Dr. Kelly Schlendorf, the Director of Heart Failure and Transplant at Vanderbilt, dives deep into heart transplant evaluations and management. She clarifies the complexities of pre-transplant strategies, exploring bridge techniques like temporary MCS and durable LVAD. The conversation touches on the current heart allocation system, donor-recipient matching, and the role of sensitization in compatibility. Efforts to expand the donor pool, including the use of HCV-positive and HIV-positive organs, highlight the evolving landscape in heart transplantation.
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volunteer_activism ADVICE
Use Temporary MCS As A Bridge Strategically
Maintain temporary mechanical support as a bridge to transplant when ongoing ischemia persists despite medical therapy.
Move femoral IABP to an axillary position to enable mobilization and reduce deconditioning while awaiting transplant.
volunteer_activism ADVICE
Consider LVAD If Temporary Support Risks Rise
Consider durable LVAD as a bridge to transplant when prolonged wait times or infection risk make continued temporary support unsafe.
Balance risks of nosocomial infection and debility when choosing between prolonged temporary MCS and LVAD.
insights INSIGHT
Modern Heart Listing Is Priority-Based
The 2018 heart allocation created six active statuses ranked by medical urgency from Status 1 (highest) to Status 6 (lowest).
Status 2 typically includes ICU patients supported with univentricular temporary devices like an IABP.
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In this episode, the CardioNerds (Dr. Rachel Goodman, Dr. Shazli Khan, and Dr. Jenna Skowronski) discuss a case of AMI-shock with a focus on listing for heart transplant with faculty expert Dr. Kelly Schlendorf. We dive into the world of pre-transplant management, discuss the current allocation system, and additional factors that impact transplant timing, such as sensitization. We conclude by discussing efforts to increase the donor pool. Audio editing for this episode was performed by CardioNerds Intern, Julia Marques Fernandes.
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Pearls
The current iteration of heart allocation listing is based on priority, with status 1 being the highest priority.
The are multiple donor and recipient characteristics to consider when listing a patient for heart transplantation and accepting a heart offer.
Desensitization is an option for patients who need heart transplantation but are highly sensitized. Protocols vary by center.
Acceptance of DCD hearts is one of many efforts to expand the donor pool
Notes
Notes: Notes drafted by Dr. Rachel Goodman
Once a patient is determined to be a candidate for heart transplantation, how is priority determined?
The current iteration of heart listing statuses was implemented in 2018. Priority is determined by acuity, with higher statuses indicating higher acuity and given higher priority. Status 1 is the highest priority status, and Status 7 is inactive patients. (1,2)
What criteria should be considered in organ selection when listing a patient for heart transplant?
Once it is determined that a patient will be listed for heart transplantation, there are certain criteria that should be assessed. These factors may impact pre-transplant care and/or donor matching (3).
(1) PVR
(2) Height/weight
(3) Milage listing criteria
(4) Blood typing/cPRA/HLA typing
What is desensitization and why would it be considered?
Desensitization is an attempt to reduce or remove anti-HLA antibodies in the recipient. It is done to increase the donor pool. In general, desensitization is reserved for patients who are highly sensitized. Desensitization protocols vary by transplant center, and some may opt against it. When considering desensitization, it is important to note two key things: first, there is no promise that it will work, and second desensitization involves the use of immunosuppressive agents, thereby putting patients at increased risk of infection and cytopenia. (4)
Can you explain DCD and DBD transplant?
DBD: donor that have met the requirements for legal definition of brain death.
DCD: donors that have not met the legal definition of brain death but have been determined to have circulatory death. Because the brain death criteria have not been met, organ recovery can only take place once death is confirmed based on cessation of circulatory and respiratory function. Life support is only withdrawn following declaration of circulatory death—once the heart has stopped beating and spontaneous respirations have stopped. (5,6)
References
1: Maitra NS, Dugger SJ, Balachandran IC, Civitello AB, Khazanie P, Rogers JG. Impact of the 2018 UNOS Heart Transplant Policy Changes on Patient Outcomes. JACC Heart Fail. 2023;11(5):491-503. doi:10.1016/j.jchf.2023.01.009
2: Shore S, Golbus JR, Aaronson KD, Nallamothu BK. Changes in the United States Adult Heart Allocation Policy: Challenges and Opportunities. Circ Cardiovasc Qual Outcomes. 2020;13(10):e005795. doi:10.1161/CIRCOUTCOMES.119.005795
3: Copeland H, Knezevic I, Baran DA, et al. Donor heart selection: Evidence-based guidelines for providers. J Heart Lung Transplant. 2023;42(1):7-29. doi:10.1016/j.healun.2022.08.030
4: Kittleson MM. Management of the sensitized heart transplant candidate. Curr Opin Organ Transplant. 2023;28(5):362-369. doi:10.1097/MOT.0000000000001096
5: Kharawala A, Nagraj S, Seo J, et al. Donation After Circulatory Death Heart Transplant: Current State and Future Directions. Circ Heart Fail. 2024;17(7):e011678. doi:10.1161/CIRCHEARTFAILURE.124.011678
6: Siddiqi HK, Trahanas J, Xu M, et al. Outcomes of Heart Transplant Donation After Circulatory Death. J Am Coll Cardiol. 2023;82(15):1512-1520. doi:10.1016/j.jacc.2023.08.006
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