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Updated: Aug 12, 2025
Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock
Published on: June 12, 2021
Racial disparity exists in the utilization and post-transplant survival benefit of ventricular assist device support
Jason W Greenberg1, Roosevelt Bryant2, Chet Villa1
1The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Insights
Minority children receive more ventricular assist devices (VADs) for heart transplantation (HTx), but experience worse long-term survival. Despite equitable VAD use, racial disparities persist in pediatric heart transplant outcomes.
Area of Science:
- Pediatric Cardiology
- Transplantation Medicine
- Health Disparities
Background:
- Children from minority racial and ethnic groups often face inferior outcomes following heart transplantation (HTx).
- Ventricular assist device (VAD) bridge-to-transplant (BTT) therapy has shown comparable or superior post-transplant survival (PTS) compared to no mechanical circulatory support.
- Existing research has not clarified whether racial and ethnic disparities influence VAD utilization and subsequent outcomes in pediatric HTx.
Purpose of the Study:
- To investigate racial and ethnic disparities in ventricular assist device (VAD) utilization among children awaiting heart transplantation (HTx).
- To compare post-transplant survival (PTS) and outcomes between different racial and ethnic groups of pediatric patients bridged to HTx with a VAD.
- To determine if race and ethnicity are independent predictors of mortality in children undergoing VAD BTT for HTx.
Main Methods:
- Utilized the United Network for Organ Sharing (UNOS) database to identify 6,121 children (<18 years) listed for HTx between 2006 and 2021.
- Compared VAD utilization, clinical status at listing, and post-transplant outcomes (including survival) across racial/ethnic groups: Black (B), Hispanic (H), and White (W).
- Employed multivariable Cox proportional analyses to assess the association of race and ethnicity with PTS in VAD BTT patients.
Main Results:
- Black children presented with greater illness severity at listing, including higher proportions of UNOS status 1A/1, severe functional limitation, and inotrope requirements.
- VAD utilization at listing and transplant was significantly higher in Black children compared to Hispanic and White children.
- While early post-VAD outcomes and one-year PTS were equivalent, long-term PTS was significantly worse for non-White children (Black and Hispanic) compared to White children.
Conclusions:
- Pediatric VAD use appears equitable, with the sickest patients receiving these devices.
- Despite similar pre-transplant status and early post-transplant benefits, non-White children exhibit inferior long-term post-transplant survival after VAD bridge-to-transplant.
- Racial and ethnic disparities continue to impact long-term outcomes in pediatric heart transplantation, even with VAD support.
Purpose:
Children of minority race and ethnicity experience inferior outcomes postheart transplantation (HTx). Studies have associated ventricular assist device (VAD) bridge-to-transplant (BTT) with similar-to-superior post-transplant-survival (PTS) compared to no mechanical circulatory support. It is unclear whether racial and ethnic discrepancies exist in VAD utilization and outcomes.
Methods:
The United Network for Organ Sharing (UNOS) database was used to identify 6,121 children (<18 years) listed for HTx between 2006 and 2021: black (B-22% of cohort), Hispanic (H-21%), and white (W-57%). VAD utilization, outcomes, and PTS were compared between race/ethnicity groups. Multivariable Cox proportional analyses were used to study the association of race and ethnicity on PTS with VAD BTT, using backward selection for covariates.
Results:
Black children were most ill at listing, with greater proportions of UNOS status 1A/1 (p < 0.001 vs H & W), severe functional limitation (p < 0.001 vs H & W), and greater inotrope requirements (p < 0.05 vs H). Non-white children had higher proportions of public insurance. VAD utilization at listing was: B-11%, H-8%, W-8% (p = 0.001 for B vs H & W). VAD at transplant was: B-24%, H-21%, W-19% (p = 0.001 for B vs H). At transplant, all VAD patients had comparable clinical status (functional limitation, renal/hepatic dysfunction, inotropes, mechanical ventilation; all p > 0.05 between groups). Following VAD, hospital outcomes and one-year PTS were equivalent but long-term PTS was significantly worse among non-whites-(p < 0.01 for W vs B & H). On multivariable analysis, black race independently predicted mortality (hazard ratio 1.67 [95% confidence interval 1.22-2.28]) while white race was protective (0.54 [0.40-0.74]).
Conclusions:
Pediatric VAD use is, seemingly, equitable; the most ill patients receive the most VADs. Despite similar pretransplant and early post-transplant benefits, non-white children experience inferior overall PTS after VAD BTT.
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