Changes in Donor Utilization and Outcomes for Patients Bridged With Durable Left Ventricular Assist Device

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Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock
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Armaan F Akbar1, Dianela Perdomo2, Benjamin L Shou1

  • 1From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.

ASAIO Journal (American Society for Artificial Internal Organs : 1992)
|May 10, 2024
PubMed

Insights

The 2018 heart allocation policy change increased mortality for left ventricular assist device (LVAD)-bridged heart transplant (HT) recipients. Patients with higher priority status (1 or 2) faced greater 1-year mortality risks post-policy implementation.

Area of Science:

  • Cardiology
  • Transplantation Medicine
  • Health Policy

Background:

  • The 2018 organ allocation policy revision aimed to optimize heart transplant (HT) distribution.
  • Left ventricular assist devices (LVADs) are crucial mechanical circulatory support for advanced heart failure patients awaiting HT.
  • Understanding the policy's impact on LVAD-bridged HT recipients is vital for patient management and outcomes.

Purpose of the Study:

  • To evaluate the effect of the 2018 heart allocation policy change on donor characteristics.
  • To assess posttransplant outcomes for left ventricular assist device-bridged heart transplant recipients.
  • To analyze outcomes in subgroups of unstable and stable LVAD-bridged recipients.

Main Methods:

  • Retrospective analysis of 7,384 adult LVAD-bridged HT recipients from the United Network for Organ Sharing database (October 2014-October 2022).
  • Categorization into pre-policy (Old Allocation Policy - OAP) and post-policy (New Allocation Policy - NAP) cohorts.
  • Comparison of baseline characteristics, donor factors, and posttransplant survival rates using multivariable analysis.

Main Results:

  • The NAP cohort (41.2%) showed a shift towards lower priority statuses (3 and 4) compared to the OAP cohort (58.8%, predominantly status 1A).
  • NAP recipients had a higher median donor sequence number (9 vs. 3, p < 0.001).
  • NAP recipients experienced a 20% higher 1-year mortality (aHR=1.20, p=0.01), and status 1 or 2 recipients had 28% higher 1-year mortality (aHR=1.28, p=0.04) compared to OAP and status 1A, respectively.

Conclusions:

  • The 2018 allocation policy change was associated with increased 1-year mortality among LVAD-bridged HT recipients, particularly those with higher acuity statuses (1 and 2).
  • The findings suggest a potential disadvantage for sicker LVAD-supported patients under the new policy, necessitating careful monitoring for waitlist decompensation.
  • Enhanced surveillance and potential policy adjustments may be needed to ensure equitable outcomes for LVAD-bridged HT candidates.

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