Impact of mechanical circulatory support on donor heart allocation: past, present, and future
The United Network for Organ Sharing (UNOS) recently revised its heart allocation policy to address numerous shortcomings of the previous system. Implemented in 2018, the changes sought to reduce waiting list mortality, clearly define urgency status based on objective physiologic variables, decre...
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| Format: | Article |
| Language: | English |
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IMR Press
2021-03-01
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| Series: | Reviews in Cardiovascular Medicine |
| Subjects: | |
| Online Access: | https://rcm.imrpress.com/fileup/2153-8174/PDF/1617068623536-1349810301.pdf |
| _version_ | 1818918657266286592 |
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| author | Robert T. Tatum H. Todd Massey Vakhtang Tchantchaleishvili |
| author_facet | Robert T. Tatum H. Todd Massey Vakhtang Tchantchaleishvili |
| author_sort | Robert T. Tatum |
| collection | DOAJ |
| description | The United Network for Organ Sharing (UNOS) recently revised its heart
allocation policy to address numerous shortcomings of the previous system.
Implemented in 2018, the changes sought to reduce waiting list mortality, clearly
define urgency status based on objective physiologic variables, decrease
exemption requests, and introduce geographic modifications to ensure organ
distribution favors the highest urgency candidates. In large part, UNOS policy
revisions were driven by the growing use of continuous flow left ventricular
assist devices (CF-LVADs) and the relevant device complications that led to an
unacceptably high number of status exemptions. The new 6-tiered system assigns a
comparatively lower urgency status to patients supported on CF-LVADs and higher
urgency to patients supported on short-term mechanical circulatory assist (MCA)
such as extracorporeal membrane oxygenation (ECMO) and intraaortic balloon pump
(IABP) counterpulsation. LVAD use as bridge to transplant (BTT) therapy increased
steadily throughout the preceding decade due to technological improvements and
increased physician familiarity, but the recent policy changes introduce
incentives for physicians to withhold this life-saving therapy in order to
achieve higher urgency status for their patients. This paper will explore the
technological evolution of MCA and the pertinent clinical trials that have led to
their FDA approval as BTT and destination therapy. A review of the inception and
development of the donor allocation system will be provided before examining
available post-policy outcome data. Finally, we will highlight successes and
shortcomings of the implemented changes before commenting on areas to potentially
expand upon the existing policy. |
| first_indexed | 2024-12-20T00:53:27Z |
| format | Article |
| id | doaj.art-6acb792910f64394949b8a2c95527633 |
| institution | Directory Open Access Journal |
| issn | 2153-8174 |
| language | English |
| last_indexed | 2024-12-20T00:53:27Z |
| publishDate | 2021-03-01 |
| publisher | IMR Press |
| record_format | Article |
| series | Reviews in Cardiovascular Medicine |
| spelling | doaj.art-6acb792910f64394949b8a2c955276332022-12-21T19:59:10ZengIMR PressReviews in Cardiovascular Medicine2153-81742021-03-01221253210.31083/j.rcm.2021.01.2301617068623536-1349810301Impact of mechanical circulatory support on donor heart allocation: past, present, and futureRobert T. Tatum0H. Todd Massey1Vakhtang Tchantchaleishvili2Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, 19107 Philadelphia, USADivision of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, 19107 Philadelphia, USADivision of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, 19107 Philadelphia, USAThe United Network for Organ Sharing (UNOS) recently revised its heart allocation policy to address numerous shortcomings of the previous system. Implemented in 2018, the changes sought to reduce waiting list mortality, clearly define urgency status based on objective physiologic variables, decrease exemption requests, and introduce geographic modifications to ensure organ distribution favors the highest urgency candidates. In large part, UNOS policy revisions were driven by the growing use of continuous flow left ventricular assist devices (CF-LVADs) and the relevant device complications that led to an unacceptably high number of status exemptions. The new 6-tiered system assigns a comparatively lower urgency status to patients supported on CF-LVADs and higher urgency to patients supported on short-term mechanical circulatory assist (MCA) such as extracorporeal membrane oxygenation (ECMO) and intraaortic balloon pump (IABP) counterpulsation. LVAD use as bridge to transplant (BTT) therapy increased steadily throughout the preceding decade due to technological improvements and increased physician familiarity, but the recent policy changes introduce incentives for physicians to withhold this life-saving therapy in order to achieve higher urgency status for their patients. This paper will explore the technological evolution of MCA and the pertinent clinical trials that have led to their FDA approval as BTT and destination therapy. A review of the inception and development of the donor allocation system will be provided before examining available post-policy outcome data. Finally, we will highlight successes and shortcomings of the implemented changes before commenting on areas to potentially expand upon the existing policy.https://rcm.imrpress.com/fileup/2153-8174/PDF/1617068623536-1349810301.pdfventricular assistmechanical circulatory assisttunos heart allocationlvadmcadestination therapybridge-to-transplant |
| spellingShingle | Robert T. Tatum H. Todd Massey Vakhtang Tchantchaleishvili Impact of mechanical circulatory support on donor heart allocation: past, present, and future Reviews in Cardiovascular Medicine ventricular assist mechanical circulatory assistt unos heart allocation lvad mca destination therapy bridge-to-transplant |
| title | Impact of mechanical circulatory support on donor heart allocation: past, present, and future |
| title_full | Impact of mechanical circulatory support on donor heart allocation: past, present, and future |
| title_fullStr | Impact of mechanical circulatory support on donor heart allocation: past, present, and future |
| title_full_unstemmed | Impact of mechanical circulatory support on donor heart allocation: past, present, and future |
| title_short | Impact of mechanical circulatory support on donor heart allocation: past, present, and future |
| title_sort | impact of mechanical circulatory support on donor heart allocation past present and future |
| topic | ventricular assist mechanical circulatory assistt unos heart allocation lvad mca destination therapy bridge-to-transplant |
| url | https://rcm.imrpress.com/fileup/2153-8174/PDF/1617068623536-1349810301.pdf |
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