AT THE WTSA ANNUAL MEETING
COLORADO SPRINGS (FRONTLINE MEDICAL NEWS) – Diminished left ventricular systolic function alone should not be used as a basis for declining a donor heart for transplantation, Agustin Sibona, MD, asserted at the annual meeting of the Western Thoracic Surgical Association.
“Expansion of the donor pool to include more of these organs is appropriate,” said Dr. Sibona of Loma Linda (Calif.) University.
He presented an analysis of the United Network for Organ Sharing database that encompassed all adult isolated first-time heart transplants in the United States from 2000 through March 2016.
During a mean follow-up of 1,890 days, there was no significant difference in survival between the 28,044 patients whose donor heart had a normal LVEF of 55% or greater at the last measurement done before transplantation, the 2,187 recipients of a donor heart with an LVEF of 50%-54.9%, the 595 with a donor heart LVEF of 40%-49.9%, and the 95 patients whose donor heart had an LVEF of 30%-39.9%, Dr. Sibona reported .
“Carefully selected potential donor hearts with LVEF of 30% or higher should not be excluded from consideration of transplantation on the basis of depressed LVEF alone,” he concluded. “We’re not saying we should use every heart that has an EF of 35% or 45%. We say you should thoroughly evaluate those patients and those hearts and consider them.”
Roughly 500,000 people develop new end-stage heart failure each year. Heart transplantation has long been considered the definitive therapy for this condition. However, heart transplantation rates have remained static at 2,000-2,500 per year in the United States for the past 15 years because of the shortage of donor organs.
Previous work by Dr. Sibona’s senior coinvestigators has documented that 19% of potential donor hearts are not utilized for transplant solely based upon the presence of left ventricular dysfunction. That’s about 1,300 hearts per year.
“About 60% of those hearts had an LVEF greater than 40%. That’s 785 hearts. If only half of those are used, that still represents an increase in the domestic transplant rate of almost 20%,” he observed.
Twenty-one patients in the study received a heart with an LVEF of 20%-29.9%. They had an unacceptably high perioperative mortality.
There was no significant difference between the LVEF groups in terms of race, cause of death, or ischemic time.
Mean transplantation hospital length of stay varied inversely with donor heart LVEF, from 20.3 days in patients with a normal LVEF, to 23.9 days with an LVEF of 40%-49.9%, and 31.1 days with an LVEF of 30%-39.9%.
Study discussant Murray H. Kwon, MD, of Ronald Reagan UCLA Medical Center, speculated that the longer hospital stays may have been due to increasing degrees of primary graft dysfunction in concert with lower donor heart LVEF, necessitating interventions such as open-chest extracorporeal membrane oxygenation and an increased requirement for high-dose inotropes.
Dr. Sibona replied that unfortunately the UNOS database is not informative on that score.
Dr. Kwon offered a practical reservation about embracing the use of compromised donor hearts: “Ninety-one percent of programs in the U.S. do less than 30 heart transplants per year, and 76% do less than 20. Smaller programs won’t necessarily have the luxury of 6,000 days to see if their survival statistics bear out. If they have two or three deaths per year, that’s enough to get a notice from UNOS and CMS and private payers. So I would note some caution in that regard.”
He also posed a question: In this new era of highly effective left ventricular assist devices serving as a long-term bridge to transplant, does it make sense to turn to dysfunctional donor hearts?
“Ventricular assist devices are an evolving technology,” Dr. Sibona responded. “Short-term outcomes are equivalent to transplant, but the devices often have complications: GI bleed, stroke, thrombosis, and infections. So we still believe that heart transplantation is the gold standard for treatment. Remember, these patients have end-stage heart failure. Many can’t get out of bed without shortness of breath. So, yes, I would take those hearts.”
He reported having no financial conflicts regarding his study, which was supported by Loma Linda and Stanford universities.