Outcomes of Non-Urgent Heart Transplant Candidates: A Nationwide Analysis

C. M.. Jarrett¹, O. Mahmoud², K. Gray³, Y. Elgudin², M. Pelletier⁴, C. ElAmm², Y. Abu-Omar^2
1University Hospitals Cleveland, Avon, Ohio ²University Hospitals Cleveland, Cleveland, Ohio ³University Hospitals Cleveland Medical Center, Shaker Heights, Ohio ⁴University Hospitals, Cleveland, Ohio

Purpose: UNOS status 4 and 6 includes heart transplant candidates who are stable enough to remain home, and includes patients with inotrope dependence and durable LVADs. Given their stability, what is their fate? We sought to determine the outcomes of status 4 and 6 patients in a nationwide analysis.

Methods: We included all adults (age≥18) in the UNOS STAR file who underwent heart transplant from 10/18/2018-9/30/2022 with any time as status 4 or 6. Primary endpoints were percent of patients transplanted, time to transplant, and survival on the waitlist. Survival was estimated using the Kaplan-Meier method and compared using the log-rank test. Alluvial plots were created to show patient flows between status changes, deaths on the waiting list, delistings, and transplants at specific time points.

Results: A total of 9,285 unique patients were listed as status 4 with 62.3% (5,780/9,285) as initial status 4, and a total of 4,808 unique patients were listed as status 6 with 67.3% (3,238/4,808) as initial status 6. Most (95.9%, 5,542/5,780) initial status 4 patients had no change in the indication for status 4. Overall, 62.0% (3,586/5,780) of status 4 patients were transplanted with a median 67 days (IQR: 24-181) to transplant. At 1, 3, 6, 12, and 24 months, 19.2% (1,111/5,780), 37.7% (2,129/5,641), 50.0% (2,729/5,459), 62.1% (3,227/5,195), and 73.1% (3,541/4,847) of status 4 patients were transplanted, respectively (Figure 1A). Overall, 56.7% (1,836/3,238) of status 6 patients were transplanted with a median 71 days (IQR: 23-201) to transplant. At 1, 2, 3, 6, 12, 24, 36, and 48 months, 17.4% (562/3,238), 27.0% (852/3,152), 33.3% (1,038/3,117), 44.3% (1,332/3,009), 51.4% (1,509/2,935), 56.0% (1,605/2,867), 67.3% (1,787/2,654), 71.6% (1,827/2,553), and 73.6% (1,839/2,497) of status 6 patients were transplanted, respectively (Figure 1B). Percent of total transplants by indication and median days to transplant were: 34.4% (1,232/3,586) and 124 for LVAD; 21.5% (772) and 29 for IV inotropes; 18.1% (648) and 57 for exceptions; 12.3% (442) and 58 for cardiomyopathy; 6.4% (230) and 105 for congenital heart disease; 5.1% (184) and 6 for re-transplant; and 2.2% (78) and 42 for ischemic heart disease, respectively. Waitlist survival was highest with ischemic cardiomyopathy and LVAD indications, and lowest with re-transplant and inotrope dependent indications (p < 0.0001).

Conclusion: For status 4 and status 6 patients, half of patients will be transplanted within 6 months and 9 months of initial listing, and two-thirds of patients will be transplanted within 1 year and 2 years of initial listing, respectively. Waitlist survival for status 4 patients is heterogeneous with better survival in LVAD compared to inotrope-dependent patients. In status 6 patients, there is a gradual decrease in survival until 2 years with a sharper decline thereafter leading to a 50% survival of approximately 3.5 years. These results should be considered in advanced heart failure shared decision making.

Identify the source of the funding for this research project: None