Racial disparities and outcomes of left ventricular assist device implantation as a bridge to heart transplantation

Abstract

Aims This study investigated outcomes after continuous flow left ventricular assist device (CF-LVAD) implantation as bridge to heart transplantation (BTT) in advanced heart failure patients stratified by race. Methods and results De-identified data from the United Network for Organ Sharing database was obtained for all patients who had a CF-LVAD as BTT from 2008 to 2018. Patients were stratified into four groups on the basis of ethnicity [Caucasian, African American (AA), Hispanic, and others (Asian, Pacific Islanders, and American Indian)]. Outcomes investigated were waitlist mortality or delisting and post-transplant 5 year survival. Cox proportional hazards modelling was used to identify independent predictors of waitlist mortality or delisting and post-transplant survival. We used Kaplan-Meier survival curves and the log-rank test to estimate and compare survival among groups. A total of 14 234 patients who had CF-LVADs as BTT were identified. Of these, 64% (n = 9058) were Caucasians, 26% (n = 3677) were AA, 7% (n = 997) were Hispanic, and 3% (n = 502) had a different race. Compared with Caucasian, AA, and Hispanic patients had higher body mass indexes and a lower level of education and are more likely to be public health insurance beneficiaries. There was a significantly lower incidence of transplantation in AAs compared with Caucasians, Hispanics, and others at 12, 24, and 60 months, respectively (Gray's test, P < 0.001). The AA race was a significant predictor of waitlist mortality or delisting owing to worsening clinical status [hazard ratio, 95% confidence interval: 1.10 (1.01 to 1.16; P < 0.001)]. Among those who were successfully BTT, risk-adjusted posttransplant survival was similar among the four groups (log-rank test: P = 0.589). Conclusions Disparities exist among different races that receive a CF-LVAD as a BTT. These disparities translate into increased waitlist morbidity and mortality but not long-term post-transplant survival among those who successfully reach transplant.

Racial and socioeconomic disparity associates with differences in cardiac DNA methylation among men with end-stage heart failure

“…Although limited by sample size, this preliminary comparison revealed a significantly higher mortality in AA (8/15) relative to CA (2/14) subjects over the subsequent 2 yr ( P = 0.033), though there were no racial differences in the transplantation rate (2 AA, 2 CA). This observation is consistent with prior reports of poorer outcomes among underrepresented minorities following LVAD implantation ( 25 ).…”

“…As also found in our patient cohort, African Americans experience worse clinical outcomes than any US race or ethnicity, even after adjusting for traditional risk factors ( 25 , 47 ). Although HF is a common reason for hospitalization nationwide ( 48 ), AAs with HF are hospitalized at a rate 2.5-times higher than other races/ethnicities ( 49 ).…”

A scoping review of inequities in access to organ transplant in the United States

“…Black and Hispanic patients were more likely to be listed with higher urgency (listing status 1A/1B) compared with White patients, and Hispanic patients were at higher risk of waitlist mortality [ 167 ]. Black race was found to be significantly associated with longer time to cardiac transplantation [ 168 ], lower likelihood of receiving a heart transplant, and greater likelihood of being removed from the waitlist due to worsening health [ 169 , 170 ]. Women receiving LVAD support also had a reduced chance of heart transplantation and increased risk of waitlist mortality and delisting for worsening clinical status within 2 years post-implantation [ 171 ].…”

Are the current evaluation tools for advanced therapies biased?

“…One-year post-HT survival is roughly comparable regardless of race, but Black recipients have higher long-term rates of death or graft failure in most United Network for Organ Sharing (UNOS) registry analyses [ 2 – 5 ], including that presented in Fig. 2 .…”

“…Only half of candidates have undergone HT by 1 year after listing, and roughly 22% have experienced death or delisting [ 7 ]. Compared to White BTT patients, African-Americans are more likely to die or be delisted and less likely to receive HT [ 2 ]. The 2018 revision to the UNOS heart allocation strategy additionally advantages patients on temporary mechanical circulatory support.…”