The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.
Original clinical science|Articles in Press

Impact of 2018 allocation system change on outcomes in patients with durable left ventricular assist device as bridge to transplantation: A UNOS registry analysis

Published:February 10, 2023DOI:


      This study compared outcomes of patients waitlisted for orthotopic heart transplantation with durable left ventricular assist devices (LVAD) before and after the October 18, 2018 heart allocation policy change.


      The United Network of Organ Sharing database was queried to identify 2 cohorts of adult candidates with durable LVAD listed within seasonally-matched, equal-length periods before (old policy era [OPE]) and after the policy change (new policy era [NPE]). The primary outcomes were 2-year survival from the time of initial waitlisting, as well as 2-year post-transplant survival. Secondary outcomes included incidence of transplantation from the waitlist and de-listing due to either death or clinical deterioration.


      A total of 2,512 candidates were waitlisted, 1,253 within the OPE and 1,259 within the NPE. Candidates under both policies had similar 2-year survival after waitlisting, as well as a similar cumulative incidence of transplantation and de-listing due to death and/or clinical deterioration. A total of 2,560 patients were transplanted within the study period, 1,418 OPE and 1,142 within the NPE. Two-year post-transplant survival was similar between policy eras, however, the NPE was associated with a higher incidence of post-transplant stroke, renal failure requiring dialysis, and a longer hospital length of stay.


      The 2018 heart allocation policy has conferred no significant impact on overall survival from the time of initial waitlisting among durable LVAD-supported candidates. Similarly, the cumulative incidence of transplantation and waitlist mortality have also been largely unchanged. For those undergoing transplantation, a higher degree of post-transplant morbidity was observed, though survival was not impacted.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Heart and Lung Transplantation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Khush KK
        • Hsich E
        • Potena L
        • et al.
        The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Thirty-eighth adult heart transplantation report — 2021; Focus on recipient characteristics.
        J Hear Lung Transplant. 2021; 40: 1035-1049
        • Everly MJ.
        Cardiac transplantation in the United States: an analysis of the UNOS registry.
        Clin Transpl. January 2008; (Accessed January 10, 2022): 35-43
        • Colvin M
        • Smith JM
        • Ahn Y
        • et al.
        OPTN/SRTR 2019 Annual Data Report: Heart.
        Am J Transplant. 2021; 21: 356-440
        • Shore S
        • Golbus JR
        • Aaronson KD
        • Nallamothu BK.
        Changes in the United States adult heart allocation policy: Challenges and opportunities.
        Circ Cardiovasc Qual Outcomes. 2020; : 798-802
        • Kilic A
        • Mathier MA
        • Hickey GW
        • et al.
        Evolving Trends in Adult Heart Transplant With the 2018 Heart Allocation Policy Change.
        JAMA Cardiol. 2021; 6: 159-167
        • Truby LK
        • Farr MA
        • Garan AR
        • et al.
        Impact of Bridge to Transplantation with Continuous-Flow Left Ventricular Assist Devices on Posttransplantation Mortality: A Propensity-Matched Analysis of the United Network of Organ Sharing Database.
        Circulation. 2019; 140: 459-469
        • Suarez-Pierre A
        • Zhou X
        • Fraser CD
        • et al.
        Survival and Functional Status After Bridge-to-Transplant with a Left Ventricular Assist Device.
        ASAIO J. 2019; 65: 661-667
      1. Analyzing adult heart allocation policy - UNOS. Accessed January 10, 2022.

        • Goff RR
        • Uccellini K
        • Lindblad K
        • et al.
        A change of heart: preliminary results of the US 2018 adult heart allocation revision.
        Am J Transplant. 2020; 20: 2781-2790
        • Mullan CW
        • Chouairi F
        • Sen S
        • et al.
        Changes in use of left ventricular assist devices as bridge to transplantation with new heart allocation policy.
        JACC Hear Fail. 2021; 9: 420-429
        • Srinivasan AJ
        • Seese L
        • Mathier MA
        • Hickey G
        • Lui C
        • Kilic A.
        Recent changes in durable left ventricular assist device bridging to heart transplantation.
        ASAIO J. 2021;
        • Motter JD
        • Segev DL
        • Massie AB.
        Don't stop thinking about tomorrow: Ascertainment bias in pre-post design transplant registry studies.
        Am J Transplant. 2022; 22: 1513-1514
        • Hsich EM
        • Thuita L
        • McNamara DM
        • et al.
        Variables of importance in the Scientific Registry of Transplant Recipients database predictive of heart transplant waitlist mortality.
        Am J Transplant. 2019; 19: 2067-2076
        • Kilic A
        • Allen JG
        • Weiss ES.
        Validation of the United States-derived Index for Mortality Prediction after Cardiac Transplantation (IMPACT) using international registry data.
        J Hear Lung Transplant. 2013; 32: 492-498
      2. OPTN Policies Effective as of June 18 2020. Accessed June 20, 2022

        • Kilic A
        • Hickey G
        • Mathier MA
        • et al.
        Outcomes of the first 1300 adult heart transplants in the United States after the allocation policy change.
        Circulation. 2020; 141: 1662-1664
        • Mehra MR
        • Uriel N
        • Naka Y
        • et al.
        A fully magnetically levitated left ventricular assist device - final report.
        N Engl J Med. 2019; 380: 1618-1627
        • Hess NR
        • Hickey GW
        • Keebler ME
        • et al.
        Left ventricular assist device bridging to heart transplantation: comparison of temporary versus durable support.
        J Heart Lung Transplant. 2023; 42
        • Molina EJ
        • Shah P
        • Kiernan MS
        • et al.
        The Society of Thoracic Surgeons Intermacs 2020 Annual Report.
        Ann Thorac Surg. 2021; 111: 778-792
        • Lazenby KA
        • Narang N
        • Pelzer KM
        • Ran G
        • Parker WF.
        An updated estimate of posttransplant survival after implementation of the new donor heart allocation policy.
        Am J Transplant. 2022; 20: 1683-1690
        • Batchelor RJ
        • WONG N
        • LIU DH
        • et al.
        Vasoplegia following orthotopic heart transplantation: prevalence, predictors and clinical outcomes.
        J Card Fail. 2022; 28: 617-626
        • Asleh R
        • Alnsasra H
        • Daly RC
        • et al.
        Predictors and clinical outcomes of vasoplegia in patients bridged to heart transplantation with continuous-flow left ventricular assist devices.
        J Am Heart Assoc. 2019; 8e013108
        • Khush KK
        • Potena L
        • Cherikh WS
        • et al.
        The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: 37th adult heart transplantation report—2020; focus on deceased donor characteristics.
        J Hear Lung Transplant. 2020; 39: 1003-1015