title: Matching high-risk recipients with marginal donor hearts is a clinically effective strategy.
abstract: BACKGROUND
  The purpose of this study is to determine the clinical outcomes associated with alternate listing transplantation, which utilizes "marginal" donor organs by transplanting them into high-risk recipients who fail to meet the standard criteria for transplantation.
  
  
  METHODS
  The United Network for Organ Sharing provided de-identified patient-level data. Analysis focused on patients undergoing heart transplantation between January 1, 1999, and December 31, 2005 (n = 13,024). High-risk criteria included age more than 65 years old, retransplantation, hepatitis C-positive, human immunodeficiency virus-positive, creatinine clearance less than 30 mL/min, diabetes mellitus with peripheral vascular disease, and diabetes with creatinine clearance less than 40 mL/min. Marginal donor criteria included age more than 55 years, diabetes mellitus, hepatitis C-positive, human immunodeficiency virus-positive, ejection fraction less than 45%, and donor:recipient weight less than 0.7.
  
  
  RESULTS
  Survival in the standard transplant group, defined as non-high-risk patients who received nonmarginal organs, was better than in all other groups (p < 0.001). Alternate listing transplantation patients had the worst survival (p < 0.001). The 5-year survival for the alternate listing transplantation group was 51.4%, compared with 75.1% in the standard transplant group; the standard transplant patients, with the lowest incidence of in-hospital infection (21.1%) and dialysis (7.1%), also had the best transplant hospitalization outcomes (p < 0.001). In contrast, alternate listing transplantation patients had the highest incidence of in-hospital infection (35.4%; p < 0.001). Length of stay during transplant hospitalization was also shortest in the standard transplant group (18.8 days; p < 0.001).
  
  
  CONCLUSIONS
  Alternate listing transplantation is associated with greater morbidity and resource utilization compared with standard transplantation. However, this strategy offers a median survival of 5.2 years to patients who would otherwise be expected to live 1 year, and therefore, may be reasonably applied to expand the benefits of transplantation. Further studies examining the costs and quality of life related to this approach are needed.
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York, USA. mr2143@columbia.edu
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Russo
authors.forename: Ryan R
authors.initials: RR
authors.lastname: Davies
authors.forename: Kimberly N
authors.initials: KN
authors.lastname: Hong
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Chen
authors.forename: Michael
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authors.lastname: Argenziano
authors.forename: Alan
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authors.lastname: Moskowitz
authors.forename: Deborah D
authors.initials: DD
authors.lastname: Ascheim
authors.forename: Isaac
authors.initials: I
authors.lastname: George
authors.forename: Allan S
authors.initials: AS
authors.lastname: Stewart
authors.forename: Mathew
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authors.lastname: Williams
authors.forename: Annetine
authors.initials: A
authors.lastname: Gelijns
authors.forename: Yoshifumi
authors.initials: Y
authors.lastname: Naka