Heart: Year in Review OSOTC 2018 Transplant Symposium September 7, 2018 Brent C. Lampert, DO, FACC Medical Director, Heart Transplantation and Mechanical Circulatory Support Associate Professor of Clinical Medicine

Objectives Review the most recent heart transplant volume and survival statistics Understand current allocation system and its limitations Discuss upcoming changes to the heart allocation system

50 Years of Heart Transplantation December 3, 1967

Number of heart transplants by year All time high 2015 was an Lund et al, JHLT 2017

Adult heart transplants: survival by era Lund et al, JHLT 2017

Current Allocation Policy Adult Candidate Prioritization: Status 1A MCS 30 days elective VAD time TAH IABP ECMO VAD with complication Mechanical ventilation PAC + 1 high-dose or multiple inotropes Exception Status 1B LVAD/RVAD Continuous inotropes Status 2 Those who do not meet 1A or 1BB Geographic Allocation Local: Status 1A, Status 1B Zone A: Status 1A, Status 1B Local: Status 2 Zone B: Status 1A, Status 1B Zone A: Status 2 Zone B: Status 2 Etc…

Problems with the Current System Status 1A candidates are 3x more likely to die on the waiting list than candidates in any other status High # of exception requests indicates certain candidates not served well by current system Policy out of date re: increased use of MCSDs and associated complications Current geographic sharing scheme is inequitable

Categories for Adult 1A Exceptions Am J Transplantation 2015;15:44-54

Where Would You Want to Be Waiting as Status I?

New Statuses: High Level Current Status New Status 1A 1 2 3 1B 4 5 6 Statuses 1-3 generally defined by current status 1A criteria Status 4 generally defined by current status 1B criteria Statuses 5-6 generally defined by current status 2 criteria

Status Overview: Status 1

Status Overview: Status 2

Status Overview: Status 3 Status 1 & 2 Time Limited: VA ECMO: 7 Days Perc endovascular circulatory support or IABP: 14 days

Device Complications Specified

Status Overview: Status 4

Status Overview: Status 5

Status Overview: Status 6

Heart Distribution Changes Current Distribution 1A & 1B get local preference If no local match, next level is within 500 nautical miles Then expand to 1000 miles

Heart Distribution Changes – Broader Sharing Status 1 and 2 will be considered first up to 500 miles from donor location before candidates with status 3-6

2 Yr Post Transplant Mortality Simulation Data 2 Yr Post Transplant Mortality Waitlist Mortality SRTR Data 2/2014

Two Phase Implementation

Limitations / Controversies Redesign does not account for all groups Sensitized patients Refractory angina Should 30 day elective VAD time be extended or eliminated? Will the community agree upon the selected physiological principles that qualify a patient for inotrope or temporary support use?

Summary Current candidate prioritization and donor allocation is not contemporary resulting in inequities Reduce waitlist mortality – allocate organs to most critically ill Addresses issues with specific patient groups that may be marginalized with current system Incorporates broader geographic sharing to optimize access and limit regional disparities Post transplant survival within each status projected to remain comparable to current system

Thank you