Division of Cardiac Surgery, Department of Surgery, Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA. Electronic address: http://www.twitter.com/CoreLabUCLA.
Division of Cardiac Surgery, Department of Surgery, Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA. Electronic address: http://www.twitter.com/DrZacharyTran.
Surgery. 2022 Sep;172(3):844-850. doi: 10.1016/j.surg.2022.03.032. Epub 2022 Apr 28.
The present study characterizes the association of center-level temporary mechanical circulatory support use with waitlist outcomes after the 2018 adult heart allocation policy change.
The United Network for Organ Sharing database was queried for all single-organ, adult heart transplant candidates from November 2015 to October 2021. The study population was divided into 2 cohorts, prepolicy and postpolicy, centered around the rule change on October 18, 2018. The primary study outcome was center-level rate of poor waitlist outcome, defined as death or deterioration on the waitlist. Competing-risks regression was used to generate risk-adjusted rates of poor waitlist outcome at each center, while Pearson's correlation coefficient (r) was used to assess the significance of center-level temporary mechanical circulatory support use (defined as the proportion listed with temporary mechanical circulatory support) and poor waitlist outcome.
Of 22,077 transplant candidates included in analysis, 50.5% were listed during postpolicy. Compared to prepolicy, postpolicy candidates were more often listed with temporary mechanical circulatory support and less commonly listed with a durable left-ventricular assist device. The proportion of hospitals not using any temporary mechanical circulatory support decreased significantly from prepolicy to postpolicy (15% to 1%, P < .001). During prepolicy, center-level temporary mechanical circulatory support use showed no correlation with adjusted poor waitlist outcome. However, center-level temporary mechanical circulatory support use showed a negative correlation with poor waitlist outcome during postpolicy (r = -0.42, P < .001).
The 2018 adult heart allocation policy appears to benefit patients listed at high temporary mechanical circulatory support using centers, with significant interhospital variation in temporary mechanical circulatory support use in the new era. Given the growing role of temporary mechanical circulatory support on the heart transplant waitlist, greater standardization of its application is warranted.
本研究描述了 2018 年成人心脏分配政策改变后，中心层面临时机械循环支持使用与等待名单结果的关联。
本研究通过查询 United Network for Organ Sharing 数据库，获取了 2015 年 11 月至 2021 年 10 月期间所有单器官、成人心脏移植候选者的数据。研究人群分为两个队列，分别为政策前和政策后队列，以 2018 年 10 月 18 日的规则改变为中心。主要研究结果是中心层面较差等待名单结果的发生率，定义为等待名单上的死亡或恶化。竞争风险回归用于生成每个中心较差等待名单结果的风险调整发生率，而 Pearson 相关系数（r）用于评估中心层面临时机械循环支持使用（定义为列出临时机械循环支持的比例）和较差等待名单结果的意义。
在纳入分析的 22077 名移植候选者中，50.5%是在政策后列出的。与政策前相比，政策后候选者更常被列入临时机械循环支持，而较少被列入耐用性左心室辅助设备。从政策前到政策后，不使用任何临时机械循环支持的医院比例显著下降（从 15%降至 1%，P<0.001）。在政策前，中心层面临时机械循环支持的使用与调整后的较差等待名单结果无相关性。然而，在政策后，中心层面临时机械循环支持的使用与较差等待名单结果呈负相关（r=-0.42，P<0.001）。
2018 年成人心脏分配政策似乎使在高临时机械循环支持使用中心列出的患者受益，在新政策时代，临时机械循环支持的使用在医院之间存在显著差异。鉴于临时机械循环支持在心脏移植等待名单上的作用越来越大，有必要对其应用进行更大程度的标准化。
