Page 11 - Heart Transplant Protocol

Heart Function Service: Heart Transplant Protocols

Non adherence*
Inadequate social or financial support*
*Non- adherence and inadequate social/financial support are absolute contraindications
after attempts to mitigate risk have been exhausted

Donor Offers

The national rate of rejection of donor hearts is 44%. The current literature on possible donor criteria,
risk factors and their associations with outcomes (age, gender, size mismatch, mode of death,
downtime, cardiac function, inotropes, ischemic time, travel distance, infections, HR social behavior and
HLA compatibility), as well as impact of multiple risk factors (calculators) is not robust. The data has
severe limitations; specifically a lack of prospective studies, heavy reliance on registry data, small
retrospective single center studies and outcomes assessing survival from transplant rather than survival
from listing. The only convincing evidence of risk factors causing worse transplant outcomes is extremes
of ischemic time (less than 1 hour or more than 6 hours) with a relative risk ratio of 1.7 and use of
donors more than 25 years older than the recipient (relative risk 1.5). Putting these into context,
recipient risk factors and center volume have hazard ratios between 1.9 and 4.5. The data showed no
evidence of worse outcomes when “marginal donors” were used.

The psychology and behavioral science of using marginal donors in status 1A patients and not in Status 2
patients was explored. An adult cardiac study reported that status 2 recipients had equal outcomes with
any donor quality.

The meeting unanimously agreed that our practice should change to reflect this information. The team
will avoid taking donors older than 40 yrs or who have significant cardiac trauma or large size
mismatches (D:R ratio of <0.8 or >3) unless exceptional circumstances existed. Any other concerns
regarding the donor quality (structural heart disease, HLA compatibility, malignancy, infection, ischemic
time, distance, questionable cause of death, deconditioned donor, inotrope use, function,
CPR/downtime) would be a reason for discussion with the relevant physicians. For example HLA
incompatibility would be discussed with transplant immunology, an infected patient would be discussed
with ID team etc. Patient status would no longer be a significant consideration in evaluating donors with
concerns regarding quality.

ABO-Incompatible Heart Transplantation

Introduction
ABO-Incompatible heart transplantation (ABOi) was first undertaken in young infants by Lori West’s
1
group in Toronto in 1997 to maximize the chance of an infant being transplanted and minimize refusal
of otherwise suitable donor organs. Error! Reference source not found. demonstrates the various
combinations of transplant compatibility. Multicenter collaborations have demonstrated long term
2
outcomes indistinguishable from ABO compatible transplants . Since then the indications have

Updated November 9, 2017 11