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The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

A national assessment of one-year heart outcomes after the 2018 adult heart allocation change

      Purpose

      On 10/18/2018 the Organ Procurement and Transplantation Network (OPTN) implemented modifications to adult heart allocation to better stratify the most medically urgent candidates by WL mortality. This paper reviews two years of post-policy monitoring with focus on post-transplant outcomes, especially for recipients with MCSDs.

      Methods

      Cohorts of WL additions and recipients pre (10/18/16-10/17/18) and post (10/18/18-10/17/20) policy implementation were compared using the OPTN database. Competing risks analyses of waitlist mortality and Kaplan-Meier one-year post-transplant survival were performed by medical urgency statuses and policy era. Similar analyses were performed for subsets of candidates and recipients on devices.

      Results

      Pre-implementation status 1A candidates had the highest cumulative incidence of removal from the waitlist due to death or too sick to transplant and the highest cumulative incidence of transplant, followed by statuses 1B and 2. Median time to transplant decreased from 226 to 85 days for those transplanted. There was no difference in one-year patient survival (pre=91.3% [90.2, 92.4]; post=91.8% [90.8, 92.9]; p=0.44) overall, or for recipients transplanted with an LVAD (pre=91.7% [90.1, 93.2]; post=91.4% [89.7, 93.2]; p=0.85) or IABP (pre=91.7% [88.1, 95.4]; post=92.1% [90.1, 94.0]; p=0.92).

      Conclusion

      The policy improved stratification of the most medically urgent candidates according to risk of death on the WL with decreased median wait times, higher transplant rates and no observed adverse effect on 1-year patient survival. No adverse effects for candidates listed or transplanted on IABP, ECMO, or LVAD were observed.

      KEYWORDS

      Abbreviations:

      OPTN (Organ Procurement and Transplantation Network), HRSA (Health Resources and Services Administration), LVAD (Left Ventricular Assist Device), TAH (Total Artificial Heart), IABP (Intra-Aortic Balloon Pump), MCSD (Mechanical Circulatory Support Device), tMCSD (Temporary Mechanical Circulatory Support Device), WL (Waitlist), TX (Transplant), TCR (Transplant Candidate Registration), TRR (Transplant Recipient Registration), DSA (Donor Service Area)
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      References

      1. OPTN/UNOS Public Comment Proposal. Proposal to modify the adult heart allocation system.https://optn.transplant.hrsa.gov/media/1921/thoracic_adult_heart_allocation_modification_20160815.pdf. Accessed April 26, 2021.

      2. OPTN/UNOS policy notice proposal to modify the adult heart allocation system. https://optn.transplant.hrsa.gov/media/2538/thoracic_policynotice_201807_heart.pdf. Accessed April 26, 2021.

      3. OPTN/UNOS Board Briefing. Proposal to modify the adult heart allocation system. https://optn.transplant.hrsa.gov/media/2006/thoracic_brief_201612.pdf. Accessed April 27, 2021.

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