Should Orthotopic Heart Transplantation Using Marginal Donors Be Limited to Higher Volume Centers?

摘要

Study DesignData and Statistical AnalysisResultsOverall Study PopulationMarginal Versus Standard DonorsBaseline Donor Differences in Centers Using Marginal DonorsRecipient CharacteristicsPosttransplant MortalityPosttransplant ComplicationsCauses of DeathCommentVolume and Posttransplant Mortality in Marginal Donor OHTVolume and Secondary OutcomesStudy LimitationsReferencesThis study examined whether institutional volume impacts outcomes after orthotopic heart transplantation (OHT) utilizing marginal donors.MethodsAdult patients undergoing OHT with the use of marginal donors between 2000 and 2010 were identified in the United Network for Organ Sharing database. A previously derived and validated donor risk score (range, 1 to 15) was used to define marginal donors as those in the 90th percentile of risk (score ≥7). Patients were stratified into equal-size tertiles based on overall institutional OHT volume. Posttransplant outcomes were compared between these center cohorts.ResultsA total of 3,176 OHTs utilizing marginal donors were identified. In Cox regression analysis, recipients undergoing OHT at low-volume centers were at significantly increased risk of 30-day (hazard ratio 1.82 [1.31 to 2.54], p < 0.001), 1-year (hazard ratio 1.40 [1.14 to 1.73], p = 0.002), and 5-year posttransplant mortality (hazard ratio 1.29 [1.10 to 1.52], p = 0.02). These findings persisted after adjusting for recipient risk, differences in donor risk score, and year of transplantation (each p < 0.05). In Kaplan-Meier analysis, there was a similar trend of decreasing 1-year survival with decreasing center volume: high (86.0%), intermediate (85.7%), and low (81.2%; log rank p = 0.003). Drug-treated rejection within the first post-OHT year was more common in low-volume versus high-volume centers (34.3% versus 24.2%, p < 0.001). At an overall mean follow-up of 3.4 ± 2.9 years, low-volume centers also had higher incidences of death due to malignancy (2.8% versus 1.3%, p = 0.01) or infection (6.2% versus 4.1%, p = 0.02).ConclusionsConsolidating the use of marginal donors to higher volume centers may be prudent in improving post-OHT outcomes in this higher risk patient subset.CTSNet classification:34Adult Cardiac SurgeryThe Annals of Thoracic Surgery CME Program is located online at http://cme.ctsnetjournals.org. To take the CME activity related to this article, you must have either an STS member or an individual non-member subscription to the journal.The strategy of offering orthotopic heart transplantation (OHT) with marginal donor organs to high-risk candidates who do not meet standard listing criteria appears to offer some survival benefit to these patients, whose life expectancy is likely limited to several months without transplant.[