Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD...

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Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington March 5, 2015

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Page 1: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Donor Utilization:Making Use of a Precious Resource in

Cardiac Transplant

Jason W. Smith, MD

Assistant Professor of Surgery

The University of Washington

March 5, 2015

Page 2: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Prevalence of heart failure by sex and age (National Health and Nutrition Examination Survey: 2007–2010).

Go A S et al. Circulation. 2014;129:e28-e292

Copyright © American Heart Association, Inc. All rights reserved.

Page 3: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Hospital discharges for heart failure by sex (United States: 1980–2010).

Go A S et al. Circulation. 2014;129:e28-e292

Copyright © American Heart Association, Inc. All rights reserved.

Page 4: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Heart Failure StatisticsUS Population [1] 301,000,000

Target Population – 35-74 Age Cohort [1] 139,100,000

Diagnosed CHF Population [2]

All ages 5,520,00035 to 74 years 3,744,000NYHA Class IIIB and IV [3] in 35 – 74 Age Cohort

374,400

Co-morbidities estimated in this Cohort (280,800)

Potential Patients – 35 to 74 years 93,600

Simple Math: Patients per 100,000 Population 30

[1] US Census Bureau Statistics (2008)[2] Heart and Stroke Statistics, American Heart Association (2008) [3] Cardiovascular Roundtable research and analysis, The Advisory Board Company (2008)

(75%)

Jeevanandan V, Oral Presentation, Society of Thoracic Surgeons, 2011

Page 5: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Our Population

6,724,540

= 2017 pts

Washington state:

Page 6: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Orthotopic Heart Transplant

Page 7: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Two Decades of Stability

J Heart Lung Transplant, vol 33, 2014

Page 8: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Total heart transplants

SRTR

Page 9: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Increasing MCS use

Page 10: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

The Journal of Heart and Lung Transplantation 2014 33, 555-564DOI: (10.1016/j.healun.2014.04.010) Copyright © 2014 International Society for Heart and Lung Transplantation Terms and Conditions

LVAD Survival

http://www.elsevier.com/termsandconditions
Page 11: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

HEART TRANSPLANTSKaplan-Meier Survival

(Transplants: January 1982 - June 2010)

ISHLT 2012

Survival is based on adult and pediatric transplant recipients

N = 96,273 N at risk at 25 years

= 112

J Heart Lung Transplant.  2012 Oct; 31(10): 1045-1095

Page 12: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Patient survival among adult heart transplant recipients, 2005–2007

SRTR

Page 13: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.
Page 14: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Suicide Rate in the US by Year

CDC. Web-based Injury Statistics Query and Reporting System (WISQARS). Atlanta, GA. 2013

Page 15: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.
Page 16: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.
Page 17: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

But, It’s more complicated

Khush et al, 2015

Page 18: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.
Page 19: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

So Why is That Happening?

• Decline in heart utilization from 44% to 29%

• Increasing age of the donor population

• Fear of “high risk” hearts

• Avoidance of LVH

• Fear of longer ischemic times

• Avoidance of gender and size mismatching

Page 20: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Deceased donor heart transplant rates per 100 patient years on the waiting

list

SRTR

Page 21: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Deceased donor heart donation rates (per 1,000 deaths), by

state: 2009-2011

Page 22: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

UW Donor Stats

• 2012

– 325 Donor offers

– 78 Transplanted

hearts

– 20 Transplanted at

the UW

• 2012

– 6% overall

utilization

– 26% adjusted

utilization

Page 23: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

The Plan

• Review every donor offer

• Identify missed opportunities

• Establish a Donor Review Conference

• Consensus for donor assessment

• Review our outcomes

Page 24: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Review every offer

• Careful review of

each donor offer

• Highlight hearts

transplanted by

other centers

• Identify reasons for

refusal

Page 25: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Missed Opportunities

• Initial Low EF that improves

• CPR positive donors with normal EF

• Obese donors with normal Echo and Angio

• Mild LVH in local donors

• Local older donors

• Young donors turned down for CDC high risk

status

Page 26: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Donor Conference

• Non-threatening, collaborative

• De-identified

• Thorough review of selected cases

• Discussion

• Literature review plan

Page 27: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.
Page 28: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Consensus

• Discussion leads to consensus

• Voting

• Summarize

• “newsletter”

Page 29: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Review Outcomes

• 2012

– 325 Donor offers

– 78 Transplanted hearts

– 20 Transplanted at the UW

• 2013

– 292 Donor offers

– 66 Transplanted hearts

– 31 Transplanted at the UW

• 2012

– 6% overall utilization

– 26% adjusted utilization

• 2013

– 11% overall utilization

– 47% adjusted utilization

Page 30: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

1 2 3 4 5 6 7 8 9 10 11 12

25

27

15

10

22

19

22

29

15

23

29

38

UW Transplant Volumes

One year Survival increased from 80% to 94% over the same period

Page 31: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Jan

Feb

Mar AprMay Ju

n JulAug Se

pOct

Nov Dec

Jan

2014

Feb

2014

Mar 2

014

April

2014

May 2

014

June

201

4

July

201

4

Aug 2

014

Sept

201

4

Oct 2

014

Nov 2

014

Dec 2

014

Jan

2015

Feb

2015

Mar 2

015

0

5

10

15

20

25

30

35

40

45

UW Active Waitlist Vol

Waitlist VolLinear (Waitlist Vol)

Page 32: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

Conclusions

• A small conservative program can

significantly change volumes

• Can do this safely

• This is a project about stewardship

• But………..

Page 33: Donor Utilization: Making Use of a Precious Resource in Cardiac Transplant Jason W. Smith, MD Assistant Professor of Surgery The University of Washington.

NEXT

• Increase organ donation rates

• Expand DCD

• Legislate Cortical Brain death

definition


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