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Characterizing Adaptive Changes and Patient Survival After 2018 Donor Allocation Restructuring: A UNOS Database

Takuma Miyamoto1, Christopher David Pritting1, Rob Tatum2

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The revised heart transplant allocation policy increased use of ECMO, Impella, and IABP, while decreasing LVAD and non-MCS device use. Waitlist survival improved, but long-term post-heart transplant survival declined.

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Area of Science:

  • Cardiology
  • Transplantation Medicine
  • Health Policy

Background:

  • The United Network for Organ Sharing (UNOS) revised its heart donor allocation policy to optimize organ distribution.
  • Understanding the impact of policy changes on patient management and outcomes is crucial for improving heart transplant (HTx) programs.

Purpose of the Study:

  • To analyze adaptive changes in mechanical circulatory support (MCS) device utilization following the UNOS policy revision.
  • To estimate long-term survival trends for heart transplant recipients before and after the policy change.

Main Methods:

  • Retrospective analysis of 27,523 patients listed for HTx from October 2013 to September 2021 using the UNOS database.
  • Stratification into pre- and post-policy revision groups, with subanalyses of device utilization (ECMO, LVAD, IABP, Impella, non-MCS).
  • Parametric modeling of post-HTx survival data extrapolated to 5 years.

Main Results:

  • Listings and HTx increased for ECMO, Impella, and IABP, while decreasing for LVAD and non-MCS post-policy change.
  • Waitlist survival improved overall and for ECMO, IABP, and non-MCS groups, but not significantly for LVAD or Impella groups.
  • Post-transplant survival decreased for the overall, LVAD, and non-MCS populations.

Conclusions:

  • The UNOS policy revision led to increased use of short-term support devices (ECMO, Impella, IABP) and decreased use of durable LVADs and non-MCS.
  • While waitlist survival improved, the policy change was associated with a decline in long-term post-heart transplant survival.