Characterizing Survival for Patients Supported With Inotropes After the 2018 Donor Allocation Restructuring: A UNOS...

We sought to characterize adaptive changes to the revised UNOS donor heart allocation policy in 2018 and estimate long-term survival trends for heart transplant (HTx) recipients with respect to inotropic support.

Patients listed for HTx between July 18, 2014, and July 18, 2016 (prepolicy revision) and between October 18, 2018, and October 18, 2020 (postpolicy revision) were identified from the UNOS database. Sub-analyses examined trends in device progression where patients listed on inotropes were later transplanted on inotropes and/or on extracorporeal membranous oxygenator (ECMO), durable left ventricular assist device (LVAD), temporary mechanical circulatory support (tMCS), or intra-aortic balloon pump (IABP). Survival data post-HTx were calculated and plotted.

Overall, 3,189 patients were waitlisted (pre: 1,408; post: 1,781). Patient demographics differed only by cardiac output, mean PCWP, cigarette use, ventilatory support, and time on the waitlist. Policy revisions were associated with an increase in patients transplanted while supported with IABP (p < 0.01), tMCS (p < 0.01), and ECMO (p < 0.01). In contrast, postpolicy, fewer patients were transplanted while on inotropes (p < 0.01) or an LVAD (p < 0.01), and 57.4% patients progressed from inotropes to another form of support (27.4% prepolicy, p < 0.01). Additionally, waitlisted patients in the postpolicy period were more likely to be transplanted (pre: 78.9% vs. post: 89.8%, p < 0.01) and more likely to survive (mortality, pre: 26.9% vs. post: 19.1, p < 0.01).

Allocation policy revisions have contributed to increased utilization of temporary support (ECMO, tMCS, and IABP) and decreased utilization of others such as durable LVADs. Additionally, revisions have led to improved survival and increased transplantation for patients waitlisted on inotropes, yet similar survival for each individual form of temporary support.