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Original Articles: Adult Cardiac

Matching High-Risk Recipients With Marginal Donor Hearts Is a Clinically Effective Strategy

^a Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York
^b Department of Health Policy, Mount Sinai School of Medicine, New York, New York

Accepted for publication December 5, 2008.

^_* Address correspondence to Dr Russo, New York-Presbyterian Hospital/Columbia, Milstein Hospital Bldg Room 7-435 GN, 177 Fort Washington Ave, New York, NY 10032 (Email: mr2143{at}columbia.edu).

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.

Background: The purpose of this study is to determine the clinical outcomes associated with alternate listing transplantation, which utilizes "marginal" donor organs by transplanting them into high-risk recipients who fail to meet the standard criteria for transplantation.

Methods: The United Network for Organ Sharing provided de-identified patient-level data. Analysis focused on patients undergoing heart transplantation between January 1, 1999, and December 31, 2005 (n = 13,024). High-risk criteria included age more than 65 years old, retransplantation, hepatitis C-positive, human immunodeficiency virus-positive, creatinine clearance less than 30 mL/min, diabetes mellitus with peripheral vascular disease, and diabetes with creatinine clearance less than 40 mL/min. Marginal donor criteria included age more than 55 years, diabetes mellitus, hepatitis C-positive, human immunodeficiency virus-positive, ejection fraction less than 45%, and donor:recipient weight less than 0.7.

Results: Survival in the standard transplant group, defined as non–high-risk patients who received nonmarginal organs, was better than in all other groups (p < 0.001). Alternate listing transplantation patients had the worst survival (p < 0.001). The 5-year survival for the alternate listing transplantation group was 51.4%, compared with 75.1% in the standard transplant group; the standard transplant patients, with the lowest incidence of in-hospital infection (21.1%) and dialysis (7.1%), also had the best transplant hospitalization outcomes (p < 0.001). In contrast, alternate listing transplantation patients had the highest incidence of in-hospital infection (35.4%; p < 0.001). Length of stay during transplant hospitalization was also shortest in the standard transplant group (18.8 days; p < 0.001).

Conclusions: Alternate listing transplantation is associated with greater morbidity and resource utilization compared with standard transplantation. However, this strategy offers a median survival of 5.2 years to patients who would otherwise be expected to live 1 year, and therefore, may be reasonably applied to expand the benefits of transplantation. Further studies examining the costs and quality of life related to this approach are needed.