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Waitlist Outcomes in Candidates With Rare Causes of Heart Failure After Implementation of the 2018 French Heart
Camille Legeai1, Guillaume Coutance2,3, Christelle Cantrelle1
1Agence de la Biomédecine, Saint Denis La Plaine Cedex, France (C.L., C.C., C.J., F.K., R.D.).
Insights
The new French heart transplant (HT) allocation system ensures fair outcomes for patients with rare heart failure causes. Waitlist mortality and HT access remain similar across different heart failure etiologies.
Area of Science:
- Cardiology
- Transplantation Medicine
- Public Health Policy
Background:
- France implemented an algorithm-based heart transplantation (HT) allocation system in 2018.
- The impact of this system on patients with rare causes of heart failure (HF) remained unassessed.
Purpose of the Study:
- To evaluate the effect of the new French HT allocation system on waitlist and posttransplant outcomes.
- To compare outcomes for patients with rare HF causes (restrictive cardiomyopathy, hypertrophic cardiomyopathy, congenital heart disease) versus other cardiomyopathies.
Main Methods:
- National study of adult HT candidates listed between 2018-2020.
- Analysis of waitlist mortality, delisting for clinical deterioration, and HT access.
- Used competing risk analysis and Cox models to compare outcomes between diagnosis groups.
Main Results:
- 1604 candidates were analyzed; 1040 received HT within a year.
- Candidates with rare HF causes had more frequent score exceptions.
- Waitlist mortality and HT access were similar between rare and common HF groups (P > 0.14).
- Restrictive cardiomyopathy was linked to increased 1-year posttransplant mortality (HR 2.12, P=0.03).
Conclusions:
- The French allocation scheme provides equitable waitlist outcomes for HT candidates, irrespective of HF cause.
- The system appears to ensure fair access to heart transplantation for patients with rare heart conditions.
Background:
In 2018, an algorithm-based allocation system for heart transplantation (HT) was implemented in France. Its effect on access to HT of patients with rare causes of heart failure (HF) has not been assessed.
Methods:
In this national study, including adults listed for HT between 2018 and 2020, we analyzed waitlist and posttransplant outcomes of candidates with rare causes of HF (restrictive cardiomyopathy [RCM], hypertrophic cardiomyopathy, and congenital heart disease). The primary end point was death on the waitlist or delisting for clinical deterioration. Secondary end points included access to HT and posttransplant mortality. The cumulative incidence of waitlist mortality estimated with competing risk analysis and incidence of transplantation were compared between diagnosis groups. The association of HF cause with outcomes was determined by Fine-Gray or Cox models.
Results:
Overall, 1604 candidates were listed for HT. At 1 year postlisting, 175 patients met the primary end point and 1040 underwent HT. Candidates listed for rare causes of HF significantly differed in baseline characteristics and had more frequent score exceptions compared with other cardiomyopathies (31.3%, 32.0%, 36.4%, and 16.7% for patients with hypertrophic cardiomyopathy, RCM, congenital heart disease, and other cardiomyopathies). The cumulative incidence of death on the waitlist and probability of HT were similar between diagnosis groups (P=0.17 and 0.40, respectively). The adjusted risk of death or delisting for clinical deterioration did not significantly differ between candidates with rare and common causes of HF (subdistribution hazard ratio (HR): hypertrophic cardiomyopathy, 0.51 [95% CI, 0.19-1.38]; P=0.18; RCM, 1.04 [95% CI, 0.42-2.58]; P=0.94; congenital heart disease, 1.82 [95% CI, 0.78-4.26]; P=0.17). Similarly, the access to HT did not significantly differ between causes of HF (hypertrophic cardiomyopathy: HR, 1.18 [95% CI, 0.92-1.51]; P=0.19; RCM: HR, 1.19 [95% CI, 0.90-1.58]; P=0.23; congenital heart disease: HR, 0.76 [95% CI, 0.53-1.09]; P=0.14). RCM was an independent risk factor for 1-year posttransplant mortality (HR, 2.12 [95% CI, 1.06-4.24]; P=0.03).
Conclusions:
Our study shows equitable waitlist outcomes among HT candidates whatever the indication for transplantation with the new French allocation scheme.
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