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Organ Allocation Around the World: Insights From the ISHLT International Registry for Heart and Lung Transplantation

2014; Elsevier BV; Volume: 33; Issue: 10 Linguagem: Inglês

10.1016/j.healun.2014.08.001

1557-3117

Josef Stehlik, Lynne W. Stevenson, Leah B. Edwards, María G. Crespo‐Leiro, Juan F. Delgado, Richard Dorent, Maria Frigerio, Peter S. Macdonald, Guy A. MacGowan, Alessandro Nanni Costa, Joseph G. Rogers, Ashish S. Shah, Rhiannon Taylor, Rajaiyer V. Venkateswaran, Mandeep R. Mehra,

Mechanical Circulatory Support Devices

The 2014 reports of the International Society for Heart and Lung Transplantation (ISHLT) International Registry for Heart and Lung Transplantation (Registry) bring expanded analyses of outcomes in patients who have undergone retransplantation. The experience of more than 170,000 heart, lung, and heart-lung transplant recipients transplanted over 30 years provided an opportunity for a robust exploration of this topic. The appropriateness of retransplantation has recently been undergoing critical review.1Vanderlaan R.D. Manlhiot C. Conway J. et al.Perioperative factors associated with in-hospital mortality or retransplantation in pediatric heart transplant recipients.J Thorac Cardviovasc Surg. 2014; 148: 282-289Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 2Kobashigawa J. Zuckermann A. Macdonald P. et al.Report from a consensus conference on primary graft dysfunction after cardiac transplantation.J Heart Lung Transplant. 2014; 33: 327-340Abstract Full Text Full Text PDF PubMed Scopus (428) Google Scholar, 3Conway J. Manlhiot C. Kirk R. et al.Mortality and morbidity after retransplantation after primary heart transplant in childhood: an analysis from the registry of the International Society for Heart and Lung Transplantation.J Heart Lung Transplant. 2014; 33: 241-251Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 4Khan M.S. Mery C.M. Zafar F. et al.Is mechanically bridging patients with a failing cardiac graft to retransplantation an effective therapy? Analysis of the United Network of Organ Sharing database.J Heart Lung Transplant. 2012; 31: 1192-1198Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 5Goldraich L. Stehlik J. Kucheryavaya A.Y. Edwards L.B. Ross H.J. Retransplantation versus medical therapy for cardiac allograft vasculopathy (CAV): analysis of the International Society for Heart and Lung Transplantation (ISHLT) Registry.J Heart Lung Transplant. 2014; 33: S90Abstract Full Text Full Text PDF Google Scholar We believe the analyses presented in the Registry reports provide important new information and insights that will be valuable as our professional community re-examines timing and candidate selection for retransplantation. The Registry continues to serve as a valuable tool to answer clinical questions, beyond the data presented in the annual reports. The Transplant Registry Early Career Award is a good mechanism that facilitates this work and catalyzes mentorship and collaboration across institutions and countries. Applications for the 2014 Award were submitted by applicants and mentors from 6 countries on 3 continents—Australia, Belgium, Czech Republic, Germany, Spain, Sweden, and the United States. The high quality of these applications resulted in 4 funded awards this year.6International Society for Heart and Lung Transplantation. ISHLT grants and awards program. Available at: http://ishlt.org/awards/currentRecipients.asp.Google Scholar The applications for next year’s award are due in January 2015 (http://www.ishlt.org/awards/awardTxRegistry.asp). The Registry also continued to work with members around the world to identify institutions and data collectives interested in participation in the Registry. Centers that joined the Registry in the past year include the Federal Research Center of Transplantology and Artificial Organs in Moscow, Russia, the King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia, and the Apollo Hospital in Chennai, India—all centers in countries that have not previously participated in the Registry. The Masih Daneshvari Hospital in Tehran became the second center in Iran, along with Tehran University of Medical Sciences, to join the Registry, and the Gangham Severance Hospital in Seoul joined the Severance Hospital as the second South Korean center to submit data. In addition, the Registry Committee has partnered with the International & Inter-society Coordination Committee (I2C2) of the ISHLT to work on establishing new collaborations in research, education, and advocacy. Examples include relations with the Turkish Society of Cardiovascular Surgery (activities spearheaded by Dr Ruchan Akar and Dr Murat Sargin), the Ministry of Health of Brazil (Dr Heder Borba), the Latin American and Caribbean Transplant Society (Dr Juan Mejia, Dr Alejandro Bertolotti), and the Ministry of Health of Argentina (Dr Carlos Soratti). The perspectives of an increasing number of the Registry participants (Figure 1), which mirror the breadth of the international membership in our Society, also allow for exploration of topics that may not be directly or fully addressed by Registry data collection. One of the ever more pressing topics is how to align the evolving non-transplant options in advanced heart and lung disease, the changing donor and recipient demographics, and organ allocation. To illustrate the utility of the Registry data and of the international expertise of the Society’s members, we provide a brief perspective focused on heart transplant data. During the past 3 decades, new traffic laws and improvements in automobile and workplace safety have resulted in a decrease in the accident-related death rates in young adults.7Silver D. Macinko J. Bae J.Y. Jimenez G. Paul M. Variation in U.S. traffic safety policy environments and motor vehicle fatalities 1980–2010.Public Health. 2013; 127: 1117-1125Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar In addition, the populations of many nations have continued to age. Consequently, the average age of organ donors has increased, as has the age of donors accepted for heart transplantation. The median age of a heart donor increased from 20 years in 1983 to 32 years in 2011, with the steepest increase being experienced in Europe, where the median donor age in 2011 reached 43 years.8Lund L.H. Edwards L.B. Kucheryavaya A.Y. et al.The Registry of the International Society for Heart and Lung Transplantation: thirtieth official adult heart transplant report—2013; focus theme: age.J Heart Lung Transplant. 2013; 32: 951-964Abstract Full Text Full Text PDF PubMed Scopus (470) Google Scholar These demographic changes have a real effect on post-transplant survival. For example, the higher donor age in Europe would be expected to result in a 20% increase of mortality risk compared with the North American donor pool. Donor medical comorbidities, such as diabetes mellitus and hypertension, have also increased.9Nativi J.N. Brown R.N. Taylor D.O. Kfoury A.G. Kirklin J.K. et al.Temporal trends in heart transplantation from high-risk donors: are there lessons to be learned? A multi-institutional analysis.J Heart Lung Transplant. 2010; 29: 847-852Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar The demographics of the heart transplant recipient have changed perhaps even more dramatically. Recipients being transplanted in their 60s now comprise 30% of all adult heart transplants, with patients in their 70s receiving heart transplants with a higher frequency than ever before.8Lund L.H. Edwards L.B. Kucheryavaya A.Y. et al.The Registry of the International Society for Heart and Lung Transplantation: thirtieth official adult heart transplant report—2013; focus theme: age.J Heart Lung Transplant. 2013; 32: 951-964Abstract Full Text Full Text PDF PubMed Scopus (470) Google Scholar Recipient comorbidities have increased steadily; at the time of transplant, 25% of recipients have diabetes mellitus, 45% have hypertension, 46% have had prior sternotomy, 7% have had malignancy, and 33% are allosensitized. The most visible recent change probably relates to the use of mechanical assist devices as a bridge to transplantation. Close to 40% of all adult recipients are bridged to transplant with a durable device. Further, although use of mechanical assist as a bridge to transplant had been infrequent in older patients in the recent past, this trend was fully reversed. As of 2011, transplant candidates older than 60 years are equally or even more likely to be supported by a mechanical assist device at the time of transplant compared with younger recipients. In view of the increasing complexity of donor and recipient profiles, the charge we have is to find ways to maintain (or increase) transplant volumes, preserve good post-transplant outcomes, maintain equity in organ allocation, and keep mortality on the transplant waiting list as low as possible. Renewed efforts to optimize the donation process and donor management have shown promise.10Kransdorf E.P. Stehlik J. Donor evaluation in heart transplantation: the end of the beginning.J Heart Lung Transplant. 2014; ([E-pub ahead of print])https://doi.org/10.1016/j.healun.2014.05.002Abstract Full Text Full Text PDF Scopus (38) Google Scholar Interventions to improve donor hemodynamic management have been tested in different countries, and sizeable increases in the number of organs suitable for transplantation resulted from these efforts. These interventions included sharing and implementing best practices from top performing organ procurement teams,11U.S. Department of Health and Human Services, Health Resources and Services Administration. Office of Special Programs, Division of Transplantation. The organ donation breakthrough collaborative: best practices final report. Contract 240-94-0037. Task Order No. 12. Washington, DC: U.S. Department of Health and Human Services; 2003Google Scholar implementing early protocol-driven donor management,12Venkateswaran R.V. Patchell V.B. Wilson I.C. et al.Early donor management increases the retrieval rate of lungs for transplantation.Ann Thorac Surg. 2008; 85 (discussion 286): 278-286Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar, 13Venkateswaran R.V. Steeds R.P. Quinn D.W. et al.The haemodynamic effects of adjunctive hormone therapy in potential heart donors: a prospective randomized double-blind factorially designed controlled trial.Eur Heart J. 2009; 30: 1771-1780Crossref PubMed Scopus (91) Google Scholar and introducing didactic training for key hospital-based health care professionals.14de la Rosa G. Dominguez-Gil B. Matesanz R. et al.Continuously evaluating performance in deceased donation: the Spanish quality assurance program.Am J Transplant. 2012; 12: 2507-2513Crossref PubMed Scopus (64) Google Scholar, 15Matesanz R. Dominguez-Gil B. Coll E. de la Rosa G. Marazuela R. Spanish experience as a leading country: what kind of measures were taken?.Transplant Int. 2011; 24: 333-343Crossref PubMed Scopus (178) Google Scholar Recent studies have also examined the next step of the donation-transplantation process—the decisions surrounding acceptance of a particular donor allograft. It appears that current heart allograft utilization could be increased without elevating the risk of post-transplant mortality. Empiric quantification of the risk associated with a particular donor is difficult, and it has been proposed that a number of donor allografts with acceptable risk are currently being discarded. Ongoing studies are examining whether better assessment of risk associated with a particular donor allograft may result in an increase in the number of available donor hearts accepted for transplantation.16Weiss E.S. Allen J.G. Kilic A. et al.Development of a quantitative donor risk index to predict short-term mortality in orthotopic heart transplantation.J Heart Lung Transplant. 2012; 31: 266-273Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar, 17Smits J.M. De Pauw M. de Vries E. et al.Donor scoring system for heart transplantation and the impact on patient survival.J Heart Lung Transplant. 2012; 31: 387-397Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Finally, there is the task of adapting our organ allocation processes to the changing epidemiology of donors and recipients and the evolving therapeutic options for advanced heart disease. Although the logistical challenges associated with the process of organ donation and organ management are reasonably similar among countries with established organ transplantation programs, organ donation rates and heart transplantation rates vary significantly among these countries. The differences among organ allocation rules are even more pronounced. Key heart transplant indicators from a sample of countries are listed in Table 1. All sampled countries have established different tiers of transplant urgency status; however, the definition of urgency is variable. Large differences also exist among the individual countries in the proportion of patients who are transplanted in the highest urgency status and in the median time from listing to transplantation in the high urgency status. This illustrates that the specifics of an allocation system have great effect on these key parameters.Table 1Key Heart Transplant Waiting List Parameters in a Sample of 5 Countries in North America, Europe, Australia, and New ZealandCountryAllocation algorithmTransplanted in statusMedian waiting timePatients transplanted in 2012Patients on the list in 2012 (at start of the year/newly listed)Transplant rate in 2012Patients with MCS at transplantDonor consent legislationHeart transplantsaBased on 2010 data.Organ donorsaBased on 2010 data.Patients transplanted/patients on the listPatients transplanted/patients newly listed(VAD/ECMO)(%)(days)(No.)(No.)(%)(%)(%)(per million)(per million)United KingdomUrgent6014116352 (141/212)335419 (16/3)Opt in2.117Non-urgent40293FranceHigh urgency 1399397830 (300/530)487527 (13/14)Opt out6.125High urgency 28102Regional urgency8219Non-urgent45189SpainUrgent status 0148247433 (101/332)577415 (9/6)Opt out5.335Urgent status 1217Elective status6580Italy1 high urgency1432311,100 (709/391)32599 (9/0)Opt in/opt outbAll are invited to register their donation intent. In the absence of declared intent, the law establishes presumed consent, but family input is typically sought.4.6202A, 2B86292Australia & New ZealandUrgent81585186 (78/108)467940 (40/0)Opt in3.315Non-urgent92120USA1A high urgency64782,3786,669 (3,526/3,143)367640% (39/1)Opt in7.6261B intermediate312242 low urgency5618ECMO, extracorporeal membrane oxygenation; MCS, mechanical circulatory support; USA, United States of America; VAD, ventricular assist device (temporary or durable) or total artificial heart.a Based on 2010 data.b All are invited to register their donation intent. In the absence of declared intent, the law establishes presumed consent, but family input is typically sought. Open table in a new tab ECMO, extracorporeal membrane oxygenation; MCS, mechanical circulatory support; USA, United States of America; VAD, ventricular assist device (temporary or durable) or total artificial heart. Some countries have a fairly restrictive definition of highest urgency such that only <15% of listed patients are transplanted in this status (Spain, Italy, Australia/New Zealand); this, in turn, results in short median times to transplantation of 8, 3, and 15 days, respectively. Then there are countries where a significant proportion of patients are transplanted in the highest urgency status—United Kingdom (60%) and France (39%)— yet, the median waiting time to transplant is still short, at 14 and 9 days, respectively. This would suggest that the waiting list is managed very carefully in these countries, such that the number of patients placed in the highest urgency status does not overwhelm the limited supply of donor organs. Finally, data for the United States show that most patients in this country are transplanted in a high urgency status (64% in status 1A, 31% in status 1B, and only 5% in lower urgency status 2) but also that under the current allocation rule, the ability to expeditiously transplant a heart patient has been lost, for the median waiting time for a transplant in the highest urgency status 1A is now 78 days.18Stevenson L.W. The urgent priority for transplantation is to trim the waiting list.J Heart Lung Transplant. 2013; 32: 861-867Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Regardless of the specifics of a particular allocation system, 2 aspects of the allocation rules continue to present a particular challenge. The first is that allocation algorithms often incorporate provisions for allocation to an individual center or an arbitrarily defined geographic area, rather than exclusively allocation to an individual patient. On the positive side, these geographic arrangements provide a strong incentive for local teams to create efficient processes that maximize the use of organs by increasing donation awareness, early identification of potential donors, and implementation of optimal donor management. However, allocation of organs based on a wider regional, national, and even multinational prioritization of candidates at the highest risk of death has been shown to result in a decrease of waiting list mortality and an increase of transplant benefit.19Singh T.P. Almond C.S. Taylor D.O. Graham D.A. Decline in heart transplant wait list mortality in the United States following broader regional sharing of donor hearts.Circ Heart Fail. 2012; 5: 249-258Crossref PubMed Scopus (81) Google Scholar In our assessment, most allocation algorithm revisions are therefore moving away from center-specific rules (including “pay-back” rules) and in favor of broader sharing of organs. Continuation of active efforts to improve the number and quality of donors across the board will eventually benefit every region, even with the wider regional sharing of organs. The second highly charged aspect of heart allocation relates to the now prevalent use of mechanical assist therapies in transplant candidates. Allocation arrangements in the countries reviewed in Table 1 range from a significant advantage to even stable patients supported with ventricular assist devices (VADs) to no advantage unless a serious VAD complication occurs. Supporters for higher priority for transplant candidates receiving VAD would argue that lack of allocation priority for VAD patients results in very long waiting times in many. And, when a serious VAD-associated complication occurs, this may negate the expected benefit of the bridge-to-transplant therapy, because a sub-set of these patients will become transplant ineligible or have a higher risk of post-transplant morbidity and mortality. On the other hand, the concern with providing a significant advantage to patients with VADs brings up questions of equity, because these patients often have a lower risk of waiting list mortality compared with patients with other indications for urgent listing.20Wever-Pinzon O. Drakos S.G. Kfoury A.G. et al.Morbidity and mortality in heart transplant candidates supported with mechanical circulatory support: is reappraisal of the current United network for organ sharing thoracic organ allocation policy justified?.Circulation. 2013; 127: 452-462Crossref PubMed Scopus (122) Google Scholar The specifics of the algorithms may also influence the likelihood with which the transplant candidates will require mechanical assist therapies. This is being taken into consideration by health care funding agencies in the individual countries, which further complicates possible decisions on allocation rule changes. In summary, changes in donor and recipient profiles, coupled with new therapeutic options in advanced heart and lung disease, present new perspectives on organ allocation and candidate selection. As we embrace these new realities, and as changes in thoracic allocation policies are being considered by many, the rich international experience offers an opportunity to identify and implement regulatory and clinical practice changes that will ensure transplantation continues to provide our patients an opportunity to regain longevity and an active lifestyle. We would like to thank the members and staff at the many participating centers and data exchange organizations around the world for making these global observations possible (Appendix 1). The authors thank staff at the national transplant organizations for contributing data for this report. All relevant disclosures for the authors are on file with the ISHLT and can be made available for review by contacting the Executive Director of the ISHLT. All relevant disclosures for the Registry Director, Executive Committee Members and authors are on file with the ISHLT and can be made available for review by contacting the Executive Director of the ISHLT AppendixList of Thoracic Transplant Centers Reporting Data to the International Society for Heart and Lung Transplantation Transplant Registry for Transplants Performed Between January 1, 2012, and June 30, 2013Country (ISO code)CenterArgentina (ARG)Fundacion FavaloroHospital ItalianoAustraliaaData provided via Australia and New Zealand Cardiothoracic Transplant Registry (ANZCOTR). (AUS)St. VincentRoyal ChildrenThe Prince Charles HospitalThe Alfred HospitalRoyal Perth HospitalAustriabData provided via Eurotransplant (ET). (AUT)Allgemeines Krankenhaus WienUniversitätsklinik InnsbruckLandeskrankenhaus GrazBelgiumbData provided via Eurotransplant (ET). (BEL)Hôpital Erasme BruxellesUniversitair Ziekenhuis AntwerpenOnze Lieve Vrouw Ziekenhuis AalstUniversitair Ziekenhuis GentCentre Hospitalier Universitaire LiègeCliniques Universitaires, Université Catholique de LouvainUZ Gasthuisberg LeuvenBrazil (BRA)Heart Institute–Universidade São Paulo Hospital das ClinicasHospital de MessejanaReal Hospital Portugues de Beneficiencia Em PernambucoInstituto de Medicina IntegralInstituto de Cardiologia do Distrito FederalHospital de Clinicas de Porto AlegreCanada (CAN)Royal Victoria HospitalThe Toronto General HospitalHospital Notre-DameQuebec Heart Institute–Laval HospitalUniversity of Alberta Hospitals/Walter C. Mackenzie Health SciencesSt. Paul’s HospitalVancouver General HospitalThe Hospital For Sick ChildrenChile (CHL)Hospital Gustavo FrickeInstituto Nacional del ToraxColombia (COL)Clinica CardiovascularFundacion Valle Del LiliFundacion Cardioinfantil–Instituto de CardiologiaFundacion Cardiovascular de ColombiaFundacion Clinica ShaioCroatiabData provided via Eurotransplant (ET). (HRV)University Clinical Hospital ZagrebUniversity Hospital DubravaThe Czech Republic (CZE)University Hospital MotolDenmarkcData provided via Scandiatransplant. (DNK)Skejby University HospitalRigshospitalet, National University HospitalEstonia (EST)Tartu University HospitalFinlandcData provided via Scandiatransplant. (FIN)Helsinki University Central HospitalChildren’s Hospital, University of HelsinkiFrancedData provided via L’Agence de la Biomédicine. (FRA)Marseille Sainte Marguerite (APM) (A)–Chirurgie ThoraciqueMarseille Timone adultes (APM) (A)–Chirurgie CardiaqueMarseille Timone enfants (APM) (A+P)–Chirurgie Cardio-VasculaireCaen (A)–Chirurgie CardiaqueDijon (A)–Chirurgie CardiaqueToulouse (A)–Chirurgie ThoraciqueToulouse (A)–Chirurgie Cardio-VasculaireBordeaux (A+P)–Unite de Transplantation CardiaqueBordeaux (A+P)–Chirurgie ThoraciqueMontpellier (A)–Unite de Transplantation Cardio-ThoraciqueRennes (A)–Centre Cardio-PneumologiqueTours (A+P)–Chirurgie CardiaqueGrenoble (A)–Chirurgie CardiaqueGrenoble (A)–PneumologieNantes (A+P)–Chirurgie Cardio-VasculaireNancy (A+P)–Chirurgie Cardio-PulmonaireLille (A+P)–Chirurgie Cardio-VasculaireClermont-Ferrand (A)–Chirurgie CardiaqueStrasbourg (A)–Chirurgie ThoraciqueStrasbourg (A)–Chirurgie Cardio-PulmonaireLyon (A+P)–Pole de Transplantation PulmonaireLyon I (HCL) (A+P)–Pole de Transplantation CardiaqueLyon II (HCL) (A)–Pole de Transplantation CardiaqueParis Pitié-Salpêtrière (AP-HP) (A+P)–Chirurgie Cardio-VasculaireParis Necker Enfants Malades (AP-HP) (A+P)–Cardiologie PediatriqueClichy Beaujon (AP-HP) (A)–Pneumologie B et Transplantation PulmonaireParis Bichat (AP-HP) (A)–Chirurgie Cardio-VasculaireParis Georges Pompidou (AP-HP) (A)–Transplantation CardiaqueParis Georges Pompidou (AP-HP) (A+P)–Transplantation. Pneumologie et Cardio-PulmonaireRouen (A+P)–Chirurgie Thoracique et Cardio-VasculaireLimoges (A)–Chirurgie CardiaqueSuresnes Foch (A)–Chirurgie ThoraciqueLe Plessis-Robinson Marie-Lannelongue (A+P)–Chirurgie CardiaqueLe Plessis-Robinson Marie-Lannelongue (A+P)–Chirurgie Thoracique Cardio-VasculaireCréteil Henri Mondor (AP-HP) (A)–Chirurgie Cardio-VasculaireGermanybData provided via Eurotransplant (ET). (DEU)Universität des Saarlandes Homburg/SaarHerzzentrum Dresden GmbHDeutsches Herzzentrum BerlinUniversitätsklinik KölnUniversität Leipzig–HerzzentrumKerckhoff Klinik, Bad NauheimKlinikum der Universität RegensburgHerzzentrum Nordrhein-Westfalen Bad OeynhausenUniversitätsklinikum EssenJohannes Gutenberg Universität MainzHeinrich-Heine-Universität DüsseldorfUniversitätsklinikum MünsterRuprecht-Karls-Universität HeidelbergMedizinische Hochschule HannoverUniversitätsklinikum GöttingenUniversitätsklinikum AachenKlinikum der Justus-Liebig-Universität GiessenUniversitätsklinikum Schleswig-Holstein KielJohann Wolfgang Goethe Universität Frankfurt/MainFriedrich Schiller Universität JenaFriedrich Alexander Universität ErlangenUniversitätsklinikum WürzburgLudwig Maximilians Universität MünchenUniversitätsklinikum HamburgKlinikum der Albert-Ludwigs-Universität Freiburg im BreisgauIndia (IND)Apollo HospitalIran (IRN)Cardiac Surgery and Transplantation Research CenterMasih Daneshvari HospitalIrelandeData provided via United Kingdom Transplant Support Service Authority (UKTSSA). (IRL)Mater HospitalIsrael (ISR)Rabin Medical Center (Belinson Campus)Sheba Medical CenterItaly (ITA)Policlinico S. Orsola–Universita degli StudiJapan (JPN)Tohoku University HospitalOsaka University HospitalNetherlandsbData provided via Eurotransplant (ET). (NLD)Universitair Medisch Centrum UtrechtErasmus Medisch Centrum RotterdamUniversitair Medisch Centrum GroningenNew Zealand (NZL)Green Lane HospitalAuckland City HospitalNorwaycData provided via Scandiatransplant. (NOR)Rikshospitalet–National Hospital of NorwayPoland (POL)Regional Pulmonary HospitalThe Republic of Korea (KOR)Gangnam Severance HospitalSeverance HospitalRussia (RUS)Federal V. Shumakov Research Centre of Transplantology & Artificial OrgansSaudi Arabia (SAU)King Faisal Specialist Hospital and Research CenterSloveniabData provided via Eurotransplant (ET). (SVN)University Medical Center LjubljanaSouth Africa (ZAF)Milpark HospitalSpain (ESP)Complejo Hospitalario Universitario Juan CanalejofLung data provided via OrganizaciónNacional de Trasplantes (ONT).,gHeart data provided directly to ISHLT Registry.Hospital Universitario Marques de ValdecillafLung data provided via OrganizaciónNacional de Trasplantes (ONT).,hHeart data provided via RegistroEspañol de TrasplanteCardíaco.Hospital de Bellvitge, BarcelonahHeart data provided via RegistroEspañol de TrasplanteCardíaco.Hospital Virgen Del Rocio, SevillahHeart data provided via RegistroEspañol de TrasplanteCardíaco.Hospital Santa Creu I Sant Pau, BarcelonahHeart data provided via RegistroEspañol de TrasplanteCardíaco.Hospital Universitario 12 de OctubrefLung data provided via OrganizaciónNacional de Trasplantes (ONT).,hHeart data provided via RegistroEspañol de TrasplanteCardíaco.Hospital Universitario Reina SofiafLung data provided via OrganizaciónNacional de Trasplantes (ONT).,hHeart data provided via RegistroEspañol de TrasplanteCardíaco.Hospital Gregorio Marañón, MadridhHeart data provided via RegistroEspañol de TrasplanteCardíaco.Hospital Universitario Puerta de HierrofLung data provided via OrganizaciónNacional de Trasplantes (ONT).Hospital Universitari I Politècnic La Fe, ValenciafLung data provided via OrganizaciónNacional de Trasplantes (ONT).,hHeart data provided via RegistroEspañol de TrasplanteCardíaco.Hospital Clinic I Provincial, BarcelonahHeart data provided via RegistroEspañol de TrasplanteCardíaco.Hospital Universitario Vall D’HebronfLung data provided via OrganizaciónNacional de Trasplantes (ONT).,hHeart data provided via RegistroEspañol de TrasplanteCardíaco.Hospital Central de AsturiasgHeart data provided directly to ISHLT Registry.Hospital La Paz InfantilfLung data provided via OrganizaciónNacional de Trasplantes (ONT).,hHeart data provided via RegistroEspañol de TrasplanteCardíaco.Hospital Virgen de La Arrixaca, MurciahHeart data provided via RegistroEspañol de TrasplanteCardíaco.Hospital Miguel Servet, ZaragozahHeart data provided via RegistroEspañol de TrasplanteCardíaco.Hospital Clínico, ValladolidhHeart data provided via RegistroEspañol de TrasplanteCardíaco.SwedencData provided via Scandiatransplant. (SWE)Sahlgrenska University HospitalUniversity Hospital of LundSwitzerland (CHE)University Hospital ZurichTurkey (TUR)Istanbul Florence Nightingale HospitalHeart Center, Ankara UniversityHospital of Akdeniz UniversityUnited KingdomeData provided via United Kingdom Transplant Support Service Authority (UKTSSA). (UK)Great Ormand Street Hospital for ChildrenUniversity of Glasgow/Glasgow Royal InfirmaryThe Freeman HospitalHarefield HospitalWythenshawe HospitalQueen Elizabeth HospitalPapworth HospitalUnited StatesiData provided via United Network for Organ Sharing (UNOS). (USA)University of Alabama Hospital, Birmingham, ALBaptist Medical Center, Little Rock, ARArkansas Children’s Hospital, Little Rock, ARPhoenix Children’s Hospital, Phoenix, AZMayo Clinic Hospital, Phoenix, AZSt. Joseph’s Hospital and Medical Center, Phoenix, AZUniversity Medical Center, University of Arizona, Tucson, AZChildren’s Hospital Los Angeles, Los Angeles, CACedars-Sinai Medical Center, Los Angeles, CALoma Linda University Medical Center, Loma Linda, CALucile Salter Packard Children’s Hospital, Palo Alto, CACalifornia Pacific Medical Center, San Francisco, CAUCSD Medical Center, San Diego, CAUCSF Medical Center, San Francisco, CASutter Memorial Hospital, Sacramento, CASharp Memorial Hospital, San Diego, CAStanford University Medical Center, Stanford, CAUCLA Medical Center, Los Angeles, CAKeck Hospital of USC, Los Angeles, CAChildren’s Hospital Colorado, Aurora, COUniversity of Colorado Hospital/HSC, Aurora, COHartford Hospital, Hartford, CTYale New Haven Hospital, New Haven, CTChildren’s National Medical Center, Washington, DCWashington Hospital Center, Washington, DCAlfred I duPont Hospital for Children, Wilmington, DEAll Children’s Hospital, St. Petersburg, FLFlorida Hospital Medical Center, Orlando, FLMemorial Regional/Joe DiMaggio Children’s Hospital, Hollywood, FLJackson Memorial Hospital, Miami, FLMayo Clinic Florida, Jacksonville, FLTampa General Hospital, Tampa, FLShands Hospital at University of FL, Gainesville, FLChildren’s Healthcare of Atlanta, Atlanta, GAEmory University Hospital, Atlanta, GAPiedmont Hospital, Atlanta, GASt. Joseph’s Hospital of Atlanta, Atlanta, GAUniversity of Iowa Hospital and Clinics, Iowa City, IAAdvocate Christ Medical Center, Oak Lawn, ILAnn and Robert H. Lurie Children’s Hospital, Chicago, ILLoyola University Medical Center, Maywood, ILNorthwestern Memorial Hospital, Chicago, ILRush University Medical Center, Chicago, ILUniversity of Chicago Medical Center, Chicago, ILIndiana University Health, Indianapolis, INLutheran Hospital of Ft Wayne, Ft Wayne, INSt. Vincent Hospital and Health Care Center, Indianapolis, INJewish Hospital, Louisville, KYUniversity of Kentucky Medical Center, Lexington, KYOchsner Foundation Hospital, New Orleans, LABoston Children’s Hospital, Boston, MAMassachusetts General Hospital, Boston, MATufts Medical Center, Boston, MABrigham and Women’s Hospital, Boston, MAJohns Hopkins Hospital, Baltimore, MDUniversity of Maryland Medical System, Baltimore, MDChildren’s Hospital of Michigan, Detroit, MIHenry Ford Hospital, Detroit, MISpeCenterum Health, Grand Rapids, MIUniversity of Michigan Medical Center, Ann Arbor, MIAbbott Northwestern Hospital, Minneapolis, MNSt. Mary’s Hospital (Mayo Clinic), Rochester, MNUniversity of Minnesota Medical Center, Minneapolis, MNBarnes-Jewish Hospital, St. Louis, MOCardinal Glennon Children’s Hospital, St. Louis, MOSt. Louis Children’s Hospital, St. Louis, MOSt. Luke’s Hospital of Kansas City, Kansas City, MOUniversity of MS Medical Center, Jackson, MSWake Forest Baptist Medical Center, Winston-Salem, NCCarolinas Medical Center, Charlotte, NCDuke University Hospital, Durham, NCUNC Hospitals, Chapel Hill, NCChildren’s Hospital and Medical Center, Omaha, NEThe Nebraska Medical Center, Omaha, NENewark Beth Israel Medical Center, Newark, NJRobert Wood Johnson University Hospital, New Brunswick, NJNew York-Presbyterian/Columbia, New York, NYStrong Memorial Hospital, Rochester, NYMontefiore Medical Center, Bronx, NYMount Sinai Medical Center, New York, NYWestchester Medical Center, Valhalla, NYCleveland Clinic Foundation, Cleveland, OHNationwide Children’s Hospital, Columbus, OHChildren’s Hospital Medical Center, Cincinnati, OHOhio State University Medical Center, Columbus, OHUniversity Hospital of Cleveland, Cleveland, OHIntegris Baptist Medical Center, Oklahoma City, OKOregon Health and Science University, Portland, ORAllegheny General Hospital, Pittsburgh, PAChildren’s Hospital of Pittsburgh of UPMC, Pittsburgh, PAChildren’s Hospital of Philadelphia, Philadelphia, PAPenn State Milton S Hershey Medical Center, Hershey, PAHahnemann University Hospital, Philadelphia, PAUniversity of Pittsburgh Medical Center, Pittsburgh, PAThomas Jefferson University Hospital, Philadelphia, PATemple University Hospital, Philadelphia, PAThe Hospital of the University of PA, Philadelphia, PACardiovascular Center of Puerto Rico, San Juan, PRMedical University of South Carolina, Charleston, SCBaptist Memorial Hospital, Memphis, TNVanderbilt University Medical Center, Nashville, TNUniversity Hospital, San Antonio, TXChildren’s Medical Center of Dallas, Dallas, TXSeton Medical Center, Austin, TXMedical City Dallas Hospital, Dallas, TXMemorial Hermann Hospital, Houston, TXSt Luke’s Episcopal Hospital, Houston, TXMethodist Specialty and Transplant Hospital, San Antonio, TXUniversity of Texas Medical Branch, Galveston, TXThe Methodist Hospital, Houston, TXUniversity Hospital–St. Paul, Dallas, TXScott and White Memorial Hospital, Temple, TXTexas Children’s Hospital, Houston, TXBaylor University Medical Center, Dallas, TXIntermountain Medical Center, Murray, UTUniversity of Utah Medical Center, Salt Lake City, UTPrimary Children’s Medical Center, Salt Lake City, UTInova Fairfax Hospital, Falls Church, VAMCV Hospitals, Richmond, VAMcGuire VA Medical Center, Richmond, VASentara Norfolk General Hospital, Norfolk, VAUniversity of Virginia HSC, Charlottesville, VASeattle Children’s Hospital, Seattle, WASacred Heart Medical Center, Spokane, WAUniversity of Washington Medical Center, Seattle, WAChildren’s Hospital of Wisconsin, Milwaukee, WIFroedtert Memorial Lutheran Hospital, Milwaukee, WIAurora St. Luke’s Medical Center, Milwaukee, WIUniversity of Wisconsin Hospital and Clinics, Madison, WIISO, International Organization for Standardization.a Data provided via Australia and New Zealand Cardiothoracic Transplant Registry (ANZCOTR).b Data provided via Eurotransplant (ET).c Data provided via Scandiatransplant.d Data provided via L’Agence de la Biomédicine.e Data provided via United Kingdom Transplant Support Service Authority (UKTSSA).f Lung data provided via OrganizaciónNacional de Trasplantes (ONT).g Heart data provided directly to ISHLT Registry.h Heart data provided via RegistroEspañol de TrasplanteCardíaco.i Data provided via United Network for Organ Sharing (UNOS). Open table in a new tab ISO, International Organization for Standardization.