One in five who declined donor heart still waiting a year later
Heart transplant recipients who accepted donor hearts considered to have an increased risk for disease had a better 1-year survival rate than transplant candidates who refused the higher-risk donor organs, a retrospective analysis of data from the United Network of Organ Sharing (UNOS) found.
Roughly one in five patients who declined the increased-risk donor offers were still waiting for heart transplants 1 year after the initial offer, and 7.9% had been removed from the waitlist due to death or decompensation, reported Michael S. Mulvihill, MD, of Duke University Medical Center in Durham, North Carolina, and colleagues.
The survival rate among patients who accepted the initial increased-risk donor offer was 92.1% a year later, compared with 83.1% among those who declined.
Previous studies have shown survival outcomes to be similar among transplanted patients receiving donor hearts from donors considered to have a normal risk and increased risk for disease.
But the retrospective registry study, published as a research letter in the Journal of the American College of Cardiology, is among the first to examine the impact of declining an increased-risk donor heart, Mulvihill told MedPage Today.
"What we showed here is that a significant fraction of candidates waiting for a heart transplant who received these offers but declined them hadn't been transplanted 1 year later," he said.
Mulvihill explained that all hearts considered for transplant are from donors who test negative for HIV, HCV, and HBV. Hearts are considered high risk if donors had certain life-style traits that would place them at high risk for inadvertent transmission due to undetected infection, such as injection drug use, having sex for money, and incarceration.
"The testing that we use to determine risk has gotten better and better, and so more and more centers are recommending these hearts," he said, adding that at Duke Health well over 90% of transplant candidates offered hearts from IRDs accept them.
The analysis of UNOS data included adult heart transplant candidates who received an offer for an IRD heart from 2007 to 2017. To measure the risks of competing outcomes following IRD offer decline, the researchers followed candidates who declined offers from the time of response until eventual heart transplant, death, or decompensation precluding transplant.
To determine the survival benefit associated with acceptance of the IRD offer, the researchers identified candidates who accepted the IRD offer, and compared them with matched candidates who had declined IRD offers.
- 58% underwent non-IRD heart transplant, 12.4% underwent later IRD transplant, 7.9% were removed from the waitlist due to death or decompensation, and 21.1% were still awaiting transplant a year later
- Stratified Cox-adjusted estimates of survival at 1 year from IRD offer were 92.1% for those who accepted and 83.1% for those who declined initial IRD
- The adjusted restricted mean survival time (RMST) model again favored acceptance, with an RMST of 4.31 years for the accept group versus 3.84 years for the decline group (P<0.001)
The researchers concluded that the study findings, "should be incorporated into discussions between candidates and listing centers to promote better understanding of the risks and benefits of IRD allografts."
"The hope is that this will become part of the conversation," Mulvihill said.
He added that the findings also add to the evidence showing use of IRD hearts to be an important strategy for addressing heart transplant wait-list mortality: "Changing attitudes towards these donors -- among patients and at transplant centers -- could make a big difference," he said. "This is a low-tech solution, but it could have a significant impact."
Funding for the research was provided by the National Institute of Health's Cardiothoracic Surgery Trials Network.
Mulvihill reported having no conflicts of interest; one co-author reported financial relationships with Novartis and Amgen.
Journal of the American College of Cardiology
Source Reference: Mulvihill MS, et al “Decline of increased risk donor offers on waitlist survival in heart transplantation” JACC 2018; 72(19): 2408-2409.
Read the original article on Medpage Today: Accepting Higher-Risk Donor Heart Linked to Better Survival at 1 Year