1. 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

2. 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

3. 50 Years of Heart Transplantation
December 3, 1967

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

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

6. 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…

7. 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Policy out of date re: increased use of MCSDs and associated complications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

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

9. Where Would You Want to Be Waiting as Status I?

10. 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

11. Status Overview: Status 1

12. Status Overview: Status 2

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

14. Device Complications Specified

15. Status Overview: Status 4

16. Status Overview: Status 5

17. Status Overview: Status 6

18. 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

19. 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

20. 2 Yr Post Transplant Mortality
Simulation Data
2 Yr Post Transplant Mortality
Waitlist Mortality
SRTR Data 2/2014

21. Two Phase Implementation

22. 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?

23. 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

24. Thank you