Organ allocation in adults with congenital heart disease listed for heart transplant: impact of ventricular assist devices

Abstract

Background: Adults with congenital heart disease (CHD) listed for heart transplantation are rarely supported by ventricular assist devices (VADs). This may be a disadvantage to their priority for organ allocation. We sought to determine the relationship between VAD implantation and successful transplantation among patients listed for heart transplant.

Methods: Adults with CHD patients (N = 1,250) were identified from the United Network for Organ Sharing (UNOS) database from 1985 to 2010 and compared to patients without congenital etiology for heart failure (N = 59,606). VAD use at listing, listing status, status upgrades and reasons for upgrade prior to transplant were trended at 5-year intervals and appropriate statistical comparisons were made between groups.

Results: Since 1985, VAD use prior to transplant has increased significantly in patients without CHD, but not in CHD patients (17% vs 3% in 2006 to 2010, p < 0.0001). CHD patients were more likely to be listed as Status 2, compared to those without (66% vs 40%, p < 0.001 for 2006 to 2010), and less likely to be upgraded to Status 1 after listing (43% vs 55%, p = 0.03). Among those upgraded to Status 1, CHD patients were less likely to have a VAD at transplant than those without (3% vs 18%, p = 0.005). VAD use was more likely to result in death in CHD patients.

Conclusions: VAD use is less common in CHD patients than in patients without CHD, both at the time of listing and transplantation. Reduced VAD use appears to contribute to lower listing status and organ allocation. These differences have grown more disparate over time. Separate criteria for organ allocation for CHD patients may be justified.

Keywords: congenital; heart defects; heart failure; heart transplantation; transplant organ allocation; ventricular assist device.

Figure 1

Percentage of patients from each group listed in status 2 for both groups as a function of era. CHD = congenital heart disease. Controls are adult patients without CHD.

Figure 2

Percentage of patients from each group transplanted from status 2 as a function of era. CHD = congenital heart disease, control are those without CHD. P values are for comparison between eras for both patient groups.

Figure 3

Percentage of patients with implanted ventricular assist devices at listing and transplant for both congenital heart patients (CHD) and those without (controls), shown by era. P values are for comparison between patient groups for VAD use at transplant.

Figure 4

Percentage of patients from either group who were upgraded from status 2 at listing to status 1 at time of organ offering as a function of era. CHD = congenital heart disease.

Figure 5

Percentage of patients upgraded from status 2 with interval requirement of inotropic support. CHD = congenital heart disease.

Figure 6

Percentage of patients upgraded from status 2 with interval ventricular assist device implant (C). CHD = congenital heart disease.