Effect of Pediatric Heart Transplant Waitlist Inactivation on Waitlist and Posttransplant Outcomes

Little is known about pediatric heart transplant candidates facing waitlist inactivation. We characterized them and assessed the impact of inactivation on waitlist and transplant outcomes.

The Organ Procurement and Transplantation Network database was queried for pediatric heart-only transplant candidates. Characteristics, waitlist mortality, and 1-year posttransplant survival between inactivated and non-inactivated patients were compared. Predicted probability for the composite outcome of waitlist mortality or removal due to clinical deterioration over time was computed.

Of 5202 patients, 1716 (33%) were inactivated, mostly due to temporary illness (58%). Reasons for inactivation varied by age but not diagnosis. Inactivated patients had longer waitlist duration (171 [77-391] vs. 62 [21-144], p < 0.001), more congenital heart disease (61.0% vs. 55.2%, p < 0.001), and were more often supported by ventricular assist device (47.9% vs. 32.9%, p < 0.001) and invasive ventilation at listing (19.9% vs. 13.6%, p < 0.001). Inactivated patients were less likely listed Status 1A (56.8% vs. 62.3%, p < 0.001) and less likely under intensive care at transplant (43.9% vs. 50.2%, p < 0.001). Inactivated patients had higher 1-year waitlist mortality and removal due to clinical deterioration (SHR 4.40 [3.72-5.20], p < 0.001), though this risk decreased with longer inactive time. One-year posttransplant survival was similar between groups.

Waitlist inactivation was strongly associated with 1-year waitlist mortality and removal due to clinical deterioration. However, this risk decreased with longer inactive time and made no difference in short-term posttransplant survival. Thus, the prognostic implications of inactivation are dynamic and can inform future donor allocation policy development.