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Multicenter Study
. 2020 Nov 1;5(11):1227-1235.
doi: 10.1001/jamacardio.2020.2795.

Survival on the Heart Transplant Waiting List

Syed Shahyan Bakhtiyar  1 , Elizabeth L Godfrey  1 , Shayan Ahmed  2 , Harveen Lamba  3 , Jeffrey Morgan  3 , Gabriel Loor  3 , Andrew Civitello  3 , Faisal H Cheema  4 , Whitson B Etheridge  1 , John Goss  1 , Abbas Rana  1
Affiliations
Multicenter Study

Survival on the Heart Transplant Waiting List

Syed Shahyan Bakhtiyar et al. JAMA Cardiol. .

Abstract

Importance: With continuing improvements in medical devices and more than a decade since the 2006 United Network for Organ Sharing (UNOS) allocation policy, it is pertinent to assess survival among patients on the heart transplantation waiting list, especially given the recently approved 2018 UNOS allocation policy.

Objectives: To assess survival outcomes among patients on the heart transplant waiting list during the past 3 decades and to examine the association of ventricular assist devices (VADs) and the 2006 UNOS allocation policy with survival.

Design, setting, and participants: A retrospective cross-sectional used the UNOS database to perform an analysis of 95 323 candidates wait-listed for heart transplantation between January 1, 1987, and December 29, 2017. Candidates for all types of combined transplants were excluded (n = 2087). Patients were followed up from the time of listing to death, transplantation, or removal from the list due to clinical improvement. Competing-risk, Kaplan-Meier, and multivariable Cox proportional hazards regression analyses were used.

Main outcomes and measures: The analysis involved an unadjusted and adjusted survival analysis in which the primary outcome was death on the waiting list. Because of changing waiting list preferences and policies during the study period, the intrinsic risk of death for wait-listed candidates was assessed by individually analyzing, comparing, and adjusting for several candidate risk factors.

Results: In total, 95 323 candidates (72 915 men [76.5%]; mean [SD] age, 51.9 [12.0] years) were studied. In the setting of changes in listing preferences, 1-year survival on the waiting list increased from 34.1% in 1987-1990 to 67.8% in 2011-2017 (difference in proportions, 0.34%; 95% CI, 0.32%-0.36%; P < .001). The 1-year waiting list survival for candidates with VADs increased from 10.2% in 1996-2000 to 70.0% in 2011-2017 (difference in proportions, 0.60%; 95% CI, 0.58%-0.62%; P < .001). Similarly, in the setting of changing mechanical circulatory support indications, the 1-year waiting list survival for patients without VADs increased from 53.9% in 1996-2000 to 66.5% in 2011-2017 (difference in proportions, 0.13%; 95% CI, 0.12%-0.14%; P < .001). In the decade prior to the 2006 UNOS allocation policy, the 1-year waiting list survival was 51.1%, while in the decade after it was 63.9% (difference in proportions, 0.13%; 95% CI, 0.12%-0.14%; P < .001). In adjusted analysis, each time period after 1987-1990 had a marked decrease in waiting list mortality.

Conclusions and relevance: This study found temporally associated increases in heart transplant waiting list survival for all patient groups (with or without VADs, UNOS status 1 and status 2 candidates, and candidates with poor functional status).

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Loor reported receiving grants from TransMedics and JLH Foundation outside the submitted work and additionally discloses grant support from St Jude and Medtronic to his research institutions (University of Minnesota and Baylor College of Medicine) for participation in clinical trials related to left ventricular assist device therapies outside of the present study. He also discloses grant support to the same research institutions from Maquet and United Therapeutics for participation in clinical registries and translational studies pertaining to lung transplantation and lung failure support therapies, and travel and housing reimbursement from the Abiomed Breethe advisory board. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Estimated Cumulative Incidence of Mortality on the Waiting List and Waiting List Survival
A, Fine and Gray analysis. Competing outcomes were removed from the list for transplantation or clinical improvement. B, Cox proportional hazards regression analysis. Competing outcomes were removed from the list for transplantation or clinical improvement. C, Waiting list survival by eras for candidates still on the waiting list. D, Waiting list survival by eras for candidates who received a transplant. P < .001 for each group compared with the 1987-1990 era by log-rank test.
Figure 2.
Figure 2.. Waiting List Survival for Candidates by Ventricular Assist Device (VAD) and United Network for Organ Sharing (UNOS) Status
A, Candidates with VADs. B, Candidates without VADs. C, UNOS status 1 candidates. D, UNOS status 2 candidates. P < .001 for each group compared with reference era.
See this image and copyright information in PMC

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