Bridging the Gap: Equity and Access in Cardiac Transplantation

Name: Bridging the Gap: Equity and Access in Cardiac Transplantation
Uploaded: 2026-05-06T17:47:26.83Z
Duration: 1 h 1 min 59 s

May 06, 2026

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ID: 14184
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04:07Got, like, twenty people on
04:09there.
05:38Okay.
05:40Good afternoon, everyone.
05:44I'm here to introduce,
05:46doctor Michael Furey, who will
05:48be,
05:49giving our Yale Cardiovascular Medicine
05:52Grand Rounds.
05:53He's one of our,
05:55excellent
05:56graduating fellows.
05:58So Mike graduated from Georgetown
06:00University School of Medicine,
06:02and was fortunately recruited up
06:04here in New Haven
06:06to do his internal medicine
06:07residency with the Yale internal
06:09medicine residency program,
06:11where he was recognized early
06:13and often for
06:14both his clinical excellence and
06:16and research excellence.
06:18He received the doctor Peggy
06:19Bea Award for outstanding clinical
06:21teacher.
06:22And after completing his internal
06:24medicine residency here, went on
06:25to do a chief residency.
06:27And we were fortunate enough
06:29to recruit him here for
06:30our cardiology fellowship,
06:32where I've had the opportunity
06:33to really work closely with
06:34Mike. He's worked with a
06:35number of our other colleagues
06:36as well.
06:38He has, an impressive publication
06:40record that includes,
06:42publications in journals such as
06:43Jack Heart Failure and the
06:45European Heart Journal.
06:46And his focus, in terms
06:48of research has been on
06:50how to use the electronic
06:52health record, as well as
06:53implementation science to improve heart
06:55failure care, risk prediction, and
06:57policy for cardiac transplantation.
07:00I personally had the pleasure
07:02of watching Mike grow over
07:03his time during fellowship
07:05here,
07:08and, he's really become and
07:10blossomed into a truly excellent
07:12clinician educator.
07:14We've worked together both in
07:15the CICU and,
07:17at the bedside in the
07:18clinic. And, I can say
07:20that,
07:21Mike really is a truly
07:23compassionate
07:23physician who provides really the
07:25highest quality of care to
07:26his patients.
07:28So I'm looking forward to
07:29your talk today, Mike, as
07:30well as to, see where
07:31your career in cardiology takes
07:32you.
07:41Thank you so much, doctor
07:42Sikand, and for everyone in
07:44the department for,
07:46inviting me to,
07:48present at this week's grand
07:49rounds.
07:50My talk is titled bridging
07:52the gap,
07:53equity and access in cardiac
07:55transplantation.
07:57I don't have any disclosures
07:59to report.
08:00So for this talk, I'd
08:02like to achieve a few
08:03different learning objectives.
08:05First, I wanna help you
08:07understand
08:08our organ allocation system here
08:10in the United States and
08:11how it, has changed clinical
08:13practice after they made a
08:15revision to their policies back
08:17in two thousand eighteen.
08:20And second,
08:21I wanna show you,
08:23a variety of factors that
08:24can contribute to a concept
08:26known as center level variation
08:28and how that can, impact
08:30a patient's,
08:32overall likelihood of getting a
08:33transplant.
08:36So to start, I'd like
08:37to present a case. This
08:38is a fifty two year
08:39old who has a history
08:40of nonischemic cardiomyopathy
08:43with reduced, left ventricular ejection
08:45fraction,
08:46and he comes to the
08:47hospital with progressive shortness of
08:49breath and fatigue.
08:51He's hypotensive,
08:53tachycardic,
08:54tachypneic,
08:54and hypoxic re requiring
08:57non rebreather,
08:58support.
09:00He overall appears unwell.
09:02He's diaphoretic
09:03with an elevated JVP,
09:05cool extremities, and bilateral
09:07crackles.
09:10His labs are suggested of
09:11decreased end organ perfusion,
09:12and, ECHO once again shows,
09:15severe global hypokinesis.
09:17He's admitted to the cardiac
09:19intensive care unit where he
09:20started on inotropes,
09:23and,
09:24becomes
09:25slightly more hypotensive
09:27and has slight worsening of
09:28his end organ perfusion.
09:30He undergoes a right heart
09:31cath that shows a reduced
09:32cardiac index with elevated filling
09:35pressures.
09:36Given these findings,
09:38the decision is made to
09:39start him on mechanical circulatory
09:42support, specifically with an Impella
09:44device.
09:45And the patient is listed
09:46for, cardiac transplantation
09:49at status two level.
09:51He remains
09:53on inotropes
09:54and, Impella support,
09:56for over two weeks where
09:58his transplant team submits,
10:00an exception for him to
10:02remain at that status.
10:04A few more weeks go
10:05by,
10:07and he ultimately receives a
10:08donor organ offer coming from
10:11around two hundred fifty miles
10:13away
10:14from New Haven, comes from
10:16a hepatitis c positive donor
10:18that was,
10:20declined by several other transplant
10:22centers in the region.
10:24And he ultimately undergoes
10:26successful heart transplant
10:28and does well,
10:29in the postoperative
10:31course.
10:32So I wanna use this
10:33case to highlight a few,
10:36important factors
10:37about,
10:38how variable the cardiac transplant
10:40process can be.
10:43And to do that, I
10:44wanna first explore
10:46a few of the different
10:47components
10:47of the process,
10:49the different agencies are involved,
10:51and how,
10:52they have evolved over time.
10:55So the United Network for
10:56Organ Sharing also goes by
10:58UNOS.
10:59It's a nonprofit,
11:01organization that helps to oversee,
11:03solid organ transplant in the
11:05United States.
11:06And before it was created,
11:08from the mid nineteen fifties
11:10to the early nineteen seventies,
11:13the individual transplant hospitals
11:15and organ procurement organizations
11:18would manage all aspects of
11:19the organ recovery
11:21and transplant.
11:22So if an organ was
11:24found, it could not be
11:26used at a local hospital
11:27to the donor. There wasn't
11:29really a system,
11:30that would
11:31allow anyone to find a
11:33matching candidate,
11:35elsewhere.
11:35So many of the organs
11:36ultimately could not be used
11:38because they couldn't find a
11:40compatible
11:41recipient in time.
11:43And that changed in nineteen
11:45seventy seven
11:46when, the first computer based
11:48organ sys matching system called
11:50UNOS was developed,
11:52and then congress,
11:53in nineteen eighty four passed
11:55the National Organ Transplant Act,
11:57which established a framework for
11:59a national organ recovery and
12:01allocation system. And the goal
12:03was to help ensure
12:05that, the process was carried
12:07out in a fair and
12:08efficient way
12:10and led to equitable distribution
12:12of donated organs based on
12:13medical criteria.
12:16Later in nineteen eighty six,
12:18UNOS became
12:20under federal contract
12:21to operate both, the organ
12:23procurement and transplantation network, OPTN,
12:26and the scientific registry of
12:28transplant recipients.
12:30And UNOS works by ranking
12:32transplant candidates according to their
12:35medical urgency.
12:36It started as a two
12:37tier system,
12:39later developed into a three
12:41tier system,
12:42most recently was changed to
12:44a six tier system in
12:45two thousand eighteen.
12:47And UNOS created,
12:49different regions across the the
12:51United States based on, patient
12:54referral patterns and organ sharing
12:56patterns.
12:57The state of Connecticut, it's
12:59located in region one,
13:01with the other New England
13:02states like Massachusetts,
13:04Rhode Island, New Hampshire, Maine,
13:06and part of, Vermont.
13:09So how does the system
13:11work? Well, once again,
13:13UNOS ranks
13:14transplant candidates by their medical
13:16urgency
13:17and aims to match them,
13:20by other medical factors like
13:21blood type, height, weight with,
13:24donor organs that become available.
13:27And then each donor organ
13:28has a rank order match
13:30list that's offered to
13:32prospective transplant candidates at centers
13:35across, the country.
13:37Generally prioritizes
13:38local candidates,
13:40and once an offer is
13:42made, each transplant center has,
13:44the ability to accept or
13:46reject that offer at their
13:48own discretion.
13:50In two thousand and eighteen,
13:52UNOS implemented
13:54this new six tier
13:56allocation policy that replaced the
13:58old three tier system.
14:00And this was done to
14:01better stratify,
14:03transplant candidates,
14:05by their
14:06mortality on the wait list,
14:08helped to shorten,
14:09wait list times for the
14:11sickest patients,
14:12tried to add objective criteria
14:14for a variety of, cardiac
14:16conditions,
14:18and then it further broadened,
14:20sharing of, donor organs
14:22to a geographic
14:23radius of, five hundred miles.
14:26Now status, one patients are
14:29considered the highest medical priority,
14:31while statuses two through six
14:33are considered
14:34lower medical priority,
14:36in descending order. So if
14:38a patient is, placed on
14:40ECMO
14:41or, has a mechanical circulatory
14:44support device
14:45and has a significant arrhythmia,
14:47they are considered the highest
14:49priority listing.
14:51Without arrhythmia, m c MCS
14:53devices
14:54can achieve a status two
14:56listing.
14:57Notably,
14:58patients with durable LVADs
15:01were now status three,
15:03under the new system and
15:05previously had a higher designation
15:07in the older system.
15:09Similarly, patients on IV inotropes
15:12were, previously considered,
15:15high medical urgency under the
15:17old system
15:18have, gone down to,
15:20status three or four in
15:22the new system.
15:24And it's important to note
15:25that listing a patient,
15:28requires that our great transplant
15:30teams,
15:31rejustify
15:33the patient's listing every two
15:34weeks.
15:35So they need to redemonstrate,
15:37every two weeks that the
15:39patient requires
15:40an MCS device, inotropes,
15:43whatever their, level of support
15:45is, and that they're not,
15:46able to receive,
15:48an LVAD. And that's because
15:51the two long term treatment
15:52options we have for,
15:54end stage heart failure are
15:56heart transplant
15:57and, durable LVAD.
16:01So,
16:02this two thousand eighteen
16:04policy change had a very
16:06significant impact
16:07on,
16:08clinical practice patterns, which I'll
16:12explore,
16:13in detail through the rest
16:14of the talk.
16:16This was a study that
16:17was led by doctor Clancy
16:19Mullen here,
16:20of cardiac surgery as well
16:22as doctor Ahmad in in
16:23his heart failure outcomes research
16:25group.
16:26And,
16:27it showed that pretty early
16:29on, even after this,
16:31policy change, that the use
16:33of durable LVADs,
16:35declined pretty substantially.
16:37And you might infer based
16:38on what I I showed
16:40you a few slides ago
16:41that this might be because
16:43of
16:44a changing
16:45MCS support strategy
16:47that prioritizes
16:49patients who have temporary,
16:52MCS devices,
16:54who get higher priority status
16:55in the new system compared
16:57with,
16:58durable LVAD devices, which were,
17:02a lower priority in the
17:03the organ allocation system.
17:06And this has been supported
17:08by a few other studies
17:09that found that balloon pump
17:11use as well as ECMO
17:13use have increased,
17:15since,
17:16the policy change, which, those
17:18two, as I mentioned,
17:20now have higher priority status
17:22under the new system.
17:25So with all these,
17:27potential changes in clinical behavior,
17:30it, you know, raised questions
17:31in my mind how much,
17:33subjectivity
17:35there ultimately is in this,
17:37cardiac transplant
17:38process.
17:39We have all of these
17:41objective criteria that I showed
17:43you in the the different
17:44tiers,
17:45but, you know, there seems
17:46to be some sort of
17:47inherent subjectivity,
17:50that ultimately,
17:51in my view, has a
17:52tangible impact on, equitable
17:55organ allocation.
17:59And the primary drivers of
18:01this subjectivity,
18:03are factors that contribute to
18:05something called center level variation.
18:10There are four main, components
18:12to this,
18:13that I'll I'll go through
18:14one by one.
18:16Bridging strategy,
18:17listing practices,
18:19exception,
18:21utilization,
18:22and donor organ acceptance.
18:26So starting with, bridging strategy,
18:29I started talking about how
18:30there has been, some changes
18:32to how we use MCS
18:34devices since two thousand eighteen.
18:36And this has been, borne
18:38out both in national trends
18:40as well as,
18:42differences between individual
18:44transplant centers.
18:45Balloon pumps ultimately remain the
18:47most common bridging strategy
18:49followed by Impella devices and
18:52then ECMO.
18:53ECMO,
18:55gives patients the highest likelihood
18:56of transplant,
18:57but it also carries the
18:59highest mortality,
19:01rate on the wait list.
19:02But there are also other,
19:04device related complications
19:06that, patients may incur while
19:08awaiting transplant even if they're
19:10relatively,
19:11stable on the wait list.
19:14Bottom line is that,
19:16the choice of the bridging
19:17strategy
19:18is not just a choice
19:20about how we're treating the
19:21patient, but also impacts
19:23how likely it is for
19:24them to ultimately get a
19:26transplant.
19:28So this is some data
19:29from a twenty twenty two
19:31study. It showed that balloon
19:33pump and ECMO utilization
19:35have, increased significantly since two
19:37thousand eighteen,
19:39whereas the use of durable
19:41LVADs has decreased.
19:44And the same study took,
19:46their findings a little bit
19:47further.
19:49They looked at variation
19:51between centers and how they
19:52use mechanical
19:54circulatory support.
19:57Each bar in this graph
19:59reference represents an individual transplant
20:01center,
20:03and how it's been using,
20:05MCS.
20:06And you can see that,
20:08while some centers have a
20:09relatively
20:10low,
20:11proportion
20:12towards the left side of
20:13the graph,
20:14others are nearly using,
20:16mechanical circulatory support a hundred
20:18percent of the time,
20:20for their patients that get
20:22transplanted.
20:23The authors also found that,
20:26the number,
20:27the the,
20:29the,
20:30the use of MCS was
20:32associated with,
20:33overall number of transplants
20:35performed,
20:37at that center,
20:38which,
20:39suggested that,
20:41you know, we're making changes
20:43in our clinical
20:44decision making,
20:46as to the support that
20:47we're using,
20:48rather than changes in,
20:50patient demographics or patient,
20:53acuity.
20:54And, ultimately, this can have,
20:56an impact on equitable access
20:58to transplant for some patients.
21:02So now,
21:03I'd like to talk about
21:04listing behavior and how that
21:05can also be,
21:07a major,
21:08determinant of a patient's access
21:10to transplant.
21:11So many different transplant centers
21:13have,
21:14varying thresholds
21:16for,
21:17you know, listing patients,
21:19whether they're listing them very
21:20early on while they're relatively
21:22stable
21:23or, when they've progressed to
21:25a more acute status.
21:29They also need to make
21:30decisions
21:31about, you know, using inotropes,
21:33MCS, or ECMO.
21:35And since two thousand eighteen,
21:37it's been observed that higher
21:39priority listings have increased
21:41despite,
21:42you know, the clinical status
21:44of patients remaining relatively stable.
21:49Another facet that's, important to
21:51mention
21:52is that each center has
21:53its own policies
21:55for even listing patients for
21:57transplant.
21:59They might only
22:00opt to list candidates who
22:02are younger than a certain
22:03age cutoff
22:04or have varying leniency,
22:07in their,
22:08practice to list the patient
22:10of a certain BMI,
22:12who have
22:13a history of substance use,
22:15some up suboptimal
22:16social support
22:18or,
22:19others,
22:20psychosocial
22:21issues.
22:23So this graph,
22:25depicts individual
22:27transplant centers each represented by,
22:30a dot,
22:32and their probability of listing
22:33patients
22:34as a high priority, either
22:36status one or two,
22:38in the new allocation system.
22:40Those are, highlighted in, the
22:42red,
22:44dots with with bars, and
22:46the pre,
22:47two thousand eighteen data is
22:49listed in the blue.
22:52So overall, it shows that
22:53the policy change
22:55since, two thousand eighteen,
22:57nearly ninety five percent of
22:58centers list patients
23:01list more patients at a
23:02high priority status compared to
23:04their practices before the policy
23:07change.
23:08It also shows that there's,
23:10once again, significant variation between
23:12the centers enlisting their patients
23:15as high priority status even
23:17when they controlled for their
23:19individual medical factors.
23:21So overall,
23:23this highlights that some centers
23:25are more likely to list
23:26patients as a higher priority,
23:28compared to others.
23:31So, when I was a
23:32resident, I did,
23:34a research project
23:36where we looked at, what
23:37happens for patients since the
23:39two thousand eighteen allocations is
23:41some change who are considered
23:43low urgency.
23:44I thought the findings were,
23:46interesting.
23:48You know, I I we
23:49looked at both pre and
23:50post,
23:52two thousand eighteen, but, you
23:53know, since that change,
23:55you know, obviously, the number
23:57of patients transplanted at a
23:58lower
23:59urgency
24:00is much lower than
24:02those, transplanted at a higher
24:04urgency.
24:05But those who were considered
24:07low urgency,
24:09were usually older
24:11and received,
24:12donor,
24:13organs from,
24:15donors that were considered higher
24:17risk either with, you know,
24:18hepatitis c, diabetes,
24:21or,
24:22older age. And we'll discuss
24:23some of those factors in
24:25the coming slides. But I
24:26also found,
24:28you know, not surprisingly,
24:30they had longer wait list
24:32times than the higher urgency
24:33candidates.
24:36But, ultimately,
24:38their outcomes remained,
24:39pretty similar to,
24:41those who were of the
24:43higher, urgency.
24:44So there's a bit of
24:45a trade off.
24:47You know, the high urgency
24:48patients are sicker.
24:50They receive hearts faster. They're
24:52typically getting the the,
24:55you know,
24:56parts that are of optimal
24:58quality
24:59compared to the lower urgency
25:01candidates who are a bit
25:02more stable. However, the lower
25:04urgency candidates,
25:06ultimately have similar outcomes.
25:08And, this may be informative,
25:11to transplant centers as they,
25:13you know, consider risk benefits
25:15and,
25:16preferences with their patients in,
25:19making decisions about this.
25:22Another,
25:23contributor to center level variation
25:26is,
25:27the concept of exceptions.
25:29So,
25:29an exception's a request that
25:32is submitted by the transplant
25:34team,
25:36that,
25:37justifies
25:38their current
25:40listing in the allocation system.
25:44It has to be done
25:45every fourteen days as I
25:46mentioned.
25:47And it may be just
25:48because,
25:50the patient is not a
25:51candidate for,
25:53a therapy that would confer
25:55them a higher status,
25:57or it could be,
25:59more of a administrative,
26:02challenge and that their blood
26:04pressure is not their systolic
26:05blood pressure is not is
26:07ninety two instead of, below
26:09ninety,
26:10which,
26:11you know, may or may
26:12not be clinically consequential
26:14if they're on multiple forms
26:16of,
26:17cardiac support.
26:19And I think exceptions were
26:21interesting to bring up because
26:23there's great variability in,
26:25centers,
26:27willingness
26:28or practice patterns to submit
26:30them, but also because there's
26:33some data that
26:34suggests,
26:35patients,
26:36who had a re
26:38exception request submitted
26:39were twenty five percent,
26:41more likely to get a
26:43transplant compared to those listed
26:45according to
26:47standard criteria.
26:48So this can have,
26:50a tangible impact on,
26:52access to transplant for patients.
26:56So this is just some
26:57data about how exceptions have
27:00been,
27:00used
27:01both before and after two
27:03thousand eighteen.
27:06And,
27:07you know, focusing primarily on
27:09the bottom set of graphs,
27:10which is post post two
27:12thousand eighteen,
27:13it showed that
27:14overall some there was increased
27:16use of exceptions
27:18and that,
27:19they were primarily used for
27:21patients,
27:22in status one, two, and
27:24four. Their,
27:26their utilization increased substantially.
27:30And this is from a
27:31separate study that looked at
27:32both geographic
27:34patterns of exception use as
27:36well as,
27:37individual transplant center use of
27:39exceptions.
27:40So looking at the geography
27:42first on the left,
27:45exceptions were more commonly used
27:46in regions three and four,
27:48which represent the southwestern
27:51US,
27:51while,
27:53you know, other regions like
27:55five, six in the western
27:56US and parts of, the
27:57Midwest were less likely to
28:00submit,
28:01exception requests.
28:02And the authors of this
28:03study
28:04mentioned that this could be
28:05because,
28:08there are longer wait list
28:09times for,
28:10patients in,
28:12the reg regions where
28:15exception utilization was high.
28:18The figure on the right
28:19is interesting because it looks
28:20at individual transplant centers and
28:23how they vary in exception
28:24utilization.
28:26So So you can see
28:27that,
28:28the the size of the
28:29circles
28:30represents,
28:31you know, the number of
28:33transplants, that are performed at
28:34that center.
28:36And, it's once again stratified
28:38by
28:39region.
28:40So there are some high
28:42volume centers,
28:44that use transplant or,
28:46exceptions quite frequently.
28:48There are other high volume
28:50centers
28:51even in the same region
28:52that,
28:54you know, use,
28:56exception requests much less frequently.
28:58So it's sort of,
29:00across the board, a great
29:02deal of variation
29:03in how they're being applied.
29:06And finally, this is just
29:08a quick graph showing,
29:10you know, once again, as
29:12I mentioned that, patients who
29:14had exceptions submitted on their
29:15behalf,
29:16had a higher likelihood
29:18of, getting a transplant even
29:21after adjusting for,
29:23variety of medical factors.
29:28Moving on, I wanna talk
29:29about how centers differ in
29:32their,
29:32donor organ acceptance.
29:35There are some centers that
29:36might be more likely to
29:38accept donors,
29:40accept organs from donors that
29:43are older than forty years
29:45of age or so or
29:46that are hepatitis
29:47c
29:49positive
29:49or that come from a
29:51longer distance from the transplant
29:53center, typically around five hundred
29:56miles.
29:57Or,
29:58there are, different
30:01practices as to,
30:03accepting organs that have been
30:04rejected by,
30:06many other transplant centers, which
30:08is a metric known as
30:10the, donor sequence number.
30:13Another metric is the acceptance
30:16ratio,
30:17which compares how likely a
30:19transplant center is,
30:21to accept an organ,
30:24with a national average.
30:26And, these metrics are actually
30:28available online for both, patients
30:31to
30:32review if if they're so
30:34inclined or even clinicians,
30:36to be able to compare
30:37their, program to others in
30:39the region.
30:41And, you know, this data
30:42is pretty interesting because it
30:44can show that some centers
30:46are maybe even three or
30:47four times more likely,
30:50than, you know, an average
30:52center to accept organs that
30:54might be considered higher risk,
30:57by a variety of metrics
30:58compared to the national average.
31:02The implication
31:03of all of this is
31:04that,
31:06you know, one patient might
31:07have
31:08different access to different donor
31:10pools,
31:11depending on the transplant center
31:14they go to or the
31:15area that they live.
31:18So this was a nice
31:19figure that demonstrates,
31:21their,
31:23different centers with,
31:25different acceptance rates of donor
31:27organs,
31:29based on their
31:30geography
31:31in, the UNOS region.
31:34You can see,
31:35you know, some of these
31:37centers have very high acceptance
31:39rates
31:41and,
31:42receive a lot of first
31:43offer,
31:45organs from the procurement networks.
31:48Others have
31:49high first offer rates, but,
31:52low overall acceptance rates. And
31:54the converse is also true
31:56for
31:56centers that,
31:58you know, have a low
31:59acceptance rate and don't receive,
32:02many offers.
32:04There's been additional,
32:06supporting data
32:08that,
32:09you know, transplant centers that
32:10have a higher acceptance rates
32:12had lower rates of wait
32:13list mortality overall and a
32:16higher incidence
32:17of, transplant at one year,
32:19which I think makes intuitive
32:21sense if they have a
32:23larger donor pool that's,
32:26available.
32:27But, there's been a lot
32:28of concern raised,
32:30in the transplant
32:32community
32:33about, you know, how outcomes
32:34might be,
32:35impacted if these, quote, unquote,
32:38lower quality,
32:39organs
32:40are used.
32:41So I wanted to explore
32:43that a little bit more.
32:45I mentioned the donor sequence
32:47number
32:48is,
32:49the number of times that
32:51a a potential organ has
32:52been
32:53offered and then rejected by
32:56a transplant center. And typically,
32:58around fifty times is considered,
33:02you know, a high donor
33:03sequence number.
33:05So this was a study
33:06that looked at the outcomes
33:08of patients who got a
33:09transplant
33:10with an organ that had
33:11a high
33:12donor sequence number compared to
33:14low donor sequence number. And
33:16it ultimately found that, you
33:18know, the outcomes were pretty
33:19similar,
33:22three years after transplant.
33:25It also looked at reasons
33:27for why or factors associated
33:29with,
33:30why an organ might have
33:31a high donor sequence number.
33:33And they tended to be
33:34from donors of older age
33:36who had hypertension, diabetes,
33:39a re a lower ejection
33:40fraction,
33:41or were hepatitis c positive.
33:47On the,
33:48the the point of hepatitis
33:50c donors,
33:52it's kind of striking that,
33:53you know, since as of
33:55the last, data I found
33:56on this back in twenty
33:58twenty two, only about half
33:59of,
34:00transplant centers were,
34:03allowing,
34:04you know, hep c positive
34:06donor organs. I'd suspect if
34:07that was
34:08updated,
34:10in more recent years, that
34:11number is increasing, which I
34:12think is good because overall,
34:15you know, a few different
34:17studies have noted that
34:19outcomes are similar using these
34:21types of organs, and the
34:23wait list times are shorter,
34:24which is,
34:26good for our, patients and
34:28expands their,
34:29access to cardiac transplant.
34:33Up for a little bit
34:34more debate is,
34:36the ischemic time and acceptance
34:39of,
34:39donor organs from older donors.
34:43So there's the overall concern
34:45is that if
34:48a organ has a prolonged
34:50ischemic time, typically less than
34:52four hours is considered adequate,
34:55that, you know,
34:57it it it could be
34:58an increased risk of rejection
35:01in the short term, which
35:02is, you know, one of
35:03the dreaded fears of of
35:05using, you know, organs that
35:06might not be of of,
35:08optimal quality.
35:11But, you know, this has
35:12been studied a little bit,
35:13and I think the evidence
35:15is a little bit mixed.
35:17You know, a lot of
35:18centers
35:19have a a cutoff
35:21of using,
35:22organs from donors who are
35:24forty years old or less.
35:26Some have a little bit
35:28more lenient,
35:29you know, forty to forty
35:31five. Some might even go
35:32up to,
35:33donors that are fifty years.
35:35I would say that's probably
35:36the limit because,
35:38there's been some evidence showing
35:40that,
35:42those those organs are at
35:43the highest risk of rejection.
35:46But there have been also
35:47some analyses that look at,
35:49factors beyond the age. And
35:51when those analyses,
35:53adjust for,
35:55different medical factors,
35:56that
35:58initial,
36:01adverse,
36:03impact of donor age,
36:05was reduced.
36:07So, I think that's something
36:08that requires a little bit
36:10more,
36:12exploration
36:13and consistency,
36:15in our studies.
36:16And on the point of
36:17ischemic time,
36:19there have been development of
36:21more novel,
36:22cooling and perfusion,
36:24strategies in recent years, specifically,
36:27the Sherpa pack, which
36:29provides sort of uniform cooling
36:31for the the organ while
36:33it's being transplanted
36:35and allows it, to travel
36:36safely for up to four
36:38hours.
36:38And then, you know, the
36:40TransMedics
36:40device, which can,
36:43sort of artificially
36:44perfuse
36:45the donor organ with oxygenated
36:47blood.
36:48Some have called it, you
36:49know, the heart in a
36:50box,
36:51and, you know, how, that
36:53can impact ischemic times, the
36:56amount of distance that, can
36:58be traveled.
36:59All of this is also
37:01important because these technologies might
37:03not,
37:04be available,
37:05to all transplant centers and
37:06only,
37:07to those who have, you
37:09know, the highest level of
37:10resources.
37:13And finally, I wanted to
37:14talk a little bit about,
37:16transplant
37:17volume,
37:19which can contribute to center
37:20level variation.
37:22And it also has a
37:23very tangible impact on a
37:24patient's likelihood
37:26of getting a transplant.
37:28So even, in the same
37:30UNOS region where the,
37:33donor organ supply is pretty,
37:36similar,
37:37there can be up to
37:38a thirty percent difference in,
37:41transplant rates.
37:43And this might be due
37:44to a variety of factors
37:46such as,
37:48greater temporary MCS capabilities
37:51or, more resources for,
37:53organ procurement at,
37:55those high volume centers.
37:59These are some data that
38:00show,
38:01how this, transplant center volume
38:04relates to the likelihood of
38:07transplant.
38:08It found that,
38:09among the different,
38:11clinical factors associated with getting
38:13a transplant
38:15was use of,
38:17the sorry. The highest,
38:20the most important factor for,
38:22getting a transplant was being
38:23at a high volume transplant
38:25center, followed then, by ECMO
38:28and then,
38:29balloon pump use.
38:31And not surprisingly,
38:33based on what I've,
38:35showed you thus far,
38:36the factor least associated
38:38with getting a transplant was
38:40LVAD use.
38:42So, being at, a high
38:44volume center,
38:47improves significantly,
38:48your likelihood of getting a
38:50transplant.
38:51Now,
38:52imagine if your nearest transplant
38:54center didn't
38:56have a high transplant
38:57volume.
38:59Would you try to go
39:01be listed at a high
39:02volume center?
39:03What if that wasn't feasible
39:05for you economically,
39:07geographically?
39:10You know? Is that,
39:12fair for,
39:13patients who are unable to
39:15to be at those centers?
39:18This is some data that,
39:21shows,
39:22transplant rates between centers,
39:25in the same geographic region.
39:27Once again,
39:28supporting the notion of,
39:30center level
39:31disparities.
39:33Each line represents
39:35the range of values
39:36that
39:37exist within a organ procurement
39:39organization,
39:40and the diamonds represent the
39:42individual transplant centers. So despite
39:45having
39:46this shared,
39:47organ supply
39:48and a relatively small geographic
39:50distance,
39:51there were,
39:53you know, major differences,
39:55in their transplant rates.
39:58So I was curious,
39:59to look into what the
40:01high volume centers are doing.
40:03And I found a nice
40:04study,
40:05that found that looked at
40:07the practice patterns of
40:09at least the listing patterns
40:10of,
40:11the top ten,
40:13performing,
40:14heart transplant centers by volume.
40:17Even, among this group, I
40:19think there's
40:20a great deal of variability
40:22in how they're,
40:24listing their patients.
40:26But you can see that,
40:28in a majority of cases,
40:30they're listing their patients at
40:32high priority,
40:33status one or two,
40:36which,
40:37once again suggests that there
40:39might be there is a
40:40component of clinical behavior,
40:43that's driving,
40:45you know, variable experiences in
40:47the transplant process.
40:50I read a paper,
40:52by the Oregon Procurement
40:54and Transplant Network,
40:56about the ethics that underline
40:59organ,
41:00allocation.
41:01And it said that equitable
41:04access to transplant
41:05is dependent on,
41:07consistent management
41:08of advanced heart failure
41:11and cardiogenic
41:12shock across transplant centers.
41:15So,
41:16you know, based on what
41:17I've shared with you and
41:19what I've,
41:20learned,
41:21I'm not sure that we're
41:23achieving,
41:24equity with these substantial,
41:27variations
41:28in,
41:30transplant center practices.
41:33And I'm not the only
41:34one that has,
41:36raised concern about potential,
41:39inequities in this process.
41:42This was a New York
41:43Times,
41:44article from last year
41:46with sort of a jarring
41:48headline.
41:49But,
41:50the premise was that
41:52there's so much, you know,
41:53gamesmanship
41:54and strategy
41:56involved in this process,
41:58that, you know, in some
42:00instances,
42:02the waiting lists are completely
42:03bypassed,
42:05to direct organs to,
42:08certain transplant centers.
42:11But,
42:12you know, with all this
42:13talk about,
42:15policy,
42:17I wanted to recenter the
42:18discussion,
42:20to what's most important, and
42:22that is, the patient experience.
42:25So some of you may
42:26remember doctor,
42:28Colby Salerno, who was here
42:30as one of the advanced
42:31heart failure fellows last year
42:33and is now a transplant
42:35cardiologist
42:35at Baystate.
42:37And he, has the unique
42:39perspective
42:40of not only being a
42:42transplant cardiologist, but also
42:44a heart transplant recipient.
42:47And he wrote, an article,
42:49last year,
42:51in Jack heart failure, which
42:53I thought reframed,
42:54the discussion pretty nicely.
42:56So, I'll read you some
42:58some excerpts from that. He
43:00said my journey began at
43:01age twelve when I was
43:02diagnosed with hypertrophic cardiomyopathy.
43:06Years later, when I progressed
43:07to end stage heart failure,
43:08an LVAD was not an
43:09option for me, and I
43:10was listed for a transplant.
43:12I spent a hundred and
43:13eighty consecutive
43:15days in the cardiac intensive
43:17care unit
43:18before receiving my life saving
43:20lifesaving donor heart.
43:23And this month will mark,
43:24I think, fourteen years since,
43:26his initial transplant.
43:28I think just the,
43:31that that one sentence about
43:33the time he waited,
43:35is is so,
43:37important because, you know, patients,
43:39you know, lose their freedom
43:41being hospitalized,
43:42all of the things that
43:43they, you know, love doing
43:45outside of the hospital, and
43:46it can be such a
43:47grueling process. So we have
43:49to,
43:50remember that.
43:51And then, you know, at
43:52the bottom here, he said,
43:53my story is a testament
43:55to the importance of patient
43:56preference.
43:57Patients are more than medical
43:58conditions
43:59or entries on a transplant
44:01list. They have dreams, aspirations,
44:04and unique definitions
44:06of what constitutes
44:07a life worth living.
44:12So just circling back to
44:14the the case I presented
44:15at the beginning,
44:17I think
44:18through this talk, I've highlighted
44:20a few different points where,
44:23a patient's
44:24likelihood of getting a transplant
44:25could be,
44:26significantly
44:27impacted.
44:28We didn't really get into
44:29the individual patient
44:31and his
44:32specific risk factors,
44:34but, you know, knowing whether
44:36he could even be
44:38a candidate that's listed as
44:40a huge consideration in and
44:41of itself.
44:43The choice of MCS was
44:44impactful,
44:46choosing a status one or
44:48two listing for that patient,
44:51submitting exception requests,
44:53and then,
44:54acceptance of,
44:56the donor organ that,
44:58came from a hepatitis c,
45:00donor.
45:01And then,
45:03also important but not necessarily
45:06involved in the case,
45:08the transplant center volume.
45:12So to conclude,
45:13the takeaway messages would be
45:16that,
45:17center level variation is
45:19a real phenomenon,
45:21and can lead to variable
45:23pathways to getting a heart
45:24transplant.
45:25And,
45:26the transplant center,
45:28can be a significant
45:30factor itself,
45:32in that journey.
45:34And,
45:35sort of the analogy that
45:37a lot of people who
45:38work in the space share
45:40is that,
45:42since two thousand eighteen,
45:43the rules
45:44of
45:46the allocation process game were
45:48changed.
45:49And then, subsequently,
45:50as we've seen, the the
45:52players in that game, the
45:53transplant centers,
45:54the patients,
45:55they sort of adapted their
45:57strategy,
45:58to give themselves the best
46:00chance to win the game.
46:01So I think,
46:03going forward,
46:04we need to reevaluate some
46:06of,
46:08the rules of the game
46:09to,
46:10try to better achieve equity
46:12in this process.
46:15So I'd just like to
46:16thank,
46:17doctors Ahmad and Sikand
46:19as well as,
46:21doctors Sen and Clark in
46:22our heart failure division who,
46:25have not only been clinical
46:27mentors, research mentors, but they
46:29really helped me with,
46:32coming up with this concept
46:33and and and presenting this
46:35talk today.
46:37The fellowship program for supporting
46:38me through the years.
46:41That's it. Thank you very
46:43much.
46:55Alright. Good
46:57job.
47:02Mike, and that was just
47:03that was a really great
47:04talk. I learned a a
47:05ton
47:06to both, you know, increasing
47:07my knowledge also is disturbing
47:09to now understand that knowledge.
47:11And so, you know, it's
47:12kind of like under,
47:14you know, looking at the
47:15carried interest deduction and how
47:17that's impacted, you know, the
47:18choice of careers for our
47:20youth and going into, you
47:22know, the capital markets and
47:23and how the rules of
47:24the game, like you said,
47:25impact our practice.
47:27So giving you the benefit
47:28of the doubt though, since
47:29we're all ethical physicians here
47:31in this space,
47:32is there data to support
47:35that
47:36is there any data to
47:37support the change that the
47:38change in the rules
47:40and the adaptation to the
47:42increase or more frequent use
47:43of MCS
47:44has changed outcomes even for
47:46subgroups of populations, those higher
47:48risk populations.
47:49Was that,
47:50accentuation
47:51and adaptation to the rules
47:53associated with any change in
47:54or improvement in in care?
47:58What I can say that,
48:01in terms of determining the
48:03causality
48:04between, you know, selecting an
48:06m c MCS device or
48:08not, I think just the
48:09pattern that we see over
48:10and over between all these
48:11studies is pretty clear.
48:14However, we can't really, you
48:15know, link it a hundred
48:16percent to that.
48:18In terms of,
48:20overall outcomes,
48:21not really sure. I don't
48:22know if you have any
48:23I mean, that's a incredible
48:25question, and it's, one of
48:27the things that we addressed
48:28in that JAC paper that
48:29showed that the durable LVADs
48:31went down.
48:32So the before two thousand
48:34and eighteen, the patients who
48:35were critically ill would end
48:37up getting an LVAD.
48:39Those patients
48:40are now getting heart transplants.
48:43So if you were to
48:44say that, you know, for
48:45a young person getting an
48:46LVAD
48:47is better
48:48heart transplant, I think most
48:50people in our field would
48:51say a transplant.
48:52From a Kaplan Meier point
48:54of view, they may be
48:55equivalent. But what happened was
48:56that the patients who are
48:57getting LVADs are now getting
48:59heart transplants.
49:00So that's where, the move,
49:03you know, you went from,
49:04like, mechanical
49:05durable support to temporary support
49:07to get a heart transplant.
49:08So that's the big and
49:09then the number of heart
49:10transplants, like, tripled during this
49:12time as well.
49:15Just to add on to
49:16that, I think and to
49:18tie into
49:19Mike's talk, there's a lot
49:20of center variability
49:22based on that. So depending
49:24on what center you're seen
49:25at,
49:26even after the two thousand
49:28eighteen change, you may be
49:30more likely to get a
49:31heart transplant, but at a
49:32different center,
49:33the same patient may get
49:35an LVAD.
49:36And I think that's
49:37something that is not really
49:40known, and I think patients
49:41themselves don't really know this.
49:43So it really depends on
49:44what hospital you you are
49:46seen at
49:47or what health system you're
49:49seen at, because a lot
49:50of transplant centers are obviously
49:52part of bigger health systems.
49:53And so most patients are
49:55not being evaluated initially at
49:56a heart transplant center, but
49:58are seen in an affiliate
49:59hospital and subsequently referred in.
50:00So wherever your referral pattern
50:02goes to would then depend
50:04sort of what kind of
50:05therapy you got.
50:09Yeah. I'll ask a question
50:11while I'm moving around here.
50:12So you shared some,
50:14observations that
50:16the, transplant volume
50:18influences the likelihood of an
50:20organ
50:21being allocated.
50:23And I'm curious if you
50:24can explore that a little
50:25bit. And,
50:28what does that mean with
50:29regards
50:31to the utilization of of
50:32sub substandard organs, hep c,
50:36you know,
50:37organs that come that need
50:38that need bypass
50:40from older owners.
50:42Can you explore whether
50:44those centers are doing more
50:46of that
50:47to,
50:48you know, to
50:50to game the system to
50:52be more,
50:53you know, acceptable for
50:56allocation requests.
50:57Mhmm.
50:58Yes. I think,
51:00there is some data to
51:01support that,
51:03you
51:04organs that are considered of
51:06marginal quality are being used
51:08up by those high volume
51:10centers and that they're being,
51:12you know, more aggressive in
51:13working with the, organ procurement
51:17networks,
51:18to, you know, get access
51:20to those,
51:21you know, organs and transplant
51:23their patients.
51:25You know, something else I
51:26I didn't address is that
51:28there's also
51:29sort of this,
51:30you know, balance between,
51:33you know, volume,
51:35outcomes, which,
51:37are significantly
51:38important in reimbursement,
51:41structures that,
51:43are provided.
51:44So, you know, obviously, you
51:45wanna have very good outcomes,
51:47which would help with,
51:49your reimbursement
51:50for procedures,
51:51but you also want to
51:53have,
51:54you know, high volume of
51:56transplants
51:57to be able to
52:01offer patients.
52:02And,
52:03I think some of the
52:04data I presented,
52:06suggests that, you know, we
52:08can explore being a little
52:10a little bit more,
52:12lenient in terms of the,
52:14you know, quality of the
52:16organ. We're,
52:18you know, allowing for patients,
52:20with the caveat that we,
52:23you know, have these discussions
52:24with the patient, assess their
52:26preference, assess the the risk
52:28benefits for that individual
52:30person.
52:30Yeah. And that maybe is
52:31a follow-up
52:32comment I'd like to explore
52:34as well, which is the
52:35role of the patient in
52:37deciding
52:38the limits of the types
52:39of organs that they might
52:41be willing to accept. So
52:42could you, help us understand,
52:45the shared decision making around
52:47hep c
52:48and marginal donors and and
52:50what discussions
52:52happen with patients and what
52:53are what's an expected
52:54kind of pathway for that
52:56that decision or are they
52:57not involved at all? And
52:59and, yeah. So I think
53:00I know the answer, but
53:01but if you get to
53:03get, to get your perspective,
53:04and, Nick, you might have
53:05to Nick, you might have
53:06to go up to the
53:07podium there. Yeah. I mean,
53:08I can I'll let these
53:09guys speak to that because
53:11they do it more often.
53:12But I can tell you
53:13even when I was, you
53:15you know, training on
53:16the advanced heart failure service,
53:18I remember,
53:19you know, seeing a patient
53:20similar to the one I
53:21presented. In this case, his
53:23wait time had been
53:25significantly
53:26longer,
53:27and,
53:28I think he had had
53:28some initial resistance to
53:31this specific question of a
53:33hepatitis c donor.
53:35And it took, you know,
53:37a number of conversations
53:38where,
53:41actually, it was doctor Salerno,
53:43who, you know, was, you
53:45know, just reeducating
53:46and teaching and and trying
53:48to, you know, help him
53:50understand that,
53:51you know, being accepting of
53:53of that type of organ
53:54might, you know, help him
53:55get a a heart transplant,
53:58sooner.
53:59So
54:00from what I've seen, the
54:01patient is at the forefront
54:03of that discussion,
54:05in terms of, you know,
54:06the the practices of the
54:08department. Maybe you wanna talk
54:10Yeah. I can just briefly
54:12add on to that.
54:14So sort of by regulatory
54:17guidelines, our consent process does
54:20look specifically at whether,
54:22a patient will accept a
54:23hepatitis c donor or not,
54:26because you're giving that person
54:28a known communicable
54:29disease.
54:31However,
54:32the reality is that you
54:33may be giving them other
54:34diseases, other things that come
54:36with
54:37the the donor that they
54:38don't know about. Hepatitis c
54:39is just something that's prominent.
54:41I think at this stage
54:42when it was first being
54:43rolled out, it was very
54:44controversial.
54:46I think it's much less
54:47so now where we're basically
54:49at the point where
54:51I would say not a
54:52hundred percent, but virtually that
54:54of of our patients agree
54:55to accept hepatitis c donors.
54:58But we do have an
55:00extensive consent process where there's
55:02a lot of first shared
55:03decision making. But I think
55:05particularly in our region and
55:06with our wait times, it
55:07you know, I talk to
55:08patients about that being something
55:10that could be the reason
55:12that they don't get heart.
55:13And, you know, you just
55:14have to know that. There's
55:16also,
55:17you know, a a lot
55:18of talk now around donation
55:19after circulatory death, which is,
55:22a little bit different than
55:23traditional brain death donors. And
55:25we talk with our patients
55:26about accepting DCD donors, which,
55:30you know, data has shown
55:31in Yale participated in in
55:32this original,
55:34clinical trial that those patient
55:35outcomes are similar. But,
55:37because the heart, actually has
55:39to be arrested before being
55:41resuscitated, there's some concern that
55:42you could have graft dysfunction
55:44and other issues. So our
55:45patients are informed of that
55:47we will be looking into
55:48DCD donors. Currently, though, they
55:50have the right to say
55:51no to that.
55:52But, again, most of our
55:54patients accept that because it
55:55really is part of the
55:56reality of getting an organ.
55:59But there's so many other
56:00factors that go into selection
56:02of a donor that patients
56:03don't necessarily know about.
56:06And I think as, you
56:08know, Colby had alluded to
56:09in his his editorial
56:11as as of right now,
56:13the current allocation system does
56:14not
56:15give, any weight to a
56:17patient preference as to what
56:19they would want,
56:21for themselves. So and I
56:23think Mike went into it,
56:24but the current system works
56:26is that we have to
56:27readjustify
56:27every two weeks somebody waits
56:30why they cannot get durable
56:31mechanical circulatory support, meaning an
56:34LVAD. So if someone continues
56:36to wait on the transplant
56:37list after two weeks, we
56:38have to justify and say,
56:40well, no. This person is
56:41not a candidate for an
56:42LVAD, which is inherently unfair
56:44because some people are gonna
56:45get organs quicker. And, again,
56:47some patients may have a
56:49very strong preference for one
56:50or the other. So the
56:51current system doesn't take that
56:52into account.
56:55Can I ask a question
56:57along that line from
56:59the video? Variability
57:01in practice because,
57:02a lot of the centers
57:04won't even consent patients for
57:05DCD or hep c because
57:07they will consider it standard
57:08of care.
57:09And you can make a
57:10case for that because the
57:11outcomes are identical.
57:14We're one of those centers
57:15that is more conservative in
57:16that regard. I mean, you
57:17know, Nick's old institution, the
57:19head of the transplant center
57:20at NYU,
57:21got a heart transplant with
57:22a hep c donor and
57:23wrote about it in the
57:24in the New York Times.
57:26So it's the outcomes that
57:27are identical, and there's so
57:28many other factors that,
57:30like, will lead to different
57:32outcomes that you can't really
57:33consent everyone for every little
57:35thing. So there's a good
57:36case to be made that
57:37you just sign one consent,
57:39and that should cover all
57:40these things. The second thing
57:42is that there is, like,
57:43this perception of, like,
57:45less than ideal donor in
57:46the United States
57:48that
57:49works against us because there's
57:50no data that, you
57:52know, less desirable organs will
57:54lead to worse outcomes.
57:56In Europe, for example, there's
57:58far less,
57:59drug overdose and other things
58:01that lead to younger organs,
58:03and their outcomes are the
58:04same.
58:05And there's multiple,
58:06studies that have shown that,
58:08you know, these
58:09less than ideal organs lead
58:11to those identical
58:12outcomes.
58:13So I think there's this
58:14perception that we're and we
58:16turned down a lot more
58:17organs
58:18in the US than
58:20European countries. So I think
58:21that there is a you
58:23know, the centers that are
58:24more aggressive
58:25are
58:27very aggressive in terms of
58:28donor select the donor selection
58:30as well. So that's one
58:32aspect that can be modified.
58:34Yeah. I think that's very
58:35informative
58:36and
58:37that
58:38that there's no
58:40units or OPTN
58:42requirement
58:43on the kinds of consent
58:45that are mandated
58:46for these things, which I
58:47would have thought would have
58:48been consistent across centers.
58:51And, you know, if someone
58:52hasn't evaluated
58:54that consent process
58:56as a variable and in
58:57terms of organ allocation, and
58:59and I think it would
59:00be a wonderful study to
59:02do.
59:03Any other Bob, maybe the
59:05last question, and then
59:07Yeah. I think this whole
59:08idea of the high risk,
59:09donors was very interesting. One
59:11is,
59:12you know, just the fact
59:13that thing that they get,
59:14rejected by fifty different people
59:16and then get put in
59:17and do just as well.
59:18It's just amazing.
59:20But when you you were
59:21able to link it to
59:22the centers,
59:23but is there any way
59:24to link
59:25when something gets rejected or,
59:27you know, when a center
59:28doesn't accept it to those
59:30patients? Because there's gonna be
59:31an inherent time lag bias
59:33in that, that there are
59:34certain patients that don't get.
59:36Now maybe a patient that
59:37didn't take that, you know,
59:39gets
59:40transplanted two days later, but
59:41they also there's gonna be
59:42a certain number of them.
59:43They're gonna die in the
59:44transplant list
59:45waiting for a heart that
59:46they've been rejected.
59:48Right. Because if you turn
59:50down a donor
59:51and then that patient has
59:53to wait an extra month
59:54to get another heart,
59:55that month
59:57will lead to will translate
59:59to
60:00real changes
01:00:01in their they may
01:00:04survive,
01:00:05but their quality of life
01:00:06is gonna be much worse
01:00:08than if they got that
01:00:08heart sooner. And that is
01:00:10not captured appropriately. So there
01:00:12is a real downside. Is
01:00:13there any way to link
01:00:14that with the data? Or
01:00:15when you reject this when
01:00:17you reject a heart, is
01:00:18that linked to who you
01:00:19rejected or it's just linked
01:00:20to your center?
01:00:23That that goes into, like,
01:00:24weightless mortality, but I don't
01:00:26know if there's any, like,
01:00:27individual
01:00:28you know? But, you know,
01:00:30every day that you're on
01:00:31ECMO or INTELLA, like, you
01:00:32get complications, you get more.
01:00:34It's a culture that needs
01:00:35to,
01:00:37like over to viable overall.
01:00:40Some of our if you
01:00:41if a transplant goes well,
01:00:42you can live, like, twenty,
01:00:43thirty years. And
01:00:45if it doesn't, you know,
01:00:46if it doesn't
01:00:47go as well, then you're
01:00:49you know, great with these
01:00:50and other things. So I
01:00:51think they're real at a
01:00:53patient level,
01:00:55impact of of those delays.
01:00:59Fantastic talk. I know you
01:01:01learned a lot through this
01:01:02process and and through your
01:01:03entire
01:01:04Yale journey, and, we're excited
01:01:06to see how you do
01:01:07into the future. So congratulations.
01:01:09Thank you.