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Brief Report
April 15, 2020

Use of Temporary Mechanical Circulatory Support for Management of Cardiogenic Shock Before and After the United Network for Organ Sharing Donor Heart Allocation System Changes

Author Affiliations
  • 1Levine Cardiac Intensive Care Unit, Thrombolysis in Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 2Division of Cardiology, Center for Heart and Vascular Care, University of North Carolina, Chapel Hill
  • 3Division of Pulmonary and Critical Care Medicine, Center for Heart and Vascular Care, University of North Carolina, Chapel Hill
  • 4Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
  • 5Department of Cardiology, St. Vincent Hospital, Indianapolis, Indiana
  • 6Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
  • 7Interdepartmental Division of Critical Care Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
  • 8Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City
  • 9Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia
  • 10Department of Medicine, Stanford University School of Medicine, Stanford, California
  • 11Department of Critical Care, University of Alberta, Edmonton, Alberta, Canada
  • 12Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
JAMA Cardiol. Published online April 15, 2020. doi:10.1001/jamacardio.2020.0692
Key Points

Question  Was implementation of the new United Network for Organ Sharing (UNOS) donor heart allocation system associated with changes in the use of temporary mechanical circulatory support for the management of cardiogenic shock in tertiary cardiac intensive care units, and did use differ between US transplant centers and US nontransplant centers and Canadian centers?

Findings  In this cohort study from 14 centers in North America, among 384 patients admitted with acute, decompensated, heart failure–related cardiogenic shock, the use of temporary mechanical circulatory support increased significantly in US transplant centers but not in other cardiac intensive care units and not for other forms of cardiogenic shock in the year after the UNOS donor heart allocation system revisions.

Meaning  Changes in the UNOS donor heart allocation system may have been associated with changes in practitioners’ management strategies for patients with acute, decompensated, heart failure–related cardiogenic shock at US transplant centers.

Abstract

Importance  The new United Network for Organ Sharing (UNOS) donor heart allocation system gives priority to patients supported with nondischargeable mechanical circulatory support (MCS) devices while awaiting heart transplant. Whether there has been a change in temporary MCS use in cardiac intensive care units (CICUs) since the implementation of this policy is unknown.

Objectives  To examine whether the UNOS donor heart allocation system revision in October 2018 was associated with changes in temporary MCS use in CICUs and whether temporary MCS use differed between US transplant centers and US nontransplant centers and Canadian centers.

Design, Setting, and Participants  In this cohort study, 14 centers from the Critical Care Cardiology Trials Network (CCCTN), a multicenter network of tertiary CICUs in North America, contributed 2-month snapshots of consecutive medical CICU admissions between September 1, 2017, and September 1, 2018 (prerevision period), and October 1, 2018, and September 1, 2019 (postrevision period). CICUs were classified as US transplant centers (n = 7) or other CICUs (US nontransplant centers or Canadian centers; n = 7).

Exposure  Revision to the UNOS donor heart allocation system.

Main Outcomes and Measures  Treatment with temporary MCS (intra-aortic balloon pump, microaxial intracardiac ventricular assist device, percutaneous centrifugal ventricular assist device, venoarterial extracorporeal membrane oxygenation, or surgically implanted, nondischargeable MCS device) during hospital admission.

Results  A total of 384 admissions for acute, decompensated, heart failure–related cardiogenic shock (ADHF-CS) were included, among which 248 (64.6%) were to US transplant centers; 126 admissions (51%) were in the prerevision period and 122 (49%) were in the postrevision period. The mean (SD) patient age was 61.2 (14.6) years; 246 patients (64.1%) were male. The proportion of admissions with ADHF-CS managed with temporary MCS at US transplant centers significantly increased from 25.4% (32 of 126 admissions) before to 42.6% (52 of 122 admissions) after the UNOS allocation system changes (P = .004). In other CICUs, the proportion did not significantly change (24.5% [13 of 53 admissions] to 24.1% [20 of 83 admissions]; P = .95). After multivariable adjustment, patients admitted to US transplant centers in the postrevision period were more likely to receive temporary MCS compared with those admitted in the prerevision period (adjusted odds ratio, 2.19; 95% CI, 1.13-4.24; P = .02).

Conclusions and Relevance  In the year after implementation of the new UNOS donor heart allocation system, temporary MCS use in patients admitted with ADHF-CS increased in US transplant centers but not in other CICUs. Whether this shift in practice will affect outcomes of patients with ADHF-CS or organ distribution should be evaluated.

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