CHANGES IN HEART ALLOCATION FOR TRANSPLANTATION IN THE US AND WORLDWIDE: OPTIONS FOR A BETTER SOLUTION
Dan M. Meyer, M.D., University of Texas Southwestern, Med Center at Dallas, Dallas, TX, USA
Objectives: To inform the transplant community of potential modifications in the heart allocation system.
Background: Efforts to increase transplantation rates for candidates with highest waiting mortality and offer the greatest survival benefit due to transplantation remains the goal of our current systems. Modifications occurred in both the Eurotransplant system and the Organ Procurement and Transplant Network (OPTN) in 2005-6. Increases in recipients but not in available donors, continued elevated waiting list (WL) mortality in high acuity patients, and changing landscape of the WL with increased utilization of VADs, a call for a reassessment of the current allocation scheme was made. The OPTN Thoracic Committee was charged with the development a new allocation system and is considering an expanded multi-tiered scheme could potentially provide more definition of risk and disease severity.
Methods: Status IA patients over a recent 2-year period with the different criteria were analyzed, assessing WL mortality and post-transplant (PT) survival.
Results: Highest WL mortality included patients with IABP, ECMO, retransplantation, and those on mechanical ventilation. PT mortality was highest in the ECMO, TAH, retransplantation, and congenital heart disease patients, and those with ventricular arrhythmias. Many groups were small, making statistical comparison challenging. WL and PT mortality was lowest in patients on IV inotropes and invasive monitoring, and LVADs without complications.
Conclusions: Modification of the current system must encompass considerations in addition to the WL and PT mortality. LVAD utilization, presence of sensitization, and geographic variations in organ allocation will all interact to develop an effective and equitable system.