Recent Developments in Cardiothoracic Transplantation
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1 Recent Developments in Cardiothoracic Transplantation Sally Rushton Statistics and Clinical Studies NHS Blood and Transplant BTS March 2018
2 Content Heart and lung transplant activity over last decade Heart allocation impact of October 2016 changes Lung allocation impact of May 2017 changes
3 Heart and lung transplant activity
4 Heart and lung transplants in the UK Figure 2.4 Number of cardiothoracic organ transplants in the UK, by financial year, 1 April 2007 to 31 March Heart Lung No. of transplants / / / / / / / / / /2017 Heart Lung (Heart/Lung) Source: Annual Report on Cardiothoracic Organ Transplantation 2016/17, NHS Blood and Transplant
5 Heart and lung waiting lists, at 31 March Figure 2.1 Number of patients on the national active heart and lung transplant lists at 31 March each year between 2008 and Lung 378 Number of patients Heart 65% increase 162% increase Heart Lung (Heart/Lung) Source: Annual Report on Cardiothoracic Organ Transplantation 2016/17, NHS Blood and Transplant
6 Heart and lung waiting lists, at 31 March Figure 2.1 Number of patients on the national active heart and lung transplant lists at 31 March each year between 2008 and Lung % 80% % of heart transplants Number of patients Median wait days 30 days Heart Lung (Heart/Lung) 60% 40% 20% 0% Non-urgent Urgent Source: Annual Report on Cardiothoracic Organ Transplantation 2016/17, NHS Blood and Transplant
7 Heart allocation
8 Heart Allocation General principle: treat the sickest patients whilst maintaining good outcomes Urgent heart transplant outcomes just as good as non-urgent Super-urgent category implemented October 2016 for urgent adults: on short-term mechanical circulatory support OR at imminent risk of dying and not suitable for a long term VAD Superurgent tier
9 Heart Allocation Sequence Adult donor sequence (95% of matching runs) Super-urgent adults (zonal priority) Urgent adults (zonal priority) New Oct 2016 Patient specific offers Ranked by waiting time Urgent paediatrics nationally Non-urgent patients (zonal priority) Centre choice
10 Impact of 2016 changes - waiting list outcomes - post-transplant survival
11 Number of registrations Percentage of registrations HEART Waiting list outcomes Nov 2015 Oct 2016 vs Nov 2016 Oct 2017 Number of registrations 30 day registration outcomes Before After Before After % 90% 80% 2% Died on list Removed 1% Became S-U 2% % 60% 50% Still waiting % 30% 20% 10% 46% Transplanted 31% 67% Median waiting time 9 days 0 Urgent Urgent Super-Urgent 0% Urgent Urgent Super-Urgent Transplanted Still waiting Removed Became S-U Died
12 HEART 30 day patient survival post-transplant Nov 2015 Oct 2016 vs Nov 2016 Oct 2017 Before After Non-urgent Urgent p=0.5 Super-urgent Non-urgent Urgent p=0.9 No. % 30 day transplants survival (95% CI) Non-urgent (79-99) Urgent (87-96) Overall (89-97) No. transplants % 30 day survival (95% CI) Non-urgent (79-98) Urgent (84-96) Super-urgent (80-99) Overall (88-96)
13 Lung allocation
14 Lung Allocation Low donor lung utilisation rate and high waiting list mortality motivated need for allocation change % offered DBD organs transplanted CTAG proposed new scheme implemented in May Aim to prioritise the sickest on the transplant waiting list (expected survival < 90 days) Reduce waiting list mortality Preservation of current survival rates Increase utilisation through introducing national tiers of offering Utilisation rate Kidney Liver Pancreas Heart Lung Kidney Kidney Liver Pancreas Heart Lung Kidney Liver Pancreas Heart Lung 1 11 Utilisation rate % patients dying on list < 1 year 2 1 year waiting list mortality rate Source: Organ Donation and Transplantation Activity Report 2016/17, NHS Blood and Transplant
15 Lung Allocation Sequence All super-urgent patients nationally Adult donor sequence (95% of matching runs) Urgent paediatrics/small adults nationally Urgent adults nationally New May 2017 Patient specific offers Ranked by waiting time Non-urgent paediatrics Non-urgent small adults (zonal priority) Centre choice Non-urgent adults (zonal priority)
16 Impact of 2017 changes - waiting list outcomes - post-transplant survival
17 Number of registrations Percentage of registrations LUNG Waiting list outcomes May-Nov 2016 vs May-Nov 2017 Number of registrations 30 day registration outcomes Before After 100% 90% Before 3% Died on list After 2% 3% 29% Became U Became S-U 3% % 70% % % 40% 30% 20% Still waiting Median waiting 71% time 14 days 57% 20 0 Non-urgent All patients Non-urgent Urgent Super-Urgent 7 10% 0% 9% Transplanted 8% All Non-urgent patients Non-urgent Urgent Super-Urgent Transplanted Still waiting Removed Became U Became S-U Died
18 LUNG 30 day patient survival post-transplant May-Nov 2016 vs May-Nov 2017 Before After All patients Non-urgent p=0.5 Urgent/ super-urgent No. % 30 day transplants survival (95% CI) All patients (84-96) Overall (84-96) No. % 30 day transplants survival (95% CI) Non-urgent (80-96) Urgent/super-urgent (66-94) Overall (81-94)
19 Summary Activity Lung transplants up this financial year Heart transplants similar Heart allocation 2016 changes have improved access to transplantation for the sickest patients median waiting time just 9 days for Super-Urgent patients few waiting list deaths good short-term transplant outcomes Lung allocation 2017 changes seem to be driving up transplant activity No initial improvement in waiting list mortality Need longer review period to properly assess impact
20 Thank you! Acknowledgements: Cardiothoracic Advisory Group Policies and reports: Contact:
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