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Progression to Transplant Under the New Heart Allocation System: The Society of Thoracic Surgeons Intermacs Database
Leora T Yarboro1, J Hunter Mehaffey1, Ryan Cantor2
1Division of Cardiac Surgery, University of Virginia, Charlottesville, Virginia.
Insights
New heart transplant policies lower priority for durable left ventricular assist device patients. Successful transplant predictors include bridge-to-transplant status, while blood type O is a negative predictor. Heart teams must consider longer wait times.
Area of Science:
- Cardiology
- Transplantation Medicine
- Medical Device Technology
Background:
- The current heart allocation policy deprioritizes patients requiring durable left ventricular assist devices (LVADs).
- Understanding predictors of successful heart transplantation post-LVAD implantation is crucial for optimizing patient care under the new policy.
Purpose of the Study:
- To identify factors predicting successful heart transplant in patients with durable LVADs.
- To inform clinical decision-making regarding bridging strategies in the current era of heart allocation.
Main Methods:
- Analysis of 25,164 patients with primary durable LVAD implant from The Society of Thoracic Surgeons Intermacs database (2010-2019).
- Evaluation of patients designated as bridge-to-transplant (BTT) or bridge-to-candidacy.
- Comparison of transplant rates before and after the October 18, 2018, allocation system change using multivariable hazard modeling.
Main Results:
- Overall, 45.5% of patients progressed to transplant, with BTT patients having a higher rate (53.0%).
- Progression to transplant significantly decreased under the new allocation system (18.6% vs. 34.8% at 14 months).
- Bridge-to-transplant status remained a positive predictor (HR 1.79), while blood type O was a negative predictor (HR 0.43) under the new policy.
Conclusions:
- Less than half of LVAD patients progressed to transplant even with previous priority.
- The current allocation system further reduces transplant progression rates for LVAD patients.
- Heart teams must carefully consider extended wait times and optimal bridging strategies for LVAD recipients.
Background:
Under the new heart allocation policy patients needing durable left ventricular assist devices receive lower priority on the transplant list. We sought to identify predictors of successful heart transplant after durable device implant as a means to inform patient care in the current era.
Methods:
All patients (N = 25,164) undergoing primary durable left ventricular device implant in The Society of Thoracic Surgeons Intermacs database (2010-2019) were evaluated. Patients identified as bridge to transplant (BTT; n = 5242) or bridge to candidacy (n = 6248) were analyzed with the endpoint of transplant before (n = 10,588) and after (n = 902) the change in the heart allocation system on October 18, 2018. Multivariable hazard modeling was used to assess risk-adjusted time to event associations.
Results:
Of 11,490 patients, 45.5% progressed to transplant (BTT, 53.0%; bridge to candidacy, 36.6%), most by 14 months after left ventricular assist device implant. Under the new allocation system progression to transplant was significantly lower at 14 months (18.6% vs 34.8%, P < .001). Factors associated with successful BTT before the allocation change included BTT status, white race, and married. Under the new allocation system BTT status (hazard ratio, 1.79; 95% confidence interval, 1.19-2.69; P < .0054) remained a positive predictor, whereas blood type O (hazard ratio, 0.43; 95% confidence interval, 0.28-0.65; P < .0001) remained a negative predictor.
Conclusions:
Despite having priority in the previous allocation system, less than half of BTT and bridge to candidacy patients progressed to transplant. Under the current system these numbers are further reduced. Heart teams should consider the implications of longer wait times for a durable left ventricular assist device when determining the optimal bridging strategy.
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