US transplant system may undergo new rules for sharing of adult hearts

The nation's transplant system is proposing wider geographic sharing of adult hearts and a new way of ranking prospective recipients on waiting lists so organs more often get to the sickest patients.

The proposal, open for public comment, bears similarities to recommendations made in 2014 for changing how livers are allocated. Those recommendations, still up in the air, have drawn opposition from medical centers opposed to sharing livers across bigger swaths of the country.

About 2,800 people received heart transplants last year, and nearly 4,200 are waiting.

"The new rules improve on the fairness of how hearts are allocated. ... I personally believe the new policy will result in more lives being saved," said Jim Gleason, a director of the United Network for Organ Sharing.

Jeffrey Teuteberg, director of the advanced heart failure program and medical director of the mechanical circulatory support program at the University of Pittsburgh Medical Center, called the proposal "pretty well thought out."

Based on sickness, prospective recipients now are assigned one of three statuses - 1A, 1B or 2 - on waiting lists.

When a heart becomes available, it is offered to 1A and then 1B candidates in the "donation service area" that provided the organ. The nation has 58 such areas.

If there is no match, the heart is offered to 1A and then 1B candidates within 500 miles of the "donor hospital" recovering the organ. If there is still no match, the heart is offered to status 2 candidates in the donation service area, then beyond it.

A UNOS committee said the three classifications are overly broad, with short-term waiting list mortality rates among 1A patients ranging from about 5 percent to 36 percent. It recommended replacing the current system with six new statuses better delineating levels of sickness.

The committee also proposed broader sharing despite the tradition of favoring local candidates.

Under the proposal, a heart would be offered initially to the sickest pediatric patients and to status 1 adult patients both within the donation service area and within 500 miles of the donor hospital. It then would be offered to the sickest pediatric patients and to status 1 adults within 1,000 miles of the donor hospital; next, to status 2 adults within the donation service area and 500 miles of the donor hospital; and afterward to status 2 adults within 1,000 miles of the donor hospital.

A new classification system would be welcomed by those with conditions disadvantaged by the current structure, such as those with conditions unrelated to heart muscle weakness, Teuteberg said.

Raymond Benza, medical director for cardiac transplant and the program at Allegheny Health Network, and Stephen Bailey, program surgical director, lauded efforts to better prioritize candidates. But Bailey noted that organs traveling greater distances are more likely to become medically compromised.

Bailey said wider sharing also can mean a drawn-out recovery process, which may place added stress on donor families. "It's just something that needs to be factored into the equation."

To preserve organ viability, "our preference is always to work with our local centers first," said Patti Niles, president and CEO of Southwest Transplant Alliance in Texas. If a recovery team travels a great distance and learns the organ is not suitable for its patient, she said, her organization has little time to find another recipient.

To comment on this proposal go to optn.transplant.hrsa.gov/gover … -allocation-changes/


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