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Heart transplant waiting list implications of increased ventricular assist device use as a bridge strategy: A
Jason J Han1, Hadi Elzayn2, Matthew M Duda3
1Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
Insights
Ventricular assist devices (VADs) as a bridge to heart transplant (HT) increased, leading to longer waits and more competition. VAD use showed decreased transplant rates but stable survival, highlighting the need for VAD improvements.
Area of Science:
- Cardiology
- Transplant Surgery
- Medical Devices
Background:
- The increasing use of ventricular assist devices (VADs) as a bridge to heart transplant (HT) contrasts with stagnant HT volumes.
- This trend may lead to extended waiting times and a more competitive landscape for heart transplant candidates.
Purpose of the Study:
- To analyze trends in heart transplant waiting times, transplant rates, and patient outcomes.
- To evaluate the impact of VADs as a bridge strategy on the heart transplant waiting list over time.
Main Methods:
- Retrospective analysis of patients listed for HT in the United Network for Organ Sharing (UNOS) database from 2000 to 2015.
- Calculation of mean waiting time, proportion of HT reception, death, and waiting list removal across three distinct eras.
- Comparison of outcomes for directly transplanted patients versus those receiving VADs (bridge to decision or bridge to transplant).
Main Results:
- Average number of annual registrants increased across the study period.
- Mean waiting time for HT increased from 2000 to 2015 for all patient groups.
- Patients using VADs as a bridge strategy experienced a decrease in the proportion of heart transplants received and an increase in waiting list removal, despite stable survival rates.
Conclusions:
- Waiting times for heart transplantation have significantly increased between 2000 and 2015.
- While VADs offer stable survival, their use as a bridge strategy is associated with reduced transplant rates and increased waiting list removals.
- Improvements in VAD safety and durability are crucial for their continued success under evolving organ allocation policies.
Abstract:
The use of ventricular assist devices (VADs) as a bridge to heart transplant (HT) is increasing, while HT volume remains stagnant. This may portend longer waiting times and an otherwise more competitive environment for all patients on the HT waiting list. A retrospective analysis of patients who were listed for HT in the United Network for Organ Sharing (UNOS) database from 2000 to 2015 was conducted. Mean waiting time, proportion of HT reception (%HT), proportion of death (%death), and proportion of waiting list removal (%removal) were calculated across three eras: Era 1 (2000-2007), Era 2 (2008-2011), and Era 3 (2012-2015). During the study period, 29 728 patients successfully underwent HT. 19 127 (64.3%) were directly transplanted (direct HT); 4491 (15.1%) received VADs prior to listing as a bridge to decision (BTD); and 4593 (15.5%) received VADs after listing as a bridge to transplant (BTT). Across the three eras, the average number of registrants per year grew. Among all groups, waiting time increased across the eras. %HT generally decreased in the BTD and BTT groups but remained constant in the direct HT group. %removal increased, while %death decreased in all group across the eras. Waiting time for HT increased from 2000 to 2015. Patients with VADs as a bridge strategy experienced decreasing %HT and increasing %removal but stable survival. Improvements in VAD safety and durability will ensure their success as part of a bridge strategy to HT under the new UNOS allocation policy.
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