Decreased frequency of transplantation and lower post‐transplant survival free of re‐transplantation in LVAD patients with the new heart transplant allocation system

Abstract

Purpose:To evaluate the effect of the new heart transplant (HT) allocation system in left ventricular assist device (LVAD) supported patients listed as bridge to transplantation (BTT).Methods: Adult patients who were listed for HT between October 18, 2016 and October 17, 2019, and were supported with an LVAD, enrolled in the UNOS database were included in this study. Patients were classified in the old or new system if they were listed or transplanted before or after October 18, 2018, respectively.Results: A total of 3261 LVAD patients were listed for transplant. Of these, 2257 were classified in the old and 1004 in the new system. The cumulative incidence of death or removal from the transplant list due to worsening clinical status at 360-days after listing was lower in the new system (4% vs. 7%, P = .011). LVAD Patients listed in the new system had a lower frequency of transplantation within 360-days of listing (52% vs. 61%, P < .001). A total of 1843 LVAD patients were transplanted, 1004 patients in the old system and 839 patients in the new system. The post-transplant survival at 360 days was similar between old and new systems (92.3% vs. 90%, P = .08). However, LVAD patients transplanted in the new system had lower frequency of the combined endpoint, freedom of death or re-transplantation at 360 days (92.2% vs. 89.6%, P = .046). Conclusion:The new HT allocation system has affected the LVAD-BTT population significantly. On the waitlist, LVAD patients have a decreased cumulative frequency of transplantation and a concomitant decrease in death or delisting due to worsening status. In the new system, LVAD patients have a decreased survival free of retransplantation at 360 days post-transplant.

Durable mechanical circulatory support as bridge to heart transplantation

“…Similarly, Nordan et al [22 ▪ ]. and Jani et al [23 ▪ ] in very similar analyses, reported the results of patients awaiting heart transplant with a durable LVAD from October 2015 to March 2020 and October 2016 to October 2019, respectively identified in the UNOS database. Both groups found that those listed under the new allocation system were less likely to die awaiting transplant or be removed from the waitlist compared to the old allocation system but that they were less likely to undergo heart transplantation.…”

Predictors of Survival After Heart Transplant in the New Allocation System: A UNOS Database Analysis

“…These results support prior findings published early after the allocation system change which demonstrated that listing with IABP 10 and Impella 11 were not associated with posttransplant outcomes while durable LVAD at listing was associated with adverse posttransplant outcomes. 12–14 Given significant decline in the use of durable LVAD as a bridge to transplant, with patients eligible for LVAD potentially being bridged directly to transplant with tMCS—these results have important implications for evaluation of the current allocation system and for potential consideration of changes for future allocation systems. Particularly, as patients with the current generation of durable LVADs demonstrate improving intermediate term survival, 15 with patients without high-risk features demonstrating 2 years survival which is similar or better than transplant, 16 addition consideration for the role of durable LVAD within the allocation system will be needed to balance waitlist and posttransplant outcomes.…”

Donor Utilization in the Recent Era: Effect of Sex, Drugs, and Increased Risk

“…While this has led to shorter time to transplantation for those acutely ill patients, it has led to fewer patients in the less urgent priority categories receiving a transplant. 33 , 34 A potential solution is to incentivize centers to expand donor selection criteria while reducing the risk of regulatory consequences for resultant outcomes, which may be marginally lower but would result in increased transplantation and ultimately longer survival in aggregate for patients waiting for transplantation.…”