Mostly Positive Outcomes After 2018 Adult Heart Transplant Allocation Changes

By Linda Carroll

October 29, 2020

(Reuters Health) - Adult heart transplant policy allocation changes enacted in the U.S. in 2018 have led to mostly positive outcomes, a new study suggests.

An analysis of data on more than 15,000 patients who received heart transplants revealed that compared to patients added to the waiting list during the three years before the changes took effect, patients added afterward were less likely to die on the list and more likely to be transplanted. One-year survival rates, however, decreased after the change.

The transplant community opted to make the policy changes because it was felt that the old three-tier system, "was not granular enough to distinguish the urgency of patients on the wait list," said lead author Dr. Arman Kilic, associate director of the Advanced Heart Failure Program at UPMC in Pittsburgh.

The current paper provides "a snapshot" of the effects of the policy changes, Dr. Kilic said. "There have been several papers that looked at early outcomes, and this paper demonstrated that a lot of those early changes persisted at the one-year mark."

Dr. Kilic and colleagues write in JAMA Cardiology, "The existing 3-tier system was converted to a 6-tier system to provide more granular separation of wait listed patients by clinical condition and urgency of transplant. For example, patients receiving extracorporeal membrane oxygenation (ECMO) were given the highest priority, whereas stable patients with durable left ventricular assist devices (LVADs) were given a lower priority."

"As technology and management got better, outcomes got much better as well," Dr. Kilic said. "A lot of patients with durable LVADs could live many years without complications or problems, so that was one of the impetuses for change."

The new system stratifies patients into six tiers of illness severity. After it took effect, "higher-risk patients were being transplanted sooner and patients were much less likely to die on the wait list," Dr. Kilic said. But "absolute one-year survival decreased by 5%."

Dr. Kilic and his colleagues analyzed data from the United Network for Organ Sharing on 15,631 heart transplants in adults. Patients receiving multi-organ transplants were excluded.

Of the 15,631 patients who received new hearts, 10,671 (mean age 53.1) were waitlisted before the change and 4,960 (mean age 52.7) were waitlisted after.

A comparison of competing waitlist outcomes found significant differences after the policy change: the risk of death or clinical deterioration was reduced (sub-hazard ratio, SHR: 0.60); the odds of undergoing transplant were significantly greater (SHR: 1.38); and the likelihood of waitlist removal because of recovery, while low in both groups, was significantly decreased among more recent patients (SHR: 0.54).

Post-transplant survival was lower, at 87.5% in the post-policy-change group versus 92.1% in the pre-policy-change group.

Most of the findings were positive, said Dr. Donna Mancini, medical director of heart transplantation and heart failure at Mount Sinai Hospital in New York City and across the Mount Sinai system. "The problem is they also identified an increase in post-transplant mortality which they attribute to the redirection of organs to the sickest patients," Dr. Mancini said.

That may change as more data come in, said Dr. Mancini, who wasn't involved in the study. "The time to really assess one-year outcomes in totality with complete data checking is in the spring of 2021," she explained. "Part of the problem is that the initial results may be inaccurate because a lot of data may not be entered yet."

In sum, Dr. Mancini said, "The good thing is the shorter waitlist time and the improved survival on the waitlist. I'm just saying we really have to wait to really assess the patient outcomes because we need more time."

SOURCE: https://bit.ly/37PvFPp and https://bit.ly/2HIVB4r JAMA Cardiology, online October 28, 2020.

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