RESUMO
Heart transplantation and durable left ventricular assist devices (LVADs) represent two definitive therapies for end-stage heart failure in the modern era. Despite technological advances, both treatment modalities continue to experience unique risks that impact surgical and perioperative decision-making. Here, we review special populations and factors that impact risk in LVAD and heart transplant surgery and examine critical decisions in the management of these patients. As both heart transplantation and the use of durable LVADs as destination therapy continue to increase, these considerations will be of increasing relevance in managing advanced heart failure and improving outcomes.
RESUMO
BACKGROUND: Donation after circulatory death (DCD) has reemerged as a method of expanding the donor heart pool. Given the high waitlist mortality of multiorgan heart candidates, we evaluated waitlist outcomes associated with willingness to consider DCD offers and post-transplant outcomes following DCD transplant for these candidates. METHODS: We identified adult multiorgan heart candidates and recipients between January 1, 2020 and March 31, 2023 nationally. Among candidates that met inclusion criteria, we compared the cumulative incidence of transplant, with waitlist death/deterioration as a competing risk, by willingness to consider DCD offers. Among recipients of DCD versus brain death (DBD) transplants, we compared perioperative outcomes and post-transplant survival. RESULTS: Of 1,802 heart-kidney, 266 heart-liver, and 440 heart-lung candidates, 15.8%, 12.4%, and 31.1%, respectively, were willing to consider DCD offers. On adjusted analysis, willingness to consider DCD offers was associated with higher likelihood of transplant for all multiorgan heart candidates and decreased likelihood of waitlist deterioration for heart-lung candidates. Of 1,100 heart-kidney, 173 heart-liver, and 159 heart-lung recipients, 5.4%, 2.3%, and 2.5%, respectively, received DCD organs. Recipients of DCD and DBD heart-kidney transplants had a similar likelihood of perioperative outcomes and 1-year survival. All other DCD multiorgan heart recipients have survived to the last follow-up. CONCLUSIONS: Multiorgan heart candidates who were willing to consider DCD offers had favorable waitlist outcomes, and heart-kidney recipients of DCD transplants had similar post-transplant outcomes to recipients of DBD transplants. We recommend the use of DCD organs to increase the donor pool for these high-risk candidates.
RESUMO
The COVID-19 pandemic has differentially impacted people according to their race/ethnicity, socioeconomic status, and preexisting conditions. Public health surveillance efforts, especially those occurring early in the pandemic, did not gather nor report adequate individual-level demographic information to identify these differences, and thus, neighborhood-level characteristics were used to note striking disparities in the US. We sought to determine whether risk factors associated with COVID-19 incidence and mortality in five Southeastern Pennsylvania counties could be better understood by using neighborhood-level demographic data augmented with health, socioeconomic, and environmental characteristics derived from publicly available sources. Although we found that education level and age of residents were the most salient predictors of COVID-19 incidence and mortality, respectively, neighborhoods exhibited a high degree of segregation with multiple correlated factors, which limits the ability of neighborhood-level analysis to identify actionable factors underlying COVID-19 disparities.
RESUMO
A wide range of datasets containing geographically distributed measures of the environment and social factors is currently available, and as low-cost sensors and other devices become increasingly used, the volume of these data will continue to grow. Because such factors influence many health outcomes, researchers with varied interests often repeat tasks related to gathering and preparing these data for studies. We created Sensor-based Analysis of Pollution in the Philadelphia Region with Information on Neighborhoods and the Environment (SAPPHIRINE), offered as a web application and R package, to integrate pollution, crime, social disadvantage, and traffic data relevant to investigators, citizen scientists, and policy makers in the Greater Philadelphia Area. SAPPHIRINE's capabilities include providing interactive maps and customizable data retrieval to aid in the visual identification of pollution and other factor hotspots, as well as hypothesis generation regarding relationships among these factors and health outcomes.
