Recent Developments in Cardiothoracic Transplantation Sally Rushton Statistics and Clinical Studies NHS Blood and Transplant BTS March 2018
Content Heart and lung transplant activity over last decade Heart allocation impact of October 2016 changes Lung allocation impact of May 2017 changes
Heart and lung transplant activity
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 2017 240 220 Heart Lung 218 200 180 172 180 191 198 181 187 195 188 198 178 No. of transplants 160 140 120 100 128 123 130 146 121 151 131 141 145 80 60 40 20 0 2007/2008 2008/2009 2009/2010 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 Heart Lung (Heart/Lung) Source: Annual Report on Cardiothoracic Organ Transplantation 2016/17, NHS Blood and Transplant
Heart and lung waiting lists, at 31 March 2008 2017 Figure 2.1 Number of patients on the national active heart and lung transplant lists at 31 March each year between 2008 and 2017 400 Lung 378 Number of patients 350 300 250 200 150 287 229 266 126 130 225 169 232 242 246 200 287 338 267 330 248 249 Heart 65% increase 162% increase 100 95 93 50 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Heart Lung (Heart/Lung) Source: Annual Report on Cardiothoracic Organ Transplantation 2016/17, NHS Blood and Transplant
Heart and lung waiting lists, at 31 March 2008 2017 Figure 2.1 Number of patients on the national active heart and lung transplant lists at 31 March each year between 2008 and 2017 400 350 Lung 338 330 378 100% 80% % of heart transplants Number of patients Median wait 300 250 200 150 100 50 0 287 287 266 267 242 246 248 249 232 225 229 200 169 126 130 223 243 217 220 95 93 179 154 118 116 88 88 7 5 8 14 15 21 23 24 31 29 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 10 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
Heart allocation
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
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
Impact of 2016 changes - waiting list outcomes - post-transplant survival
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 180 160 140 162 148 100% 90% 80% 2% Died on list Removed 1% Became S-U 2% 120 100 70% 60% 50% Still waiting 80 60 40 20 57 40% 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
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 30 97 (79-99) Urgent 134 93 (87-96) Overall 164 94 (89-97) No. transplants % 30 day survival (95% CI) Non-urgent 33 94 (79-98) Urgent 89 92 (84-96) Super-urgent 37 95 (80-99) Overall 159 93 (88-96)
Lung allocation
Lung Allocation Low donor lung utilisation rate and high waiting list mortality motivated need for allocation change % offered DBD organs transplanted 85 83 CTAG proposed new scheme implemented in May 2017 34 30 22 85 83 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 34 30 22 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 8 17 1
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)
Impact of 2017 changes - waiting list outcomes - post-transplant survival
Number of registrations Percentage of registrations LUNG Waiting list outcomes May-Nov 2016 vs May-Nov 2017 Number of registrations 30 day registration outcomes 200 180 180 Before After 100% 90% Before 3% Died on list After 2% 3% 29% Became U Became S-U 3% 160 140 143 80% 70% 120 60% 100 80 60 40 37 50% 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
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 78 92 (84-96) Overall 78 92 (84-96) No. % 30 day transplants survival (95% CI) Non-urgent 60 91 (80-96) Urgent/super-urgent 30 85 (66-94) Overall 90 89 (81-94)
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
Thank you! Acknowledgements: Cardiothoracic Advisory Group Policies and reports: www.odt.nhs.uk Contact: sally.rushton@nhsbt.nhs.uk