Regional and Racial Variability in Waitlist Outcomes: The Need for Increased Acceptance of Hearts from Donation after Cardiac Death and Hepatitis-C Virus Positive Donors

E. Rodriguez¹, H. Rando², J. Lawton³, I. Barbur⁴, I. D. Chinedozi⁵, Z. Darby⁶, A. Kilic^2
1Johns Hopkins University School of Medicine, Baltimore, Maryland ²The Johns Hopkins Hospital, Baltimore, Maryland ³University of Maryland School of Medicine, Baltimore, Maryland ⁴Johns Hopkins University School of Medicine, Akron, Ohio ⁵Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland ⁶Johns Hopkins, Baltimore, Maryland

Purpose: The use of Hepatitis C virus-positive (HCV+) donor hearts and hearts donated after cardiac death (DCD) has expanded the donor pool for orthotopic heart transplantation (OHT) without compromising post-transplant outcomes. Our objective was to evaluate the impact of regional variability in HCV+ and DCD organ use on waitlist outcomes.

Methods: We conducted a cross-sectional analysis of all adult OHT candidates in the United Network for Organ Sharing (UNOS) database listed between November 1, 2018 and April 30, 2022. Patients were excluded if they were removed from the waitlist for reasons other than transplant, death, or medical unsuitability. Patients were categorized as “high-use” if they were listed in a region with >15% HCV+ or DCD transplants, and “low-use” otherwise. Baseline characteristics and waitlist outcomes were compared between the two groups using chi-squared, student t-tests, and Wilcoxon rank-sum tests, as appropriate. The statistical associations presented in the text were validated using multivariable regression models, controlling for the other sociodemographic characteristics and comorbidities listed.

Results: Of 10,608 patients included, 3,041(29%) were categorized as being in high-use regions and 7,567 (71%) in low-use. Patients in high-use regions were more likely to be White (65% vs 58%, p< 0.001) and less likely to be Hispanic (4% vs 13%, p< 0.001) compared to patients in low-use regions. Patients in high-use regions spent a similar amount of time on the waitlist (median 27 vs 29 days, p=0.03) but were less likely to require intravenous inotropic medication (28% vs 37%, p< 0.001) or cardiac surgery (10% vs 15%), p< 0.001) while on the waitlist. When analyzing individual patient perceptions, more patients in high-use regions were willing to accept HCV+ hearts (67% vs 54%, p< 0.001). This pattern also pertained to DCD hearts (8% vs 3%, p< 0.001), although willingness to accept a DCD heart was significantly less than willingness to accept HCV+ hearts in both groups. Patients who were willing to accept an HCV+ or DCD heart were more likely to be White (60.6% vs 58.5%, p=0.02) and less likely to be Hispanic (9.1% vs 11.9%, p< 0.001). Mediation analysis showed evidence that reluctance to accept HCV+/DCD hearts may be a primary factor driving the relationship between race/ethnicity and low regional usage of these hearts (p < 0.001).

Conclusion: HCV+ and DCD hearts remain under-utilized, with significant regional variability. Increased complications and inferior outcomes in low-use regions may be due to patient hesitancy to accept these hearts. Patient education on the non-inferiority of HCV+ and DCD hearts may shift perceptions and translate into improved waitlist outcomes in these regions.

Identify the source of the funding for this research project: N/a