Changes in heart transplant allocation policy benefit some on waitlist, not all
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Key takeaways:
- Heart transplant allocation policy changes in 2016 and 2018 improved waitlist outcomes for children born with heart defects but not adults.
- The changes benefited adults with cardiomyopathy but not children.
Recent changes to a heart transplant allocation policy improved waitlist outcomes for children born with heart defects and adults with cardiomyopathy, but not in children with cardiomyopathy or adults with heart defects, data show.
In 2016, the Organ Procurement and Transplantation Network modified the heart transplant allocation policy for pediatric patients, which decreased priority for children with cardiomyopathy on inotropic support and decreased overall status 1A listings, according to the study published in Circulation.
In 2018, the allocation policy was also modified for adults, with the three-tier status system being expanded to a six-tier system. Patients with durable left ventricular assist devices were deprioritized and patients with acute mechanical circulatory support maintained highest priority, according to the study.
As Healio previously reported, a study in the Journal of the American College of Cardiology showed that decades of improvement in pediatric heart transplant waitlist mortality occurred independently of the 2016 revisions to the United Network for Organ Sharing (UNOS) pediatric heart transplant allocation policy.
Luke Wooster, MD, resident physician at Children’s Hospital of Philadelphia, and colleagues conducted the present study to understand whether these changes may have impacted waitlist outcomes for children and adults.
“Both allocation policy changes aimed to maximize waitlist and posttransplant outcomes in a heterogenous population of children and adults with varied pathogeneses of heart failure and options for mechanical circulatory support,” the researchers wrote. “Given the growing population of patients with congenital heart disease and refractory advanced HF, as well as the continued evolution of temporary and durable mechanical circulatory support, addressing this knowledge gap is a critical step, both to evaluate the effectiveness of the recent allocation changes and to inform the next iteration of the allocation system.”
To evaluate the impact of allocation policy changes on heart transplant waitlist outcomes, Wooster and colleagues pulled data from the UNOS database and identified 11,637 pediatric and adult patients with a congenital heart disease or cardiomyopathy listed for transplantation.
Patients were grouped based on when they were waitlisted for heart transplantation: pediatric patients from Jan. 1, 2011, to March 21, 2016 (pre-allocation change), and Jan. 1, 2017, to Dec. 31, 2021 (post-allocation change); and adult patients from Jan. 1, 2015, to Oct. 17, 2018 (pre-allocation change), and Jan. 1, 2019, to Dec. 31, 2021 (post-allocation change).
Who benefited from transplant allocation changes
After adjusting for demographic and clinical factors, the pediatric allocation changes were associated with lower risk for death or waitlist removal within 1 year of heart transplant listing among infants and children with congenital heart disease (HR for infants = 0.75; 95% CI, 0.57-0.99; P = .04; HR for children = 0.61; 95% CI, 0.43-0.86; P = .005), according to the study.
In a similarly adjusted analysis, the adult allocation changes were also associated with lower risk for death or waitlist removal within 1 year of heart transplant listing among adults with cardiomyopathy (HR = 0.6; 95% CI, 0.44-0.81; P = .001).
Who did not benefit from allocation changes
The pediatric allocation changes did not significantly change risk for 1-year pretransplant death for infants and children with cardiomyopathy (HR for infants = 1.02; 95% CI, 0.6-1.71; P = .96; HR for children = 0.84; 95% CI, 0.51-1.37; P = .49); nor did allocation changes improve waitlist outcomes among adults with congenital heart disease (HR = 0.61; 95% CI, 0.29-1.31; P = .21).
“After the recent Organ Procurement and Transplantation Network allocation changes, children with cardiomyopathy and adults with congenital heart disease did not experience the mortality benefits experienced by adults with cardiomyopathy and children with congenital heart disease,” the researchers wrote. “The changes in the allocation system coincide with significant changes in clinical practice; children with congenital heart disease are now less sick at the time of listing and are more frequently supported with ventricular assist devices, children with cardiomyopathy are less frequently mechanically ventilated or on inotropes and more frequently supported with durable ventricular assist devices, and the use of intra-aortic balloon pump and extracorporeal membrane oxygenation in adults with cardiomyopathy has increased substantially.”
References:
- Code of Federal Regulation. PART 121— Organ Procurement and Transplantation Network. https://www.ecfr.gov/current/title-42/chapter-I/subchapter-K/part-121. Last updated Jan. 13, 2025. Accessed Jan. 15, 2025.
- Organ Procurement and Transplantation Network. Proposal to Modify the Adult Heart Allocation System. https://optn.transplant.hrsa.gov/media/1244/08_adult_heart_allocation_part1.pdf. Accessed Jan. 15, 2025.
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