BACKGROUND:The United Kingdom (UK) was one of the first countries to pioneer donation after circulatory death (DCD) heart transplants. To establish equitable access to DCD hearts, a nationally-funded DCD program was established in 2020. We report the results of this program and examine retrieval techniques, ischemic times and survival. METHODS:This multi-center, retrospective, observational study compared DCD versus donation after brain death (DBD) heart transplant outcomes from 2020 to 2024. DCD hearts were retrieved using direct procurement and perfusion (DPP) with/without abdominal normothermic regional perfusion (A-NRP). Primary outcomes were 1-year survival and severe primary graft dysfunction (PGD). Ischemic times, cannulation techniques, and A-NRP status were analyzed. RESULTS:There were 188 DCD and 523 DBD heart transplants. There was no difference in 30-day (96% DCD vs 95% DBD, p = 0.76) or 1-year survival (87% DCD vs 88% DBD, p = 0.81). There was no difference in severe PGD (unadjusted analysis; 28% DCD vs 24% DBD, p = 0.26). DPP with A-NRP increased ischemic timings (asystole to cardioplegia delivery, 15 mins (n = 22; A-NRP/DPP) vs 13 mins (n = 166; DPP, p = 0.0022). Propensity-matched analysis showed no difference in 90-day survival (86.4% vs 88.6%; p = 0.7828). Papworth cannulation technique reduced ischemic times with no impact on outcomes. Longer implant (p = 0.03) and ex-situ perfusion (p = 0.02) times were associated with severe PGD/death at 1 year. CONCLUSION:DCD heart donation increased UK heart transplantation by 36% compared with DBD alone, with results comparable to DBD. A-NRP/DPP is feasible but prolongs ischemic times, although survival was similar to the DPP group. The main predictors of poor 1-year survival were implant and ex-situ perfusion times.

Background:Combined en-bloc heart-lung transplantation (HLT) remains the optimal treatment for selected patients with end-stage cardiopulmonary disease. The indications for and utilization of HLT have changed significantly over time. We report the changing landscape of HLT in the UK over recent decades, identifying factors that may inform future organization of services. Methods:Data were extracted from the UK Transplant Registry spanning 1984 to December 2023. All patients who were registered for and/or underwent HLT were included in our analysis. Baseline characteristics and outcomes from listing and transplantation were compared between 2 eras: pre-2000 and post-2000. Results:Pre-2000, 1,199 patients were registered for HLT, and 915 received HLT, post-2000, there were 473 registrations and 200 transplantations, reflecting a significant decline in the use of this procedure. Those listed post-2000 were older, more symptomatic, and with more prior cardiac surgeries. Cystic fibrosis, the leading indication pre-2000, declined substantially in the later era. For patients requiring HLT in the later era, the risk of dying on the waiting list exceeded the chance of receiving a transplant. Median post-transplant survival improved from 4.07 (IQR 0.2, 12.3) to 7.9 (IQR 0.8, 21.6) years. Conclusion:Although HLT activity has declined, a considerable need remains, particularly among patients with congenital heart disease and pulmonary hypertension. The changes in patient demographics and high waiting list mortality highlight systemic inefficiencies in organ allocation and underscore the need for a revised system to ensure timely and equitable access for this high-risk population.

BACKGROUND: The United Kingdom (UK) was one of the first countries to pioneer heart transplanta-tion from donation after circulatory death (DCD) donors. To facilitate equity of access to DCD hearts by all UK heart transplant centers and expand the retrieval zone nationwide, a Joint Innovation Fund (JIF) pilot was provided by NHS Blood and Transplant (NHSBT) and NHS England (NHSE). The activity and outcomes of this national DCD heart pilot program are reported. METHODS: This is a national multi-center, retrospective cohort study examining early outcomes of DCD heart transplants performed across 7 heart transplant centers, adult and pediatric, throughout the UK. Hearts were retrieved using the direct procurement and perfusion (DPP) technique by 3 specialist retrieval teams trained in ex-situ normothermic machine perfusion. Outcomes were compared against DCD heart transplants before the national pilot era and against contemporaneous donation after brain death (DBD) heart transplants, and analyzed using Kaplan-Meier analysis, chi-square test, and Wilcoxon's rank-sum. RESULTS: From September 7, 2020 to February 28, 2022, 215 potential DCD hearts were offered of which 98 (46%) were accepted and attended. There were 77 potential donors (36%) which proceeded to death within 2 hours, with 57 (27%) donor hearts successfully retrieved and perfused ex situ and 50 (23%) DCD hearts going on to be transplanted. During this same period, 179 DBD hearts were trans-planted. Overall, there was no difference in the 30-day survival rate between DCD and DBD (94% vs 93%) or 90 day survival (90% vs 90%) respectively. There was a higher rate of ECMO use post-DCD heart transplants compared to DBD (40% vs 16%, p = 0.0006), and DCD hearts in the pre pilot era, (17%, p = 0.002). There was no difference in length of ICU stay (9 DCD vs 8 days DBD, p = 0.13) nor hospital stay (28 DCD vs 27 DBD days, p = 0.46). CONCLUSION: During this pilot study, 3 specialist retrieval teams were able to retrieve DCD hearts nationally for all 7 UK heart transplant centers. DCD donors increased overall heart transplantation in the UK by 28% with equivalent early posttransplant survival compared with DBD donors.Crown Copyright (c) 2023. Published by Elsevier Inc. on behalf of International Society for Heart and Lung Transplantation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

hours.In adjusted analysis, there was evidence of a nonlinear relationship between CIT and the risk of PGD grade 3 at 0 or 24 hours (p=0.004) and 48 or 72 hours (p=0.059).Moreover, longer CIT was associated with higher incidence of tracheostomy, p=0.025, and increased length of stay, p<0.001.CIT was not associated with dialysis, p=0.098, ventilator time, p=0.911, and one-year mortality, p=0.206.Figure 1.Conclusion: In this analysis from multicenter international registry, CIT was associated with PGD grade 3 at 0 or 24 hours and a 26% greater risk of remaining in the hospital.Lung transplantation maybe performed with long ischemic times with acceptable outcomes.

Introduction A new UK Lung Allocation Scheme (UKLAS) was introduced in 2017, replacing the previous geographic allocation system. Patients are prioritised according to predefined clinical criteria into a three-tier system: the super-urgent lung allocation scheme (SULAS), the urgent lung allocation scheme (ULAS) and the non-urgent lung allocation scheme (NULAS). This study assessed the early impact of this scheme on waiting-list and post-transplant outcomes. Methods A cohort study of adult lung transplant registrations between March 2015 and November 2016 (era-1) and between May 2017 and January 2019 (era-2). Outcomes from registration were compared between eras and stratified by urgency tier and diagnostic group. Results During era-1, 461 patients were registered. In era-2, 471 patients were registered (19 (4.0%) SULAS, 82 (17.4%) ULAS and 370 (78.6%) NULAS). SULAS patients were younger (median age 35 vs 50 and 55 for urgent and non-urgent, respectively, p=0.0015) and predominantly suffered from cystic fibrosis (53%) or pulmonary fibrosis (37%). Between eras 1 and 2, the odds of transplantation within 6 months of registration were increased (OR=1.41, 95% CI 1.07 to 1.85, p=0.0142) despite only a 5% increase in transplant activity. Median time-to-transplantation during era-1 was 427 days compared with waiting times in era-2 of 8 days for SULAS, 15 days for ULAS and 585 days for NULAS patients. Waiting-list mortality (15% era-1 vs 13% era-2; p=0.5441) and post-transplant survival at 1 year (81.3% era-1 vs 83.3% era-2; p=0.6065) were similar between eras. Conclusion The UKLAS scheme prioritises the critically ill and improves transplantation odds. The true impact on waiting-list mortality and post-transplant survival requires further follow-up.

Purpose SherpaPak™ CTS is CE marked and FDA approved device for organ transportation during heart transplantation. This device maintains organ temperature between 4-8°C which is the recommended temperature range by ISHLT 2020 consensus statement1 to prevent potential freezing damage. The aim of study was to analyse the clinical outcomes since its introduction in United Kingdom. Methods Donor hearts where SherpaPak™ was used for transportation between December 2019 to September 2021 were identified and data on donor and recipient demographics, transport parameters and short-term clinical outcomes were extracted from the UK Transplant Registry held by NHS Blood and Transplant. Results A total of 30 patients had heart transplantation using SherpaPak™ across the United Kingdom, including one heart-kidney transplant. The Manchester team did 16 implants, Harefield did 11 and Papworth did 3 implants using SherpaPak™ during the 22 month period. Donor median age was 31 years (range 17-53 years). Recipients median age was 50 years (range 19 - 61 years). 6 Recipients were on super-urgent, 20 on urgent and 4 on non-urgent waiting list for heart transplantation. Median ischemic time was 3.1 hours (range 1.8 - 7 hours). Post operative ECMO support was required in 4/30 (13%) patients. Median stay in intensive care was 9 days (range 3-59 days) and in hospital was 30 days (range 15-104 days). Two patients died within 30 days resulting in 30-day survival rate of 93% (95% CI: 75-98%), which is similar to published national 30-day survival of 91.5%.2 Conclusion UK national results demonstrate that SherpaPak™ is a safe device for organ transportation during heart transplantation. Further experience is needed to understand potential benefits and costs effectiveness.

Purpose The donation after circulatory death (DCD) pathway is an emerging contributor to heart transplantation. Selected UK centres started their adult programs in 2015, followed by a centrally funded national pilot commencing September 2020. The purpose of this study is to review the activity and outcomes of the UK National DCD heart transplant program during this pilot. Methods Data on DCD heart transplants between September 2020 to August 2021 were extracted from the UK Transplant Registry, held by National Health Service Blood and Transplant. The Registry contains data on all offered organs from potential donors, proceeding donations and organ recipients. Additional data were collected on the DCD Heart travel document. The DCD hearts were procured by 3 specialist retrieval teams, with national organ allocation to all 7 adult and paediatric heart transplant centres. Endpoints The hearts of 143 potential DCD donors were referred for offering during this 12-month period, from all areas of the UK. This resulted in 77 acceptance, 60 retrievals, 33 hearts retrieved and 30 transplants. Direct procurement and machine perfusion was the technique used for all DCD heart retrievals with 2 hearts retrieved during abdominal normothermic regional perfusion. Six procurements were performed by a hybrid team consisting of members from 2 retrieval teams, and 21 were transplanted by a different centre to that of the retrieval team. Median donor and recipient age was 33 (range: 12-50) and 46 (range: 13-62), respectively. Seven recipients were super-urgent and 13 were urgent; with a median wait time of 20 days (range: 1-320). In the same period there were 105 adult and 18 paediatric donation after brain death (DBD) heart transplants; DCDs representing 19% and 22% of the programs, respectively. Two patients died within 30 days, making the 30-day survival rate 93.3% (95% CI: 76-98), similar to the DBD cohort. Extracorporeal membrane oxygenation in the first 30 days was required for 15 out of 30 transplants. Conclusion In the 12-month pilot, DCD heart transplantation was 20% of the total heart transplant activity. This UK wide program was underpinned by unprecedented collaboration between UK cardiothoracic teams, and with abdominal teams, improving communication and shared learning. High volume, specialised procurement teams are key to a successful DCD heart sharing program to overcome challenges from the learning curve.

Severe acute kidney injury (AKI), defined as requiring renal replacement therapy (RRT), is associated with higher mortality postheart transplantation, but its long-term renal consequences are not known. Anonymized data of 3365 patients, who underwent heart transplantation between 1995 and 2017, were retrieved from the UK Transplant Registry. Multivariable binary logistic regression was performed to identify risk factors for severe AKI requiring RRT, Kaplan-Meier analysis to compare survival and renal function deterioration of the RRT and non-RRT groups, and multivariable Cox regression model to identify predicting factors of mortality and end-stage renal disease (ESRD). 26.0% of heart recipients received RRT post-transplant. The RRT group has lower survival rates at all time points, especially in the immediate post-transplant period. However, conditional on 3 months survival, older age, diabetes and coronary heart disease, but not post-transplant RRT, were the risk factors for long-term survival. The predicting factors for ESRD were insulin-dependent diabetes, renal function at transplantation, eGFR decline in the first 3 months post-transplant, post-transplant severe AKI and transplantation era. Severe AKI requiring RRT post-transplant is associated with worse short-term survival, but has no impact on long-term mortality. It also accelerates recipients' renal function deterioration in the long term.

BACKGROUND:In response to a growing number of patients on the UK urgent heart transplant waiting list, the UK donor heart allocation scheme was revised in October 2016 with the introduction of a new super-urgent category. Patients with temporary mechanical circulatory support (tMCS) became eligible for super-urgent registration. The aim of this study was to compare activity, indications, and outcomes before and after the change. METHODS:Data on adult (aged ≥16 years) heart transplant registrations and recipients in the 2 years before (Era 1: July 1, 2014-June 30, 2016) and after (Era 2: January 2017-December 2018) the introduction of the new scheme were extracted from the UK Transplant Registry and analyzed using competing risks analysis, Kaplan-Meier analysis, and Cox proportional-hazards regression. RESULTS:There were 525 waiting-list registrations in Era 1 and 594 in Era 2, including 14% super-urgent registrations, with 90% having some form of tMCS. Median waiting time to transplant was 41 days for all urgent registrations in Era 1 compared with 17 days for super-urgent registrations and 71 days for urgent registrations in Era 2. Numbers of non-urgent transplants were not affected. Deaths on the waiting list significantly decreased from 5% to 2% at 6 months between Era 1 and Era 2 (adjusted hazard ratio = 0.29, 95% CI = 0.13-0.62). In addition, total number of patients with tMCS were not different between both eras, suggesting no significant change in this area of clinical decision making. Post-transplant survival at 1 year for super-urgent recipients was not significantly different from post-transplant survival at 1 year for other categories. CONCLUSIONS:The Introduction of a super-urgent heart allocation scheme in the UK reduces waiting time to transplant for the sickest patients, with comparable post-transplant survival while reducing deaths on the waiting list.

In this national dataset, we demonstrate that with 90-day conditional survival, donor age has no impact on long-term outcomes following heart transplantation. However, longer term survival appears more dependent on recipient age. These data support the utilisation of hearts from older donors.

Although the utilisation rate from older lung donors is low, expanding the donor age criteria in the UK has resulted in an additional 8 transplants, a 1.2% increase. This appears to have benefited the older, non-urgent recipient. Despite the published increases to the donor offering age criteria, 'age' continues to be documented as a reason for organ decline. Further work is required to understand and improve utilisation rates throughout UK lung transplant practice, including the use of older donors. We will continue to review the impact of expanding lung donor age criteria on UK practice, including analysis of recipient outcomes from older age donors.

The number of potential DCD lung donors and the number of DCD lung transplants in the UK have increased exponentially since 2002. DCD lung transplants now account for 21% of UK lung transplant activity. Previous analysis of the UK DCD experience had shown comparable early and 1-year outcomes. Further analysis is required to understand significant differences in early survival for DCD lung recipients in the UK.

Background: Primary graft dysfunction (PGD) is a major cause of morbidity and mortality post-heart transplantation. The rates of PGD across Europe are higher than North America possibly because of the increasing use of extended criteria donors because of organ shortage. Our aim was to derive a novel scoring system based on data collected nationally in the UK over a 3-year period. We compared this scoring system to a previously validated (RADIAL) score in a contemporary cohort of patients. Methods: Medical records of all adult patients who underwent heart transplantation between October 1, 2012 and September 30, 2016 in the 6 UK heart transplant centers were analyzed. Preoperative donor and recipient characteristics, intraoperative details and post-transplant complications were compared between the PGD and non-PGD groups using the International Society of Heart and Lung Transplant definition. Multivariable logistic regression was used to build the predictive model. An area under receiver operating characteristics curve was used to test the novel scoring system (PREDICTA) versus the RADIAL score. Results: Six hundred and thirteen heart transplants were included in the study. There were 233 patients who had PGD. The variables included in the model were recipient diabetes mellitus, preoperative mechanical circulatory support (short-term ventricular assist devices/extracorporeal membrane oxygenation), implant time, donor age, and bypass time >180 minutes. The C statistic of the PREDICTA score was 0.704 versus 0.547 for the RADIAL score indicating an acceptable discriminatory value. Conclusion: The PREDICTA score is a novel scoring tool with improved ability to predict the development of PGD compared with the RADIAL score. Its application in the prevention and early management of PGD needs further evaluation.

Purpose Primary graft dysfunction (PGD) continues to be a potentially life-threatening early complication of heart transplantation despite advances in treatment options. PGD rates in the UK are about 36% and is the leading cause of 30-day mortality. The current ISHLT definition includes a severity scale for biventricular PGD. Our aim was to ascertain if the severity of PGD influences survival post-transplantation. Methods A retrospective review all adult patients who underwent heart transplantation between 1 October 2012- 30 September 2016 in the 6 UK heart transplant centres. The cohort of patients was divided into 3 groups based on PGD severity; mild, moderate and severe PGD respectively. Time to event survival analysis was performed with all-cause mortality as the outcome measure. Multivariable Cox regression analyses were used to measure the associations between the groups and all-cause mortality after adjusting for potential confounders: recipient age, donor age, gender, warm ischaemic time, recipient diabetes mellitus, and donor-recipient gender mismatch and size mismatch. Kaplan-Meier curves were used to show survival analysis. Risk estimates were presented as hazard ratios with 95% confidence intervals. Log-rank tests were performed to compare survival curves. Results for all analyses were deemed statistically significant at p-values <0.05. Results A total of 221 patients (73% male) were included; 11(5%) in Mild PGD, 101(46%) in Moderate PGD and 109 (49%) in severe PGD. The mean age of the recipients in the study was 46.8±13.2 years. Independent predictors of 5-year survival were recipient diabetes mellitus (HR 3.0 (CI 1.8-5.1) p<0.05), Male Donor: Female recipient (HR 2.5 (CI 1.08-5.6) p<0.05), and PGD severity (HR 4.8 (CI 2.8-4.1) (p<0.05)). Conclusion Although the recovery of cardiac function post-PGD is possible using a combination of inotropes or mechanical assist devices, it still confers a poorer survival at up to 5 years. PGD severity affects outcomes post heart transplantation. Primary graft dysfunction (PGD) continues to be a potentially life-threatening early complication of heart transplantation despite advances in treatment options. PGD rates in the UK are about 36% and is the leading cause of 30-day mortality. The current ISHLT definition includes a severity scale for biventricular PGD. Our aim was to ascertain if the severity of PGD influences survival post-transplantation. A retrospective review all adult patients who underwent heart transplantation between 1 October 2012- 30 September 2016 in the 6 UK heart transplant centres. The cohort of patients was divided into 3 groups based on PGD severity; mild, moderate and severe PGD respectively. Time to event survival analysis was performed with all-cause mortality as the outcome measure. Multivariable Cox regression analyses were used to measure the associations between the groups and all-cause mortality after adjusting for potential confounders: recipient age, donor age, gender, warm ischaemic time, recipient diabetes mellitus, and donor-recipient gender mismatch and size mismatch. Kaplan-Meier curves were used to show survival analysis. Risk estimates were presented as hazard ratios with 95% confidence intervals. Log-rank tests were performed to compare survival curves. Results for all analyses were deemed statistically significant at p-values <0.05. A total of 221 patients (73% male) were included; 11(5%) in Mild PGD, 101(46%) in Moderate PGD and 109 (49%) in severe PGD. The mean age of the recipients in the study was 46.8±13.2 years. Independent predictors of 5-year survival were recipient diabetes mellitus (HR 3.0 (CI 1.8-5.1) p<0.05), Male Donor: Female recipient (HR 2.5 (CI 1.08-5.6) p<0.05), and PGD severity (HR 4.8 (CI 2.8-4.1) (p<0.05)). Although the recovery of cardiac function post-PGD is possible using a combination of inotropes or mechanical assist devices, it still confers a poorer survival at up to 5 years. PGD severity affects outcomes post heart transplantation.

On behalf of the UK national intestinal transplant programmes Introduction: Intestinal transplantation in the UK has been centrally commissioned at four centres since 2008; two paediatric centres (Birmingham Children’s Hospital and King’s College Hospital) and two adult centres (Cambridge Addenbrooke’s Hospital and Oxford Churchill Hospital). The programme has evolved; this study describes the trends over the last 10 years. Mandatory data are collected centrally by National Health Service Blood and Transplant (NHSBT). Methods: All patients were included who were registered for or received an intestinal transplant. These were classified as: bowel only (small bowel +/- colon/abdominal wall/kidney, BO), multi-visceral (liver, small bowel, pancreas +/- stomach/kidney/colon, MV), or modified multi-visceral (small bowel, pancreas +/- stomach/kidney/colon/abdominal wall, MMV)) between 1 April 2008 and 31 March 2018 were extracted from the UK Transplant Registry held by NHSBT. Trends in age, diagnosis, transplant type and survival post-transplant were analysed. Results: During the decade, 196 intestinal transplants were performed nationally with an annual increase from 16 in 2008/09 to 26 in 2017/18. Since 2011/12 more transplants have been performed in adults than children, with 65% in adults during the latest year compared with 38% during 2008/09. BO transplants represented 72% of all transplants performed in 2010/11 compared with 27% in the latest year, due to increases in both MV and MMV transplants. There were 251 registrations onto the transplant list, of which 45% were for short-bowel syndrome, 15% motility disorders, 9% tumour, 9% re-grafts, 6% mesenteric thrombosis, 5% intestinal failure associated liver disease, 4% primary mucosal disorders and 5% other identified causes. Short-bowel syndrome has been reported less in recent years. Of patients placed on the waiting list, 78% were transplanted. One year post-transplant patient survival rates are 78% (69%-85%) and 85% (73%-92%) for adults and children respectively. Conclusion: The UK programme transplants 14–26 patients per year, with a trend over time towards adult patients, multi-visceral transplants and away from short-bowel syndrome.

The demand for heart transplantation within the United Kingdom (UK) is increasing. Over the last decade, the number of patients on the heart transplant waiting list has increased by 162%. 1 National Health Service Blood and Transplant. Annual report on cardiothoracic transplantation, report for 2016/2017. Available at: https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/5418/cardiothoracic-annual-report-2016-17.pdf. Google Scholar For those on the non-urgent heart transplant waiting list, the median waiting time to transplantation is 1,280 days, associated with a 15% waiting list mortality. A significant portion (36%) will require hospital readmission for inotropic or mechanical support escalating their waiting status to urgent or super urgent, vastly increasing the cost burden for the National Health Service.

Background Heart transplantation (HTx) remains the most effective long-term treatment for advanced heart failure. Primary graft dysfunction (PGD) continues to be a potentially life-threatening early complication. In 2014, a consensus statement released by International Society for Heart and Lung Transplantation (ISHLT) established diagnostic criteria for PGD. We studied the incidence of PGD across the United Kingdom. Methods We analyzed the medical records of all adult patients who underwent HTx between October 2012 and October 2015 in the 6 UK heart transplant centers Preoperative donor and recipient characteristics, intraoperative details, and posttransplant complications were compared between the PGD and non-PGD groups using the ISHLT definition. Multivariable analysis was performed using logistic regression. Results The incidence of ISHLT PGD was 36%. Thirty-day all-cause mortality in those with and without PGD was 31 (19%) versus 13 (4.5%) (P = 0.0001). Donor, recipient, and operative factors associated with PGD were recipient diabetes mellitus (P = 0.031), recipient preoperative bilateral ventricular assist device (P < 0.001), and preoperative extracorporeal membranous oxygenation (P = 0.023), female donor to male recipient sex mismatch (P = 0.007), older donor age (P = 0.010), and intracerebral haemorrhage/thrombosis in donor (P = 0.023). Intraoperatively, implant time (P = 0.017) and bypass time (P < 0.001) were significantly longer in the PGD cohort. Perioperatively, patients with PGD received more blood products (P < 0.001). Risk factors identified by multivariable logistic regression were donor age (P = 0.014), implant time (P = 0.038), female: male mismatch (P = 0.033), recipient diabetes (P = 0.051) and preoperative ventricular assist device/extracorporeal membranous oxygenation support (P = 0.012). Conclusions This is the first national study to examine the incidence and significance of PGD after HTx using the ISHLT definition. PGD remains a frequent early complication of HTx and is associated with increased mortality.

Donor organ allocation in the United Kingdom is managed by National Health Service Blood and Transplant (NHSBT) and developed by clinical advisory groups. A substantial increase in the heart transplant waiting list without an equivalent increase in transplant activity has led to longer waiting times and a higher proportion of transplants being performed from the urgent waiting list (see Figure). A new Super-Urgent Heart Allocation Scheme was introduced on 26 October 2016 for those at imminent risk of death without transplant, primarily those on temporary mechanical circulatory support (MCS). This study describes the changes and the patient benefits so far.

OBJECTIVES Left ventricular assist devices are funded in the UK exclusively as a bridge to transplant (BTT). However, patients who potentially could receive a transplant may develop reversible contraindications to transplant. Bridge to candidacy (BTC) has sometimes been controversial, given the uncertain clinical efficacy of BTC and the risk that reimbursement could be denied. We analysed the UK ventricular assist device database to understand how common BTC was and to assess patient survival rates and incidences of transplants. METHODS We identified BTC implants in patients with pulmonary hypertension, chronic kidney disease and obesity using the UK guidelines for heart transplants. RESULTS A total of 306 of 540 patients had complete data and 157 were identified as BTC (51%). Overall, there was no difference in survival rates between patients designated as BTC and those designated at BTT (71.9 vs 72.9% at 1 year, respectively; P = 0.82). However, the survival rate was lower at all time points in those with an estimated glomerular filtration rate (eGFR) <40 and in patients with a body mass index (BMI) >32 up to 1-year postimplant. There were no significant differences in the incidence of transplant between patients who were BTC and BTT or for any subgroup up to 5 years. However, we noted a diverging trend towards a lower cumulative incidence of transplant for patients with a BMI >32. CONCLUSIONS BTC is common in the UK and appears clinically effective, given that the survival rates and the incidence of transplants were comparable with those for BTT. Patients with a high BMI have a worse survival rate through to 1 year and a trend for a lower incidence of a transplant. Patients with a low eGFR also have a worse survival rate, but a similar proportion received transplants.

In the UK, the number of heart transplants from donation after brain death (DBD) fell from 176 in year 2000 to 120 in 2010. This was accompanied by an increasing number of patients on the heart transplant waiting list. NHS Blood and Transplant (NHSBT) established a special Working Group in 2010 to increase donor heart utilisation and transplantation. UK teams have since employed a range of strategies to increase heart transplant activity. We sought to investigate if changes in donor acceptance criteria had contributed to a recovery in UK heart transplant activity following this turning point and its impact on post-transplant survival.