Practical application of the French two-score heart allocation scheme: Insights from a high-volume heart transplantation centre.

BACKGROUND: In 2018, a cardiac allocation scheme based on an individual score considering the risk of death both on the waitlist and after heart transplantation was implemented in France. AIMS: To analyse the practical application of the pre- and post-transplant risk score in a French high-volume heart transplantation centre. METHODS: All consecutive adult patients listed for a first non-combined heart transplantation between 02 January 2018 and 30 June 2022 at our centre were included. Baseline characteristics of candidates and recipients were retrieved from the national CRISTAL registry. Both scores were calculated at listing and at transplant. RESULTS: Overall, 364 patients were included. During follow-up, 257 patients (70.6%) were transplanted, and 57 (15.6%) died or were removed from the waitlist. Post-transplant 3-month survival was 84.8%. Total bilirubin and natriuretic peptides had the most important weight in the pretransplant risk score. This score had a major impact on waitlist outcomes: quartile 1 was characterized by low access to heart transplantation (58.2%) and risk of death on the waitlist (9.9%) compared with quartile 4 (heart transplantation rate 74.1%, mortality on the waiting list>20%). According to the post-transplant risk score, a minimal number of candidates were considered ineligible for heart transplantation (<1%), but 12.4% were contraindicated to at least one donor category. The number of contraindicated donor categories had a significant impact on waitlist outcomes. Although adequately calibrated, the post-transplant score had a limited discrimination (area under the curve 0.65, 95% confidence interval 0.59-0.71). CONCLUSION: Our results highlight the major impact of pre- and post-transplantation risk scores on waitlist outcomes following the allocation scheme update.

Challenges and Opportunities in Titrating Disease-Modifying Therapies in Heart Failure with Reduced Ejection Fraction and Chronic Kidney Disease.

PURPOSE OF REVIEW: Chronic kidney disease (CKD) is highly prevalent in patients with heart failure and reduced ejection fraction (HFrEF), representing a major factor of adverse outcomes. In clinical practice, it is one of the main reasons for not initiating, not titrating, and even withdrawing efficient heart failure drug therapies in patients. RECENT FINDINGS: Despite limited data, studies show that HFrEF therapies maintain their benefits on cardiovascular outcomes in patients with CKD. Most HF drugs cause acute renal haemodynamic changes, but with stabilisation or even improvement after the acute phase, thus with no long-term worsening of the renal function. In this expert opinion-based paper, we challenge the pathophysiology misunderstandings that impede HF disease-modifying therapy implementation in this setting and propose a strategy for HF drug titration in patients with moderate, severe, and end-stage chronic kidney disease.

On Public Influence on People's Interactions with Ordinary Biodiversity.

Besides direct impacts of urban biodiversity on local ecosystem services, the contact of city dwellers with urban nature in their everyday life could increase their awareness on conservation issues. In this paper, we focused on a particularly common animal urban species, the feral pigeon Columba livia. Through an observational approach, we examined behavioral interactions between city dwellers and this species in the Paris metropolis, France. We found that most people (mean: 81%) do not interact with pigeons. Further, interactions (either positive or negative) are context and age-dependent: children interact more than adults and the elderly, while people in tourist spots interact more than people in urban parks or in railway stations, a result that suggests that people interacting with pigeons are mostly tourists. We discuss these results in terms of public normative pressures on city dwellers' access to and reconnection with urban nature. We call for caution in how urban species are publically portrayed and managed, given the importance of interactions with ordinary biodiversity for the fate of nature conservation.