title: Comparison of listing strategies for allosensitized heart transplant candidates requiring transplant at high urgency: a decision model analysis.
abstract: Allosensitized children who require a negative prospective crossmatch have a high risk of death awaiting heart transplantation. Accepting the first suitable organ offer, regardless of the possibility of a positive crossmatch, would improve waitlist outcomes but it is unclear whether it would result in improved survival at all times after listing, including posttransplant. We created a Markov decision model to compare survival after listing with a requirement for a negative prospective donor cell crossmatch (WAIT) versus acceptance of the first suitable offer (TAKE). Model parameters were derived from registry data on status 1A (highest urgency) pediatric heart transplant listings. We assumed no possibility of a positive crossmatch in the WAIT strategy and a base-case probability of a positive crossmatch in the TAKE strategy of 47%, as estimated from cohort data. Under base-case assumptions, TAKE showed an incremental survival benefit of 1.4 years over WAIT. In multiple sensitivity analyses, including variation of the probability of a positive crossmatch from 10% to 100%, TAKE was consistently favored. While model input data were less well suited to comparing survival when awaiting transplantation across a negative virtual crossmatch, our analysis suggests that taking the first suitable organ offer under these circumstances is also favored.
authors.affiliation: Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA; Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, PA.
authors.forename: B
authors.initials: B
authors.lastname: Feingold
authors.forename: S A
authors.initials: SA
authors.lastname: Webber
authors.forename: C L
authors.initials: CL
authors.lastname: Bryce
authors.forename: S Y
authors.initials: SY
authors.lastname: Park
authors.forename: H E
authors.initials: HE
authors.lastname: Tomko
authors.forename: D M
authors.initials: DM
authors.lastname: Comer
authors.forename: W T
authors.initials: WT
authors.lastname: Mahle
authors.forename: K J
authors.initials: KJ
authors.lastname: Smith
mesh_terms: D064591:Allografts; D002648:Child; D002675:Child, Preschool; D003661:Decision Support Techniques; D005260:Female; D006085:Graft Survival; D016027:Heart Transplantation / Q000401:mortality; D006650:Histocompatibility Testing; D006801:Humans; D007223:Infant; D008297:Male; D008390:Markov Chains; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D015996:Survival Rate; D013997:Time Factors; D066027:Transplant Recipients; D014850:Waiting Lists / Q000401:mortality
keywords: alloantibody; cardiology; clinical decision-making; crossmatch; health services and outcomes research; heart transplantation; organ allocation; organ procurement and allocation; pediatrics; sensitization