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Published on: May 11, 2018
Differences in Status 1A Heart Transplantation Survival in the Continuous Flow Left Ventricular Assist Device Era
Jaimin R Trivedi1, Keshava Rajagopal2, Erin M Schumer1
1Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky.
Insights
Continuous flow left ventricular assist device (CFLVAD) patients transplanted on 30-day grace status 1A had similar survival to status 1B. Prioritizing CFLVAD complications and non-CFLVAD patients may improve heart transplant outcomes.
Area of Science:
- Cardiology
- Transplantation Medicine
- Medical Devices
Background:
- Heart transplantation is limited by donor organ shortage.
- Continuous flow left ventricular assist devices (CFLVADs) are increasingly used.
- Changes in CFLVAD use impact heart transplant waiting lists and organ allocation.
Purpose of the Study:
- Evaluate the impact of reasons for UNOS status 1A on post-transplant survival in CFLVAD patients.
- Analyze survival differences based on status 1A criteria for CFLVAD recipients.
- Inform organ allocation strategies for heart transplant candidates.
Main Methods:
- Utilized the UNOS thoracic organ transplantation database (2006-2013).
- Identified heart transplant recipients aged 18+ with UNOS status 1A.
- Assessed reasons for status 1A in CFLVAD patients and computed post-transplant survival.
Main Results:
- 15,779 heart transplants occurred; 8,429 were status 1A, with 3,913 having CFLVAD.
- Among status 1A CFLVAD patients, 52% had device complications, 48% were on 30-day grace.
- Three-year survival: 30-day grace 1A (84%) and status 1B (85%) similar; both better than device complications (78%).
Conclusions:
- CFLVAD patients transplanted on 30-day grace status 1A or status 1B show comparable survival.
- Suggests a need for objective organ allocation prioritizing CFVAD complications and non-CFVAD patients.
- Current allocation may not adequately prioritize critically ill CFLVAD patients over those on grace periods.
Background:
Heart transplantation remains the gold standard therapy for end-stage heart failure patients; however, volumes are limited because of donor organ shortage. With the increasing availability of more durable continuous flow left ventricular assist devices (CFLVADs), the matrix of the heart transplantation waiting list and that of donor allocation have seen substantial changes. We aimed to evaluate the impact of the stated reasons for status 1A at time of transplantation on post-transplantation survival in CFVAD patients.
Methods:
The United Network of Organ Sharing (UNOS) thoracic organ transplantation database was queried between 2006 and 2013 to identify patients aged 18 years or older who underwent heart transplantation as UNOS status 1A. We further assessed the data to identify reasons for status 1A at time of transplantation in CFVAD patients. We also computed post-transplantation survival of patients supported with CFLVAD who were status 1A at the time of transplantation.
Results:
A total of 15,779 patients underwent heart transplantation during the study time period, of whom 8,429 were Status 1A, and 3,913 had CFLVAD at time of transplantation. Of all status 1A patients, 2,737 had CFLVAD at time of transplantation, of which 52% (1,413) had device complications (thrombosis, infection, malfunction, and other) and 48% (1,314) were on 30-day grace status 1A. Post-transplantation survival (at 3 years) of CFLVAD patients who received a transplant on 30-day grace status 1A was similar to patients who underwent transplantation on status 1B (84% versus 85%, p = 0.5), both of which were significantly better than status 1A patients because of device complications (84% and 85% versus 78%, p = 0.01) (Fig 1).
Conclusions:
CFLVAD patients who underwent transplantation as Status 1B or on the 30-day grace Status 1A have similar post-transplantation survival. These data suggest that there needs to be an objective organ allocation system for recipients of heart transplant that prioritize patients with CFVAD complications and patients not eligible for CFVAD for transplantation over 30-day grace period patients.
