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Published on: February 14, 2022
Heart Retransplantation Under the 2018 Adult Heart Allocation Policy
Samuel T Kim1, Amit Iyengar2, Mark R Helmers2
1David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
Insights
The 2018 heart transplant policy improved waiting list outcomes for repeat heart transplant candidates. Post-transplant survival remained stable, indicating a positive impact of the policy change on heart retransplantation.
Area of Science:
- Cardiology
- Transplantation Medicine
- Health Policy
Background:
- The 2018 adult heart allocation policy in the United States aimed to optimize organ distribution.
- Heart retransplantation is a critical option for patients with graft failure.
- Understanding the policy's impact on retransplantation outcomes is essential for patient management.
Purpose of the Study:
- To evaluate the effect of the 2018 adult heart allocation policy change on heart retransplantation.
- To analyze changes in waiting list and posttransplant outcomes for retransplant candidates.
- To compare outcomes before and after the policy implementation.
Main Methods:
- Utilized the United Network for Organ Sharing database for adult heart retransplantation cases from May 2015 to June 2022.
- Stratified patients into two eras based on the October 18, 2018 policy change.
- Employed competing risks regressions and Cox proportional hazards models to assess outcomes.
Main Results:
- Patients in the post-policy era (era 2) were more likely to receive mechanical circulatory support (ECMO, IABP) before retransplantation.
- The likelihood of death or deterioration on the waiting list decreased significantly in era 2.
- No significant differences were observed in 30-day mortality or 1-year survival rates between the two eras.
Conclusions:
- The 2018 policy change led to improved waiting list outcomes for heart retransplantation candidates.
- Posttransplant survival rates for retransplant recipients did not significantly change after the policy update.
- The policy appears to benefit patients awaiting retransplantation without negatively impacting short-term survival post-procedure.
Background:
The purpose of the present study was to characterize the impact of the 2018 adult heart allocation policy change on waiting list and posttransplant outcomes of heart retransplantation in the United States.
Methods:
All adults listed for heart retransplantation from May 2015 to June 2022 were identified using the United Network for Organ Sharing database. Patients were stratified into eras (era 1 and era 2) based on the heart allocation change on October 18, 2018. Competing risks regressions and Cox proportional hazards models were used to assess differences across eras in waiting list outcomes and 1-year posttransplant survival, respectively.
Results:
The analysis included 356 repeat heart transplant recipients, with 207 (58%) receiving retransplantation during era 2. Patients who received a retransplant in era 2 were more commonly bridged with extracorporeal membrane oxygenation (21% vs 8%, P < .01) and intra-aortic balloon pump (29% vs 13%, P < .001) and had a lower likelihood of death/deterioration on the waiting list (subdistribution hazard ratio, 0.52; 95% CI, 0.33-0.82) compared with those in era 1. Rates of 30-day mortality (7% vs 7%, P = .99) and 1-year survival (82% vs 87%, P = .27) were not significantly different among retransplantation recipients across eras. After adjustment, retransplantation in era 2 was not associated with an increased hazard of mortality (adjusted hazard ratio, 1.13; 95% CI, 0.55-2.30). The gap in 1-year mortality between primary transplant and retransplant recipients increased from era 1 to 2.
Conclusions:
Heart retransplantation candidates have experienced improved waiting list outcomes after the 2018 adult heart allocation policy, without significant changes to posttransplant survival.
