Search

Diversity in the United States is a point of keen interest within the communities. In the heart transplant selection committees, most programs believe they have no bias in accepting patients for heart transplantation. However, there may be some inherent biases that are not due to the program's decisions, but rather institutional decisions or limitations. Such limitations may include lack of medical insurance, gender, age or geography that may be present without foreknowledge. Therefore, we assessed our heart transplant selection committee decisions to assess whether there is any inherent, institutional or voluntary bias within committee decisions. Between 2016 and 2020 we assessed 296 heart transplant candidates that were presented to the heart transplant selection committee. We assessed for various factors that may be associated with patients declined for transplant for age, gender, race, social support (SIPAT score), health insurance (Medicaid), and state of residence. The standard for comparison included a Caucasian with non-Medicaid health insurance, social support, and ability to travel. The declined patients compared to the accepted patients were significantly older (64.4 vs 54.6 years) and had a higher SIPAT score (13.7 vs 11.2). There was no difference between groups in % female, % non-Caucasian, % w/non-Medicaid health insurance and % from outside California. (see table) Inherent bias within a selection committee is difficult to interpret as older patients are held to a higher standard as older age is a risk factor for lower post-transplant survival. Higher SIPAT scores are also known to be a risk for lower survival due to higher psychosocial risk. It is comforting to appreciate that there does not appear to be inherent bias in gender, race, type of health insurance and region. Larger studies are needed. [ABSTRACT FROM AUTHOR]

Donor selection in heart transplant is not standardized. Many donor hearts (DH) are declined due to quality issues such as older age, low left ventricular ejection fraction, left ventricular hypertrophy, diastolic dysfunction, underlying coronary artery disease. Yet, DH declined at one center are subsequently accepted at another center. It is not well known whether DHs declined due to quality and accepted by another program have acceptable post-transplant outcomes. Between 2017 and 2019, we assessed 532 DHs that were allocated to a single center at Cedars-Sinai (CS). We declined 218 offers due to poor quality. We had follow-up with organ procurement organizations and found that 45 of these DHs that we turned down for poor quality were accepted by another program and transplanted. 1-year post-transplant survival of these patients were compared to those patients whose donor was accepted and transplanted at CS (n=314). The 45 declined DHs had the following issues: abnormal cardiac studies (n=12), donor cardiac history (n=6), other medical history including cirrhosis or infectious processes (n=6), possible cardiac cause of death (n=3), older age (n=14), estimated prolonged ischemic time (n=1), and other reasons (n=3). Compared to those patients transplanted at CS, there was no difference in 1-year patient or graft survival. The declined donor patients compared to CS patients had similar age and gender but had a longer cold ischemic time and less patients listed as high urgency status (status 1-3) at transplant. (see table). DHs declined for quality may be accepted at another program with good post-transplant survival. Contrary to belief, these DHs were mostly not transplanted into high urgency waitlist patients. Donor declines due to quality should be reviewed as they could lead to more lives saved. [ABSTRACT FROM AUTHOR]

Cardiac allograft vasculopathy (CAV) is one of the major factors limiting long-term survival. A severe form of CAV is small vessel disease which results in restrictive cardiac physiology (RCP). This RCP causes a very stiff heart which leads to significant reduction in cardiac index and elevation of cardiac pressures. The pathophysiology behind this RCP is most likely due to small vessel CAV with scarring and fibrosis. The outcome of patients with this RCP has not been well established. Between 2010 and 2017 we assessed 23 heart transplant patients who developed RCP defined by right atrial pressure ≥ 15 mmHg, pulmonary artery diastolic pressure ≥ 15 mmHg, pulmonary capillary wedge ≥ 15 mmHg, and cardiac index ≤ 2.2 mm. Subsequent outcomes after diagnosis of RCP were 3-year survival, freedom from CAV (angiographic stenosis>30%), non-fatal major adverse cardiac events (NF-MACE: MI, new CHF, PCI, ICD implant, stroke), development of donor-specific antibodies (DSA) and re-hospitalizations. 1-year freedom from acute cellular rejection (ACR) was also assessed as risk factors for the development of RCP. The study group was compared with a case-controlled group 2:1 matched by age, gender, and era. The average time from transplant to the diagnosis of RCP was 1.5 ± 1.4 years. The RCP group compared to control had significantly lower subsequent 3-year survival, 3-year freedom from CAV, NF-MACE and hospitalizations. There was also a lower freedom from 1-year cellular rejection episodes and DSA in the RCP group compared to control. (See table) Heart transplant patients who develop early RCP appear to have significantly reduced survival. ACR and DSA are associated with the development of RCP. As these patients do not appear to have a reversible cause, appropriate patients may be assessed for re-transplantation. [ABSTRACT FROM AUTHOR]