Extended criteria donor organ use for heart-lung transplantation in the modern era.

BACKGROUND: Demand for donor hearts and lungs exceeds their supply. Extended Criteria Donor (ECD) organs are used to help meet this demand, but their impact on heart-lung transplantation outcomes is poorly characterized. METHODS AND RESULTS: The United Network for Organ Sharing was queried for data on adult heart-lung transplantation recipients (n = 447) from 2005‒2021. Recipients were stratified based on whether they received ECD hearts and/or lungs. Morbidity was analyzed using Kruskal-Wallis, chi-square, and Fisher's exact tests. Mortality was analyzed using Kaplan-Meier estimation, log-rank tests and Cox regression. Sixty-five (14.5%) patients received two ECD organs, 134 (30.0%) received only an ECD lung, and 65 (14.5%) only an ECD heart. Recipients of two ECD organs were older, more likely to have diabetes, and more likely transplanted from 2015‒2021 (p < 0.05). Groups did not differ by pre-transplant diagnosis, intensive care unit disposition, life support use, or hemodynamics. Group five-year survival rates ranged from 54.5% to 63.2% (p = 0.428). Groups did not differ by 30-day mortality, strokes, graft rejection, or hospital length of stay. CONCLUSIONS: Using ECD hearts and/or lungs for heart-lung transplantation is not associated with increased mortality and is a safe strategy for increasing donor organ supply in this complex patient population.

Extended criteria donor organ use for heart-lung transplantation in the modern era

Abstract Background: Demand for donor hearts and lungs exceeds their supply. Extended Criteria Donor (ECD) organs are used to help meet this demand, but their impact on heart-lung transplantation outcomes is poorly characterized. Methods and results: The United Network for Organ Sharing was queried for data on adult heart-lung transplantation recipients (n = 447) from 2005‒2021. Recipients were stratified based on whether they received ECD hearts and/or lungs. Morbidity was analyzed using Kruskal-Wallis, chi-square, and Fisher's exact tests. Mortality was analyzed using Kaplan-Meier estimation, log-rank tests and Cox regression. Sixty-five (14.5%) patients received two ECD organs, 134 (30.0%) received only an ECD lung, and 65 (14.5%) only an ECD heart. Recipients of two ECD organs were older, more likely to have diabetes, and more likely transplanted from 2015‒2021 (p < 0.05). Groups did not differ by pre-transplant diagnosis, intensive care unit disposition, life support use, or hemodynam-ics. Group five-year survival rates ranged from 54.5% to 63.2% (p = 0.428). Groups did not differ by 30-day mortality, strokes, graft rejection, or hospital length of stay. Conclusions: Using ECD hearts and/or lungs for heart-lung transplantation is not associated with increased mortality and is a safe strategy for increasing donor organ supply in this complex patient population.

Neighborhood socioeconomic status is associated with differences in operative management and long-term survival after coronary artery bypass grafting.

OBJECTIVE: We sought to characterize differences in operative management and surgical outcomes after coronary artery bypass grafting associated with the socioeconomic context in which a patient lives. METHODS: We used a validated index of 17 variables derived from the US Census Bureau to assign socioeconomic status at the block group level to patients who underwent isolated coronary artery bypass grafting at a single institution over a 16-year period. Operative mortality, stroke, renal failure, prolonged ventilation, sternal wound infection, reoperation, composite morbidity or mortality, long-term survival, and use of arterial conduits were the outcomes assessed. RESULTS: This study was composed of 6751 patients. Lower socioeconomic status was significantly associated with increased rates of stroke, renal failure, prolonged ventilation, and composite morbidity or mortality in a multivariable analysis. Low socioeconomic status was significantly associated with poorer long-term adjusted survival (hazard ratio, 1.26; 95% confidence interval, 1.03-1.55). Finally, lower socioeconomic status was significantly associated with decreased use of more than 1 arterial conduits in a multivariable analysis. CONCLUSIONS: The socioeconomic context in which a patient lives is significantly associated with short- and long-term outcomes after coronary artery bypass grafting. There may also be variation in operative management, demonstrated by decreased use of arterial conduits. Lower rates of arterial revascularization among socioeconomically disadvantaged patients who undergo coronary artery revascularization may provide a target for intervention.

How Should ECMO Be Used Under Conditions of Severe Scarcity? A Population Study of Public Perception.

OBJECTIVE: To assess societal preferences regarding allocation of extracorporeal membrane oxygenation (ECMO) as a rescue option for select patients with coronavirus disease 2019 (COVID-19). DESIGN: Cross-sectional survey of a nationally representative sample. SETTING: Amazon Mechanical Turk platform. PARTICIPANTS: In total, responses from 1,041 members of Amazon Mechanical Turk crowd-sourcing platform were included. Participants were 37.9 ± 12.6 years old, generally white (65%), and college-educated (66.1%). Many reported working in a healthcare setting (22.5%) and having a friend or family member who was admitted to the hospital (43.8%) or died from COVID-19 (29.9%). MEASUREMENTS AND MAIN RESULTS: Although most reported an unwillingness to stay on ECMO for >one week without signs of recovery, participants were highly supportive of ECMO utilization as a life-preserving technique on a policy level. The majority (96.7%) advocated for continued use of ECMO to treat COVID patients during periods of resource scarcity but would prioritize those with highest likelihood of recovery (50%) followed by those who were sickest regardless of survival chances (31.7%). Patients >40 years old were more likely to prefer distributing ECMO on a first-come first-served basis (21.5% v 13.3%, p < 0.05). CONCLUSION: Even though participants expressed hesitation regarding ECMO in personal circumstances, they were uniformly in support of using ECMO to treat COVID patients at a policy level for others who might need it, even in the setting of severe scarcity.

Moderate Aortic Insufficiency with a Left Ventricular Assist Device Portends a Worse Long-Term Survival.

The development of aortic insufficiency (AI) is known to be associated with prolonged left ventricular assist device (LVAD) support, but its overall significance with regards to long-term outcomes is unclear. This uncertainty translates to a lack of consensus regarding the management of AI in this patient population-an increasingly pertinent question as more patients are placed on LVAD support as destination therapy. A retrospective review of a single, high-volume institution was performed to assess outcomes in patients who received a HeartMate II or HeartWare (LVAD) between 2008 and 2018. Patients were stratified by AI severity at 6 months, and those with LVAD support of less than 6 months were excluded. The primary endpoint was 2 year mortality, and secondary endpoints were right heart failure and functional exercise capacity. At 6 month follow-up 111, 92, and 18 patients had no (0), mild (1), and moderate (2) AI, respectively. Moderate AI was a significant predictor of 2 year mortality in a multivariable model (p = 0.024). Functional exercise capacity (measured by 6 minute walk test) and incidence of right heart failure at 1 year were not significantly different between groups (P = 0.1421; P = 0.2189). In conclusion, moderate AI at 6 months post-LVAD implant is associated with worse long-term mortality. More aggressive management strategies targeting AI development in long-term LVAD patients may be warranted.