Impact of heart transplant allocation change on competing waitlist outcomes among listing strategies

Patel, Jay; Chung, Joshua; Seliem, Ahmed; Sakr, Antoine; Stoletniy, Liset; Rabkin, David G.; Abramov, Dmitry

doi:10.1111/ctr.14345

Cited by 23 publications

(31 citation statements)

References 16 publications

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“…The Impella is known to provide excellent hemodynamic support, while unloading the left ventricle and potentially reversing end-organ dysfunction, yet allows greater ambulation compared to a patient on IABP or VA ECMO. 3,7–11 Our study demonstrated that there had been a steady increase in the use of the Impella as a BTT, even before the UNOS policy change; however, the most substantial increase (1% in 2015 to 4% in 2019) was seen after the UNOS policy change in 2018. 12…”

Section: Discussionmentioning

confidence: 66%

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Use of Impella in Patients Listed for Heart Transplantation

et al. 2022

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The new United Network for Organ Sharing (UNOS) policy has resulted in a significantly higher number of temporary mechanical circulatory support device usage such as extracorporeal membrane oxygenation, Impella, and intra-aortic balloon pump due to provision of higher priority with their use while on the waiting list. We aimed to identify Impella use in patients awaiting heart transplantation and temporal changes in its usage. The UNOS database was queried between years 2015 and 2019 for patients aged greater than or equal to 18 years, listed to undergo heart transplantation. A total of 378 patients had Impella support while listed for heart transplantation. Impella use skyrocketed from 2015 (1%) to 2019 (4%, p < 0.01). The most substantial increase in Impella use occurred after the UNOS policy change. The patients listed on Impella support after the policy change had significantly lower waiting time (median 12 days vs. 45 days, p < 0.01). More patients with Impella were directly transplanted (80% vs. 56%, p < 0.01) after the policy change, had significantly lower waitlist mortality (25% vs. 13%, p < 0.01) and fewer converted to a durable support (13% vs. 3%). The translatability (likelihood for receiving organs faster) was significantly improved after the policy change. A multivariable Cox regression model showed that post-transplant survival of Impella patients was not adversely affected after the policy change (hazard ratio = 0.9; p = 0.8). This increase in Impella use represents a substantial change in practice patterns of listing and managing patients on the heart transplant waiting list.

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Section: Discussionmentioning

confidence: 66%

“…Early investigations of transplants under the new allocation system had raised some concerns about worsening survival outcomes; however, recent reports have shown more comparable outcomes. 3,9,11,13–15…”

Section: Discussionmentioning

confidence: 99%

Use of Impella in Patients Listed for Heart Transplantation

et al. 2022

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“…The new allocation system was devised to address important limitations in the former 3‐tiered system that included discrepancies in the assignment of listing priority relative to patient risk characteristics and limitations in the allocation of donor organs based upon the use of the local organ procurement organization as the designated allocator of donor hearts. A major driver of the new allocation system was to improve equitable access to donor organs while maintaining or improving transplant outcomes, and previous studies have confirmed improved waitlist outcomes and increased transplantation rates in the new allocation system 4 . We sought to determine whether the 2018 changes to the allocation system had an impact on the traditional disadvantages experienced by patients with blood group O regarding waitlist and transplantation outcomes.…”

Section: Introductionmentioning

confidence: 99%

The heart transplant allocation change attenuates but does not eliminate blood group O waitlist outcome disadvantage

Patel

Abramov

Fudim

et al. 2022

Clinical Transplantation

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Background Patients with blood group O have historically been disadvantaged in the United Network for Organ Sharing (UNOS) heart transplant allocation system. We sought to determine whether the new UNOS allocation system implemented in 2018 had an impact on waitlist and post‐transplant outcomes among blood groups. Methods Using the UNOS database we included all adult patients listed and transplanted with first‐time single‐organ heart transplant between 10/17/15 and 10/1/21. For post‐transplant outcomes, we separately evaluated all adult patients transplanted with the same time‐frame. We used exclusion criteria and censoring to limit biases from changing clinical practices around the allocation change (10/18/2018), and from unequal or inadequate follow‐up. We compared clinical characteristics and outcomes before and after the allocation change among each blood group. Fine‐Gray and Cox regression models were used to estimate the effect of the new allocation system on competing waitlist outcomes‐ transplantation, death‐or‐removal from waitlist‐ and post‐transplant survival, respectively. Results Of the 21,565 patients listed for transplantation 14,000 met criteria for waitlist analysis (7,035 in the old system vs. 6,965 in the new), and 7,657 met criteria for post‐transplant analysis (3,519 in the old system vs. 4,138 in the new). Among each blood group, new allocation change was associated with higher transplantation rates lower waitlist days and lower waitlist mortality (except Group AB). However, despite improvements, Group O was still associated with worse waitlist outcomes for each metric compared to non‐O Groups. The new allocation system did not have a significant impact on post‐transplant survival among any blood groups. Conclusion Changes in heart transplant allocation have attenuated but not eliminated blood group O disadvantage in access to donor hearts.

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“…Body mass index (BMI) has previously been shown to affect transplant listing strategy, 1 and was associated with increased waitlist mortality, 1,2 longer wait times before transplantation, 2 and decreased post‐transplant survival 2–4 . In 2018, the United Network of Organ Sharing (UNOS) provided significant changes to the heart transplant allocation system, which resulted in changes in listing strategies (increase in temporary mechanical support and decrease in durable ventricular assist devices), decrease in waitlist times, and variable effects on post‐transplant survival 5–11 . BMI may have significant effects on decisions regarding listing strategy and the use of mechanical support, which may affect waitlist times and outcomes.…”

Section: Introductionmentioning

confidence: 99%

“…[2][3][4] In 2018, the United Network of Organ Sharing (UNOS) provided significant changes to the heart transplant allocation system, which resulted in changes in listing strategies (increase in temporary mechanical support and decrease in durable ventricular assist devices), decrease in waitlist times, and variable effects on post-transplant survival. [5][6][7][8][9][10][11] BMI may have significant effects on decisions regarding listing strategy and the use of mechanical support, which may affect waitlist times and outcomes. As the impact of BMI on these outcomes under the new allocation system have not been well characterized, we sought to evaluate the role of BMI on listing strategy, waitlist outcomes, and post-transplant outcomes in the current era.…”

Section: Introductionmentioning

confidence: 99%

The effect of recipient BMI on waitlist and post‐transplant outcomes after the 2018 heart transplant allocation policy change

Patel

Rabkin

Sperry

et al. 2022

Journal of Cardiac Surgery

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Objective: The effects of recipient body mass index (BMI) on waitlist strategies, waitlist outcomes, and post-transplant outcomes among adult patients listed for heart transplantation under the updated 2018 allocation system have not been well characterized. Methods:The United Network of Organ Sharing data set between October 2015 and March 2021 was analyzed, and patients were grouped based on recipient BMI and whether listing occurred in the old (pre-October 2018) or new allocation system.Results: Listing strategies differed by BMI group, but trends of increased use of temporary mechanical support and decreased use of durable support remained among all BMI groups, except those with BMI > 35 kg/m 2 . Waitlist outcomes improved among all BMI cohorts in the new allocation system, including among patients with BMI 30-34.9 and >35 kg/m 2 , although patients with higher BMIs continued to have longer waitlist times. Post-transplant outcomes in the new allocation system are worse for patients with BMI > 30 kg/m 2 (hazard ratio:

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Impact of heart transplant allocation change on competing waitlist outcomes among listing strategies

Cited by 23 publications

References 16 publications

Use of Impella in Patients Listed for Heart Transplantation

Use of Impella in Patients Listed for Heart Transplantation

The heart transplant allocation change attenuates but does not eliminate blood group O waitlist outcome disadvantage

The effect of recipient BMI on waitlist and post‐transplant outcomes after the 2018 heart transplant allocation policy change

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