Levine Cardiac Intensive Care Unit, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Division of Cardiology, Center for Heart and Vascular Care, University of North Carolina, Chapel Hill.
JAMA Cardiol. 2020 Jun 1;5(6):703-708. doi: 10.1001/jamacardio.2020.0692.
The new United Network for Organ Sharing (UNOS) donor heart allocation system gives priority to patients supported with nondischargeable mechanical circulatory support (MCS) devices while awaiting heart transplant. Whether there has been a change in temporary MCS use in cardiac intensive care units (CICUs) since the implementation of this policy is unknown.
To examine whether the UNOS donor heart allocation system revision in October 2018 was associated with changes in temporary MCS use in CICUs and whether temporary MCS use differed between US transplant centers and US nontransplant centers and Canadian centers.
DESIGN, SETTING, AND PARTICIPANTS: In this cohort study, 14 centers from the Critical Care Cardiology Trials Network (CCCTN), a multicenter network of tertiary CICUs in North America, contributed 2-month snapshots of consecutive medical CICU admissions between September 1, 2017, and September 1, 2018 (prerevision period), and October 1, 2018, and September 1, 2019 (postrevision period). CICUs were classified as US transplant centers (n = 7) or other CICUs (US nontransplant centers or Canadian centers; n = 7).
Revision to the UNOS donor heart allocation system.
Treatment with temporary MCS (intra-aortic balloon pump, microaxial intracardiac ventricular assist device, percutaneous centrifugal ventricular assist device, venoarterial extracorporeal membrane oxygenation, or surgically implanted, nondischargeable MCS device) during hospital admission.
A total of 384 admissions for acute, decompensated, heart failure-related cardiogenic shock (ADHF-CS) were included, among which 248 (64.6%) were to US transplant centers; 126 admissions (51%) were in the prerevision period and 122 (49%) were in the postrevision period. The mean (SD) patient age was 61.2 (14.6) years; 246 patients (64.1%) were male. The proportion of admissions with ADHF-CS managed with temporary MCS at US transplant centers significantly increased from 25.4% (32 of 126 admissions) before to 42.6% (52 of 122 admissions) after the UNOS allocation system changes (P = .004). In other CICUs, the proportion did not significantly change (24.5% [13 of 53 admissions] to 24.1% [20 of 83 admissions]; P = .95). After multivariable adjustment, patients admitted to US transplant centers in the postrevision period were more likely to receive temporary MCS compared with those admitted in the prerevision period (adjusted odds ratio, 2.19; 95% CI, 1.13-4.24; P = .02).
In the year after implementation of the new UNOS donor heart allocation system, temporary MCS use in patients admitted with ADHF-CS increased in US transplant centers but not in other CICUs. Whether this shift in practice will affect outcomes of patients with ADHF-CS or organ distribution should be evaluated.
新的美国器官共享联合网络（UNOS）供体心脏分配系统优先考虑等待心脏移植时使用不可移除的机械循环支持（MCS）设备的患者。自该政策实施以来，心脏重症监护病房（CICU）中临时 MCS 使用是否发生变化尚不清楚。
检查 2018 年 10 月 UNOS 供体心脏分配系统修订后，CICU 中临时 MCS 使用是否发生变化，以及美国移植中心与美国非移植中心和加拿大中心之间临时 MCS 使用是否存在差异。
设计、地点和参与者：在这项队列研究中，来自关键护理心脏病学试验网络（CCCTN）的 14 个中心（北美三级 CICU 的多中心网络）在 2017 年 9 月 1 日至 2018 年 9 月 1 日（修订前）和 2018 年 10 月 1 日至 2019 年 9 月 1 日（修订后）期间，连续 2 个月对连续的医学 CICU 入院进行了抽样。CICU 分为美国移植中心（n = 7）或其他 CICU（美国非移植中心或加拿大中心；n = 7）。
UNOS 供体心脏分配系统的修订。
在住院期间使用临时 MCS（主动脉内球囊泵、微轴内心室辅助装置、经皮离心心室辅助装置、静脉动脉体外膜氧合或手术植入、不可移除的 MCS 装置）。
共纳入 384 例急性失代偿性心力衰竭相关心源性休克（ADHF-CS）入院，其中 248 例（64.6%）为美国移植中心；126 例（51%）入院在修订前，122 例（49%）在修订后。患者的平均（SD）年龄为 61.2（14.6）岁；246 例患者（64.1%）为男性。在美国移植中心，管理 ADHF-CS 时使用临时 MCS 的入院比例从修订前的 25.4%（126 例入院中的 32 例）显著增加到修订后的 42.6%（122 例入院中的 52 例）（P = .004）。在其他 CICU 中，这一比例没有显著变化（24.5%[53 例入院中的 13 例]至 24.1%[83 例入院中的 20 例]；P = .95）。在多变量调整后，与修订前相比，修订后入院的美国移植中心患者更有可能接受临时 MCS（调整后的优势比，2.19；95%置信区间，1.13-4.24；P = .02）。
在新的 UNOS 供体心脏分配系统实施后的一年中，美国移植中心中 ADHF-CS 患者使用临时 MCS 的比例增加，而非其他 CICU 则没有增加。这种实践的转变是否会影响 ADHF-CS 患者的结局或器官分配，应进行评估。
