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ANNUAL ISHLT REGISTRY REPORTS

Organ Allocation Around the World: Insights Fromthe ISHLT International Registry for Heart and LungTransplantation

Josef Stehlik, MD, MPH,a,b Lynne W. Stevenson, MD,c Leah B. Edwards, PhD,aMaria G. Crespo-Leiro, MD,d Juan F. Delgado, MD,e Richard Dorent, MD,fMaria Frigerio, MD,g Peter Macdonald, MD,h Guy A. MacGowan, MD,iAlessandro Nanni Costa, MD,j Joseph G. Rogers, MD,k Ashish S. Shah, MD,lRhiannon Taylor,m Rajaiyer V. Venkateswaran, MD,n and Mandeep R. Mehra, MDc

From the aISHLT Transplant Registry, Dallas, Texas; bUniversity of Utah School of Medicine, Salt Lake City, Utah;cBrigham and Women’s Hospital Heart and Vascular Center, Harvard University, Boston, Massachusetts; dHospitalUniversitario A Coruña, La Coruña, Spain; eHospital 12 de Octubre, Madrid, Spain; fAgence de la biomédecine,Saint-Denis, France; gNiguarda-Ca’ Granda Hospital, Milan, Italy; hSt. Vincent’s Hospital, Sydney, New South Wales,Australia; iFreeman Hospital, Newcastle upon Tyne, United Kingdom; jCentro Nazionale Trapianti, Roma, Italy; kDukeUniversity, Durham, North Carolina; lThe Johns Hopkins Hospital, Baltimore, Maryland; mNational Health ServiceBlood and Transplant, Bristol, United Kingdom; and the nWythenshawe Hospital, Manchester, United Kingdom.

The 2014 reports of the International Society for Heartand Lung Transplantation (ISHLT) International Registryfor Heart and Lung Transplantation (Registry) bringexpanded analyses of outcomes in patients who haveundergone retransplantation. The experience of more than170,000 heart, lung, and heart-lung transplant recipientstransplanted over 30 years provided an opportunity for arobust exploration of this topic. The appropriateness ofretransplantation has recently been undergoing criticalreview.1–5 We believe the analyses presented in theRegistry reports provide important new information andinsights that will be valuable as our professional communityre-examines timing and candidate selection for retransplan-tation.

The Registry continues to serve as a valuable tool toanswer clinical questions, beyond the data presented in theannual reports. The Transplant Registry Early Career Awardis a good mechanism that facilitates this work and catalyzesmentorship and collaboration across institutions and coun-tries. Applications for the 2014 Award were submitted byapplicants and mentors from 6 countries on 3 continents—

t matter Published by Elsevier Inc.16/j.healun.2014.08.001

ef.stehlik@hsc.utah.edu

Josef Stehlik, MD, MPH, Division of Cardiology,alth Sciences Center, U.T.A.H. Cardiac Transplantcal Dr, 4A100 SOM, Salt Lake City, UT 84132.340. Fax: 801-581-7735.

Australia, Belgium, Czech Republic, Germany, Spain,Sweden, and the United States. The high quality of theseapplications resulted in 4 funded awards this year.6 Theapplications for next year’s award are due in January 2015(http://www.ishlt.org/awards/awardTxRegistry.asp).

The Registry also continued to work with membersaround the world to identify institutions and data collectivesinterested in participation in the Registry. Centers thatjoined the Registry in the past year include the FederalResearch Center of Transplantology and Artificial Organs inMoscow, Russia, the King Faisal Specialist Hospital andResearch Centre in Riyadh, Saudi Arabia, and the ApolloHospital in Chennai, India—all centers in countries thathave not previously participated in the Registry. The MasihDaneshvari Hospital in Tehran became the second center inIran, along with Tehran University of Medical Sciences, tojoin the Registry, and the Gangham Severance Hospital inSeoul joined the Severance Hospital as the second SouthKorean center to submit data.

In addition, the Registry Committee has partnered withthe International & Inter-society Coordination Committee(I2C2) of the ISHLT to work on establishing newcollaborations in research, education, and advocacy. Ex-amples include relations with the Turkish Society ofCardiovascular Surgery (activities spearheaded by DrRuchan Akar and Dr Murat Sargin), the Ministry of Healthof Brazil (Dr Heder Borba), the Latin American and

The Journal of Heart and Lung Transplantation, Vol 33, No 10, October 2014976

Caribbean Transplant Society (Dr Juan Mejia, Dr AlejandroBertolotti), and the Ministry of Health of Argentina (DrCarlos Soratti).

The perspectives of an increasing number of the Registryparticipants (Figure 1), which mirror the breadth of theinternational membership in our Society, also allow forexploration of topics that may not be directly or fullyaddressed by Registry data collection. One of the ever morepressing topics is how to align the evolving non-transplantoptions in advanced heart and lung disease, the changingdonor and recipient demographics, and organ allocation. Toillustrate the utility of the Registry data and of theinternational expertise of the Society’s members, we providea brief perspective focused on heart transplant data.

During the past 3 decades, new traffic laws andimprovements in automobile and workplace safety haveresulted in a decrease in the accident-related death rates inyoung adults.7 In addition, the populations of many nationshave continued to age. Consequently, the average age oforgan donors has increased, as has the age of donorsaccepted for heart transplantation. The median age of a heartdonor 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.8

These demographic changes have a real effect on post-transplant survival. For example, the higher donor age inEurope would be expected to result in a 20% increase ofmortality risk compared with the North American donorpool. Donor medical comorbidities, such as diabetesmellitus and hypertension, have also increased.9

The demographics of the heart transplant recipient havechanged perhaps even more dramatically. Recipients being

Figure 1 Countries participating in the International Society for HeLung Transplantation in 2013. A red flag indicates national or collaboratidata by individual centers. The country abbreviations are listed in the A

transplanted in their 60s now comprise 30% of all adultheart transplants, with patients in their 70s receiving hearttransplants with a higher frequency than ever before.8

Recipient comorbidities have increased steadily; at the timeof 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 useof mechanical assist devices as a bridge to transplantation.Close to 40% of all adult recipients are bridged to transplantwith a durable device. Further, although use of mechanicalassist as a bridge to transplant had been infrequent in olderpatients in the recent past, this trend was fully reversed. As of2011, transplant candidates older than 60 years are equally oreven more likely to be supported by a mechanical assist deviceat the time of transplant compared with younger recipients.

In view of the increasing complexity of donor andrecipient profiles, the charge we have is to find ways tomaintain (or increase) transplant volumes, preserve goodpost-transplant outcomes, maintain equity in organ alloca-tion, and keep mortality on the transplant waiting list as lowas possible. Renewed efforts to optimize the donationprocess and donor management have shown promise.10

Interventions to improve donor hemodynamic managementhave been tested in different countries, and sizeableincreases in the number of organs suitable for transplanta-tion resulted from these efforts. These interventionsincluded sharing and implementing best practices from topperforming organ procurement teams,11 implementing earlyprotocol-driven donor management,12,13 and introducingdidactic training for key hospital-based health care profes-sionals.14,15

art and Lung Transplantation International Registry for Heart andve data submission, and a yellow flag indicates direct submission ofppendix.

Table 1 Key Heart Transplant Waiting List Parameters in a Sample of 5 Countries in North America, Europe, Australia, and New Zealand

Country Allocation algorithmTransplantedin status

Medianwaitingtime

Patientstransplantedin 2012

Patients on the list in2012 (at start of theyear/newly listed) Transplant rate in 2012

Patients withMCS attransplant

Donor consentlegislation

Hearttransplantsa

Organdonorsa

Patientstransplanted/patients onthe list

Patientstransplanted/patients newlylisted (VAD/ECMO)

(%) (days) (No.) (No.) (%) (%) (%)(permillion)

(permillion)

UnitedKingdom

Urgent 60 14 116 352 (141/212) 33 54 19 (16/3) Opt in 2.1 17Non-urgent 40 293

France High urgency 1 39 9 397 830 (300/530) 48 75 27 (13/14) Opt out 6.1 25High urgency 2 8 102Regional urgency 8 219Non-urgent 45 189

Spain Urgent status 0 14 8 247 433 (101/332) 57 74 15 (9/6) Opt out 5.3 35Urgent status 1 21 7Elective status 65 80

Italy 1 high urgency 14 3 231 1,100 (709/391) 32 59 9 (9/0) Opt in/opt outb 4.6 202A, 2B 86 292

Australia &New Zealand

Urgent 8 15 85 186 (78/108) 46 79 40 (40/0) Opt in 3.3 15Non-urgent 92 120

USA 1A high urgency 64 78 2,378 6,669 (3,526/3,143) 36 76 40% (39/1) Opt in 7.6 261B intermediate 31 2242 low urgency 5 618

ECMO, extracorporeal membrane oxygenation; MCS, mechanical circulatory support; USA, United States of America; VAD, ventricular assist device (temporary or durable) or total artificial heart.aBased on 2010 data.bAll are invited to register their donation intent. In the absence of declared intent, the law establishes presumed consent, but family input is typically sought.

Stehliket

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AllocationAround

theWorld

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Recent studies have also examined the next step of thedonation-transplantation process—the decisions surroundingacceptance of a particular donor allograft. It appears that currentheart allograft utilization could be increased without elevatingthe risk of post-transplant mortality. Empiric quantification ofthe risk associated with a particular donor is difficult, and it hasbeen proposed that a number of donor allografts with acceptablerisk are currently being discarded. Ongoing studies areexamining whether better assessment of risk associated with aparticular donor allograft may result in an increase in the numberof available donor hearts accepted for transplantation.16,17

Finally, there is the task of adapting our organ allocationprocesses to the changing epidemiology of donors andrecipients and the evolving therapeutic options for advancedheart disease. Although the logistical challenges associatedwith the process of organ donation and organ management arereasonably similar among countries with established organtransplantation programs, organ donation rates and hearttransplantation rates vary significantly among these countries.

The differences among organ allocation rules are evenmore pronounced. Key heart transplant indicators from asample of countries are listed in Table 1. All sampledcountries have established different tiers of transplanturgency status; however, the definition of urgency isvariable. Large differences also exist among the individualcountries in the proportion of patients who are transplantedin the highest urgency status and in the median time fromlisting to transplantation in the high urgency status. Thisillustrates that the specifics of an allocation system havegreat effect on these key parameters.

Some countries have a fairly restrictive definition ofhighest urgency such that only o15% of listed patients aretransplanted in this status (Spain, Italy, Australia/NewZealand); this, in turn, results in short median times totransplantation of 8, 3, and 15 days, respectively. Then thereare countries where a significant proportion of patientsare transplanted in the highest urgency status—UnitedKingdom (60%) and France (39%)— yet, the median waitingtime to transplant is still short, at 14 and 9 days, respectively.This would suggest that the waiting list is managed verycarefully in these countries, such that the number of patientsplaced in the highest urgency status does not overwhelm thelimited supply of donor organs. Finally, data for the UnitedStates show that most patients in this country are transplantedin a high urgency status (64% in status 1A, 31% in status 1B,and only 5% in lower urgency status 2) but also that under thecurrent allocation rule, the ability to expeditiously transplant aheart patient has been lost, for the median waiting time for atransplant in the highest urgency status 1A is now 78 days.18

Regardless of the specifics of a particular allocationsystem, 2 aspects of the allocation rules continue to presenta particular challenge. The first is that allocation algorithmsoften incorporate provisions for allocation to an individualcenter or an arbitrarily defined geographic area, rather thanexclusively allocation to an individual patient. On thepositive side, these geographic arrangements provide astrong incentive for local teams to create efficient processesthat maximize the use of organs by increasing donationawareness, early identification of potential donors, and

implementation of optimal donor management. However,allocation of organs based on a wider regional, national, andeven multinational prioritization of candidates at the highestrisk of death has been shown to result in a decrease ofwaiting list mortality and an increase of transplant benefit.19

In our assessment, most allocation algorithm revisions aretherefore 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 andquality of donors across the board will eventually benefitevery region, even with the wider regional sharing of organs.

The second highly charged aspect of heart allocation relatesto the now prevalent use of mechanical assist therapies intransplant candidates. Allocation arrangements in the countriesreviewed in Table 1 range from a significant advantage to evenstable patients supported with ventricular assist devices(VADs) to no advantage unless a serious VAD complicationoccurs. Supporters for higher priority for transplant candidatesreceiving VAD would argue that lack of allocation priority forVAD patients results in very long waiting times in many. And,when a serious VAD-associated complication occurs, this maynegate the expected benefit of the bridge-to-transplant therapy,because a sub-set of these patients will become transplantineligible or have a higher risk of post-transplant morbidityand mortality. On the other hand, the concern with providing asignificant advantage to patients with VADs brings upquestions of equity, because these patients often have a lowerrisk of waiting list mortality compared with patients with otherindications for urgent listing.20

The specifics of the algorithms may also influence thelikelihood with which the transplant candidates will requiremechanical assist therapies. This is being taken intoconsideration by health care funding agencies in theindividual countries, which further complicates possibledecisions on allocation rule changes.

In summary, changes in donor and recipient profiles, coupledwith new therapeutic options in advanced heart and lung disease,present new perspectives on organ allocation and candidateselection. As we embrace these new realities, and as changes inthoracic allocation policies are being considered by many, therich international experience offers an opportunity to identify andimplement regulatory and clinical practice changes that willensure transplantation continues to provide our patients anopportunity to regain longevity and an active lifestyle. We wouldlike to thank the members and staff at the many participatingcenters and data exchange organizations around the world formaking these global observations possible (Appendix 1).

Disclosure statement

The authors thank staff at the national transplant organizations forcontributing data for this report.

All relevant disclosures for the authors are on file with theISHLT and can be made available for review by contacting theExecutive Director of the ISHLT.

All relevant disclosures for the Registry Director, ExecutiveCommittee Members and authors are on file with the ISHLT andcan be made available for review by contacting the ExecutiveDirector of the ISHLT

Appendix List of Thoracic Transplant Centers Reporting Data to the International Society for Heart and Lung TransplantationTransplant Registry for Transplants Performed Between January 1, 2012, and June 30, 2013

Country (ISO code) Center

Argentina (ARG) Fundacion FavaloroHospital Italiano

Australiaa (AUS) St. VincentRoyal ChildrenThe Prince Charles HospitalThe Alfred HospitalRoyal Perth Hospital

Austriab (AUT) Allgemeines Krankenhaus WienUniversitätsklinik InnsbruckLandeskrankenhaus Graz

Belgiumb (BEL) Hôpital Erasme BruxellesUniversitair Ziekenhuis AntwerpenOnze Lieve Vrouw Ziekenhuis AalstUniversitair Ziekenhuis GentCentre Hospitalier Universitaire LiègeCliniques Universitaires, Université Catholique de LouvainUZ Gasthuisberg Leuven

Brazil (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 Alegre

Canada (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 Children

Chile (CHL) Hospital Gustavo FrickeInstituto Nacional del Torax

Colombia (COL) Clinica CardiovascularFundacion Valle Del LiliFundacion Cardioinfantil–Instituto de CardiologiaFundacion Cardiovascular de ColombiaFundacion Clinica Shaio

Croatiab (HRV) University Clinical Hospital ZagrebUniversity Hospital Dubrava

The Czech Republic (CZE) University Hospital MotolDenmarkc (DNK) Skejby University Hospital

Rigshospitalet, National University HospitalEstonia (EST) Tartu University HospitalFinlandc (FIN) Helsinki University Central Hospital

Children’s Hospital, University of HelsinkiFranced (FRA) Marseille Sainte Marguerite (APM) (A)–Chirurgie Thoracique

Marseille Timone adultes (APM) (A)–Chirurgie CardiaqueMarseille Timone enfants (APM) (AþP)–Chirurgie Cardio-VasculaireCaen (A)–Chirurgie CardiaqueDijon (A)–Chirurgie CardiaqueToulouse (A)–Chirurgie ThoraciqueToulouse (A)–Chirurgie Cardio-VasculaireBordeaux (AþP)–Unite de Transplantation CardiaqueBordeaux (AþP)–Chirurgie ThoraciqueMontpellier (A)–Unite de Transplantation Cardio-ThoraciqueRennes (A)–Centre Cardio-Pneumologique

Continued on page 980

Stehlik et al. Organ Allocation Around the World 979

Appendix (Continued )

Country (ISO code) Center

Tours (AþP)–Chirurgie CardiaqueGrenoble (A)–Chirurgie CardiaqueGrenoble (A)–PneumologieNantes (AþP)–Chirurgie Cardio-VasculaireNancy (AþP)–Chirurgie Cardio-PulmonaireLille (AþP)–Chirurgie Cardio-VasculaireClermont-Ferrand (A)–Chirurgie CardiaqueStrasbourg (A)–Chirurgie ThoraciqueStrasbourg (A)–Chirurgie Cardio-PulmonaireLyon (AþP)–Pole de Transplantation PulmonaireLyon I (HCL) (AþP)–Pole de Transplantation CardiaqueLyon II (HCL) (A)–Pole de Transplantation CardiaqueParis Pitié-Salpêtrière (AP-HP) (AþP)–Chirurgie Cardio-VasculaireParis Necker Enfants Malades (AP-HP) (AþP)–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) (AþP)–Transplantation. Pneumologie et Cardio-PulmonaireRouen (AþP)–Chirurgie Thoracique et Cardio-VasculaireLimoges (A)–Chirurgie CardiaqueSuresnes Foch (A)–Chirurgie ThoraciqueLe Plessis-Robinson Marie-Lannelongue (AþP)–Chirurgie CardiaqueLe Plessis-Robinson Marie-Lannelongue (AþP)–Chirurgie Thoracique Cardio-VasculaireCréteil Henri Mondor (AP-HP) (A)–Chirurgie Cardio-Vasculaire

Germanyb (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 Breisgau

India (IND) Apollo HospitalIran (IRN) Cardiac Surgery and Transplantation Research Center

Masih Daneshvari HospitalIrelande (IRL) Mater HospitalIsrael (ISR) Rabin Medical Center (Belinson Campus)

Sheba Medical CenterItaly (ITA) Policlinico S. Orsola–Universita degli StudiJapan (JPN) Tohoku University Hospital

Osaka University Hospital

Continued on page 981

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Appendix (Continued )

Country (ISO code) Center

Netherlandsb (NLD) Universitair Medisch Centrum UtrechtErasmus Medisch Centrum RotterdamUniversitair Medisch Centrum Groningen

New Zealand (NZL) Green Lane HospitalAuckland City Hospital

Norwayc (NOR) Rikshospitalet–National Hospital of NorwayPoland (POL) Regional Pulmonary HospitalThe Republic of Korea (KOR) Gangnam Severance Hospital

Severance HospitalRussia (RUS) Federal V. Shumakov Research Centre of Transplantology & Artificial OrgansSaudi Arabia (SAU) King Faisal Specialist Hospital and Research CenterSloveniab (SVN) University Medical Center LjubljanaSouth Africa (ZAF) Milpark HospitalSpain (ESP) Complejo Hospitalario Universitario Juan Canalejof,g

Hospital Universitario Marques de Valdecillaf,h

Hospital de Bellvitge, Barcelonah

Hospital Virgen Del Rocio, Sevillah

Hospital Santa Creu I Sant Pau, Barcelonah

Hospital Universitario 12 de Octubref,h

Hospital Universitario Reina Sofiaf,h

Hospital Gregorio Marañón, Madridh

Hospital Universitario Puerta de Hierrof

Hospital Universitari I Politècnic La Fe, Valenciaf,h

Hospital Clinic I Provincial, Barcelonah

Hospital Universitario Vall D’Hebronf,h

Hospital Central de Asturiasg

Hospital La Paz Infantilf,h

Hospital Virgen de La Arrixaca, Murciah

Hospital Miguel Servet, Zaragozah

Hospital Clínico, Valladolidh

Swedenc (SWE) Sahlgrenska University HospitalUniversity Hospital of Lund

Switzerland (CHE) University Hospital ZurichTurkey (TUR) Istanbul Florence Nightingale Hospital

Heart Center, Ankara UniversityHospital of Akdeniz University

United Kingdome (UK) Great Ormand Street Hospital for ChildrenUniversity of Glasgow/Glasgow Royal InfirmaryThe Freeman HospitalHarefield HospitalWythenshawe HospitalQueen Elizabeth HospitalPapworth Hospital

United Statesi (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, CA

Continued on page 982

Stehlik et al. Organ Allocation Around the World 981

Appendix (Continued )

Country (ISO code) Center

UCLA 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, NY

Continued on page 983

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Appendix (Continued )

Country (ISO code) Center

Strong 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, WI

ISO, International Organization for Standardization.aData provided via Australia and New Zealand Cardiothoracic Transplant Registry (ANZCOTR).bData provided via Eurotransplant (ET).cData provided via Scandiatransplant.dData provided via L’Agence de la Biomédicine.eData provided via United Kingdom Transplant Support Service Authority (UKTSSA).fLung data provided via OrganizaciónNacional de Trasplantes (ONT).gHeart data provided directly to ISHLT Registry.hHeart data provided via RegistroEspañol de TrasplanteCardíaco.iData provided via United Network for Organ Sharing (UNOS).

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