Hendren Nicholas S, Truby Lauren K, Farr Maryjane
Division of Cardiology, Department of Internal Medicine, UT-Southwestern Medical Center, Dallas, Texas, USA.
Curr Opin Cardiol. 2023 Mar 1;38(2):124-129. doi: 10.1097/HCO.0000000000001022. Epub 2023 Jan 3.
Historically, the selection criteria for heart transplant candidates has prioritized posttransplant survival while contemporary allocation policy is focused on improving waitlist survival. Donor scarcity has continued to be the major influence on transplant allocation policy. This review will address the opportunity of donation after circulatory determination of death (DCDD) and potential impact on future policy revisions.
In 2018, changes to U.S. heart allocation policy led to several intended and unintended consequences. Beneficial changes include reduced waitlist mortality and broader geographic sharing. Additional impacts include scarcer pathways to transplant for patients with a durable left ventricular assist device, increased reliance on status exceptions, and expanded use of temporary mechanical support. DCDD is anticipated to increase national heart transplant volumes by ∼30% and will impact waitlist management. Centers that offer DCDD procurement will have reduced waitlist times, reduced waitlist mortality, and higher transplant volumes.
While DCDD will provide more transplant opportunities, donor organ scarcity will persist and influence allocation policies. Differential patient selection, waitlist strategy, and outcome expectations may indicate that allocation is adjusted based on the procurement options at individual centers. Future policy, which will consider posttransplant outcomes, may reflect that different procurement strategies may yield different outcomes.
从历史上看，心脏移植候选者的选择标准一直优先考虑移植后的生存率，而当代分配政策则侧重于提高等待名单上的生存率。供体短缺仍然是移植分配政策的主要影响因素。本综述将探讨循环判定死亡后器官捐献（DCDD）的机会以及对未来政策修订的潜在影响。
2018年，美国心脏分配政策的变化导致了一些预期和非预期的后果。有益的变化包括等待名单死亡率降低和更广泛的地理共享。其他影响包括，对于使用耐用左心室辅助装置的患者，移植途径更加稀缺，对状态例外的依赖增加，以及临时机械支持的使用扩大。预计DCDD将使全国心脏移植量增加约30%，并将影响等待名单管理。提供DCDD获取的中心将缩短等待名单时间，降低等待名单死亡率，并提高移植量。
虽然DCDD将提供更多移植机会，但供体器官短缺仍将持续并影响分配政策。不同的患者选择、等待名单策略和结果预期可能表明，分配应根据各中心的获取选项进行调整。未来考虑移植后结果的政策可能会反映出，不同的获取策略可能会产生不同的结果。
