Waitlist mortality for patients with cardiac allograft vasculopathy under the 2018 OPTN donor heart allocation system

Area of Science:

• Cardiology
• Transplantation Immunology
• Health Services Research

Background:

• The 2018 Organ Procurement and Transplantation Network (OPTN) donor heart allocation system assigns re-transplantation candidates with cardiac allograft vasculopathy (CAV) to Status 4.
• Patients with CAV are typically listed at Status 4 unless they meet specific hemodynamic criteria.

Purpose of the Study:

• To investigate the waitlist mortality outcomes for adult heart transplant candidates diagnosed with cardiac allograft vasculopathy (CAV).
• To evaluate if the current OPTN allocation system adequately prioritizes patients with CAV.

Main Methods:

• Analysis of waitlist mortality using data from the Scientific Registry of Transplant Recipients (SRTR) between October 1, 2018, and November 1, 2023.
• Kaplan-Meier curves and doubly-robust Cox regressions were employed to analyze waitlist mortality, adjusting for demographic and clinical factors.
• Comparison of CAV patients versus non-CAV patients based on initial and time-dependent waitlist statuses.

Main Results:

• Out of 21,586 listed patients, 368 had CAV. CAV patients were disproportionately listed at Status 4.
• CAV patients at Status 4 and 3 showed higher waitlist mortality compared to non-CAV patients.
• When considering patients ever listed at Status 4 and 3, CAV patients had a significantly higher probability of death (HR 1.99 for Status 4, HR 3.06 for Status 3).

Conclusions:

• Cardiac allograft vasculopathy (CAV) patients exhibit an increased risk of waitlist mortality at Status 4 and 3 under the post-2018 allocation system.
• The findings indicate potential underprioritization of CAV patients within the current heart transplant organ allocation framework.
• Re-evaluation of allocation criteria may be necessary to ensure equitable access to heart transplantation for CAV patients.