Increasing donor–recipient weight mismatch in infant heart transplantation is associated with shorter waitlist duration and no increased morbidity or mortality

Abstract

Abstract OBJECTIVES Infants awaiting paediatric heart transplantation (PHT) experience long waitlist duration and high mortality due to donor shortage. Using the United Network for Organ Sharing database, we explored if increasing donor–recipient weight ratio (DRWR) >2.0 (recommended cutoff) was associated with adverse outcomes. METHODS Between 2007 and 2020, 1392 infants received PHT. We divided cohort into 3 groups: A (DRWR ≤1.0, n = 239, 17%), B (DRWR 1.0–2.0, n = 947, 68%), C (DRWR >2.0, n = 206, 15%). Group characteristics and PHT outcomes were analysed. RESULTS DRWR ranged between 0.5 and 4.1. Underlying pathology (congenital versus cardiomyopathy), gender, race, renal function and mechanical circulatory support were comparable between groups. Group C patients were more likely to be ventilated, to receive ABO blood group (ABO)-incompatible heart and to have longer donor ischaemic time. Waitlist duration was significantly shorter for group C (33 vs 50 days, P < 0.1). Early outcomes for groups A, B and C were the following (respectively): operative death (6%, 4%, 3%, P = 0.29), primary graft dysfunction (5%, 3%, 3%, P = 0.30), renal failure (10%, 7%, 7%, P = 0.42) and stroke (3%, 4%, 1%, P = 0.36). The DRWR group was not associated with operative death in either congenital (odds ratio (OR) = 0.819, 95% confidence interval (CI) = 0.523–1.282) or cardiomyopathy (OR = 1.221, 95% CI = 0.780–1.912) patients and only significant factor was pre-PHT extracorporeal membrane oxygenation (OR = 4.400, 95% CI = 2.761–7.010). Additionally, survival at 1 year (87%, 87%, 85%, P = 0.80) and 5 years (76%, 78%, 77%, P = 0.80) was comparable between the DRWR groups. CONCLUSIONS Infants who received PHT with DRWR >2.0, up to 4.1, experienced shorter waitlist duration with no demonstrable increase in peri-transplant complications, operative or late mortality. Historic practice to avoid DRWR > 2.0 due to complications (e.g. hypertension-related stroke, graft dysfunction, death) is not currently supported in infants and stretching DRWR acceptance criteria would decrease PHT waitlist duration and potentially improve waitlist complications and mortality.