University of Louisville Louisville, Kentucky, United States
Disclosure(s):
Jaimin Trivedi, MD, MPH: No financial relationships to disclose
Purpose: The 2018 United Network for Organ Sharing (UNOS) heart allocation policy favored temporary support devices such as extracorporeal membrane oxygenation, percutaneous endovascular and intra-aortic balloon pumps. Some early reports suggested worsening outcomes and others reported similar outcomes to pre-policy era. We aimed to evaluate mid-term outcomes since the policy implementation. Methods: The UNOS thoracic transplantation data was queried from June 2013 to June 2023 to identify adults (>/=18 years) undergoing heart transplantation. Patients were divided into two groups based on the implementation of the new UNOS policy. Pre-policy group (n=13858) was before October 2018 and post-policy group (n=15705) was after October 2018. Waiting list duration, waiting list mortality (death or deterioration) as well as post-transplant survival were evaluated between the groups. Within the post-policy group yearly change in listing and transplant practices was evaluated between years 2019 and 2022 (partial years of 2018 and 2023 excluded). Descriptive, univariate and Kaplan-Meier curves were used for analysis. Results: The gender (74% v. 74%, p=0.37) and diabetes (29% v. 29%, p=0.25) were similar between the groups whereas Black race (25% v. 22%, p<.01), requirement of ECMO (6% v. 1%, p<.01) and IABP (26% v. 7%, p<.01) support was higher in the post policy group (Table 1). The median waitlist time (32 v. 108 days, p<.01) was significantly lower in the post-policy group. The waiting list mortality at 90 days was lower in the post-policy group (4% v. 6%, p<.01). The 1-year post-transplant survival between the policy groups was comparable (90% v. 90%, p=0.78) whereas the 3-year survival was significantly worse in the post-policy group (81% v. 85%, p<.01, Figure 1). Within the post-policy group, the use of ECMO (6%) and VAD (32%) remained stable whereas use of IABP (28% (2018) v. 26% (2022)) has marginally declined. Of the 15705 post-policy transplants, UNOS status 1, 2 and 3 was in 10% (n=1608), 50% (n=7822) and 16% (n=2533) patients respectively. For UNOS status 1, 2 and 3 the exception transplants were done in 41%, 45% and 30% patients respectively whereas 30%, 34% and 33% patients respectively had transplants performed after receiving extension on their latest listing status. Conclusion: The new heart allocation policy has reduced the waitlist time and early mortality. However, the mid-term post-transplant survival is significantly worse under the new policy. Considerable gaming of the new policy has occurred evident from higher use of temporary devices and extension and exception transplants.
Identify the source of the funding for this research project: Not funded.
