Higher-Risk Donor Hearts May Offer Better Survival Than Waiting

Debra L. Beck

November 02, 2018

Declining a donor heart because it comes with an increased risk for disease transmission may be a bad move, observational results suggest.

In a retrospective study published as a research letter, 1-year survival was 92.1% for patients who accepted a donor heart from an individual at increased risk for infection with HIV or hepatitis B or C virus, compared to 83.1% for those who declined an offer, a benefit that persisted through 5 years post offer.

In an analysis adjusted for the risk for mortality being different at different time points, mean survival was 4.31 years for the accept group and 3.84 for the decline group (P < .001).

"What we now know is that if you're offered an increased-risk heart but decline it and stay on the wait list, this is a riskier option," said surgical research fellow Michael S. Mulvihill, MD, from Duke University Medical Center in Durham, North Carolina.

Their report was published online October 29 in the Journal of the American College of Cardiology.

Because it's rare that an increased-risk heart is offered simultaneously with a non–increased donor risk heart, the choice is generally whether to accept the allograft with heightened perceived risk or stay on the wait list for an uncertain duration before another offer is made, explained Mulvihill to theheart.org | Medscape Cardiology.

"I think what we really highlight is that there's good reason to do what we can to get these patients off the wait list so that they can enjoy the benefit of heart transplant, because it's really a great therapy for an otherwise very sick patient population," said Mulvihill.

Mulvihill and colleagues at Duke analyzed data from the United Network of Organ Sharing (UNOS) registry looking at isolated adult heart transplant candidates who received an offer for an increased-risk donor heart allograft from 2007 to 2017.

They included data on 2602 increased-risk donor allografts offered to 10,851 candidates. All candidates had received an allograft offer and were able to accept it.

Of those who declined the higher-risk heart, 58.0% went on to receive a non-increased-risk donor heart, 12.4% underwent later increased-risk donor transplant, 7.9% were removed the waitlist owing to death or disease progression, and 21.1% were still waiting for a heart 1 year post offer.

"We find that an increased-risk allograft may be offered 50 times or more to many different people on the list before it's accepted," said Mulvihill. "You can imagine that a center that declines a lot of offers is going to put their candidates at increased risk of wait list mortality simply because they're waiting longer to get a heart."

Increased-Risk Donor Hearts Increasingly Common

"There is still a large number of organs offered in this population that we're not honoring with recoverability, and it's actually very important that we as a community of transplanters start to change our mindsets from declining increased-risk donors to managing increased-risk donors," said Mandeep R. Mehra, MD, Harvard Medical School, Boston, in an interview with theheart.org | Medscape Cardiology.

Donor hearts that come with an increased risk for disease transmission represent an increasing fraction of the donor pool. Currently, almost 1 in 5 donor hearts (19.5%) come from increased-risk donors, specifically those with elevated risk for infection from HIV, hepatitis B, or hepatitis C virus. In this analysis, the donors were at increased risk owing to behavioral risk factors but were in a window such that it wasn't clear whether or not they had contracted the virus.

"It is the uncertainty that is driving nonrecoverability of these donors, and this is unfortunate, because the actual risk of seroconversion is low, but still, some centers and some physicians are reluctant to take the chance," said Mehra, who is the medical director of the Brigham and Women's Hospital Heart and Vascular Center.

"It's not the hep C but the risk of HIV that's an issue, but there is less than a 0.1% risk of transmission, and they forget that nowadays we have good drugs to treat this," he added.

In May, Mehra's group published data showing an increase in transplant activity in the United States that was driven by about an 11-fold increase in the proportion of organ donors who died from drug intoxication in the past decade and a half.

Almost 10% of deceased donors recovered in 2015 had a documented history of IV drug use, triple the number reported in 2007. And this appears to still be rising: in the first 6 months of 2016, 11.4% of deceased donors recovered had a documented history of IV drug use.

"According to our data, about 40% of these donors have hepatitis C infection, and only 3% of those 40% are actually accepted," he said.

At the Brigham, his team will accept organs from individuals who have or are at risk for hepatitis C, he said, and treat the transplant recipients prophylactically with anti–hepatitis C drugs.

"Other centers will accept and transplant the organs and then do surveillance cultures and treat only if the patient seroconverts. But the point is that there has been very good experience coming from a number of centers suggesting that these hearts and lungs actually do just fine as long as you address the increase risk," said Mehra.

The study was supported by the NIH-funded Cardiothoracic Surgery Trials Network. Mulvihill reported that he receives support from the National Heart, Lung, and Blood Institute. Mehra is a consultant to Abbott, Medtronic, NupulseCV, FineHeart, Portola, Janssen, Bayer, and Mesoblast. No direct conflicts relevant to the discussion are inherent in these consulting agreements. He is also editor-in-chief of the Journal of Heart and Lung Transplantation. The views expressed are his own and do not represent the journal or the society that it represents, the International Society for Heart and Lung Transplantation.

J Am Coll Cardiol. Published online October 29, 2018. Article

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