt University Hospital, Nashville, TN, (2) Vanderbilt University Medical Center, Nashville, TN