Waitlist Mortality in US Children Listed for Heart Transplant - Where are We Now?

A. Power, K. R. Sweat, S. A. Hollander, J. Schmidt, J. C. Dykes, E. L. Profita, D. Bernstein, C. S. Almond

Research output: Contribution to journalArticlepeer-review

Abstract

PURPOSE: Studies suggest that pediatric heart transplant (HT) waitlist mortality has declined. The impact of factors such as heart allocation system refinements, patient selection, greater ABO incompatible (ABOI) HT, and rise in VAD use are unknown. We examined the 20-year trend in waitlist mortality to identify factors associated with declining mortality and whether allocational inefficiencies persist. METHODS: All children <18 years listed for isolated HT from 1999-2019 were identified using OPTN data and grouped into 3 eras (Era 1: 1999-2006; Era 2: 2006-2016; Era 3: 2016-2019) based on when UNOS revised the heart allocation system. Cox proportional hazards modeling was used to identify factors associated with death/deterioration. RESULTS: Overall, 10,730 patients met inclusion criteria (3,397 in Era 1; 5,359 in Era 2; 1,974 in Era 3). Waitlist mortality declined significantly across eras (22%, 17%, 14%, P<0.001). The prevalence at listing of major risk factors for mortality declined across eras including a reduction by 50% in ECMO use (12%, 9%, 6%, P<0.001), by 32% in ventilator use (28%, 22%, 19%, P<0.001), by 38% in dialysis use (2.4%, 2.0%, 1.5%, P<0.001), while VAD use at listing increased 8-fold (2%, 8%, 14%, P<0.001). Infant mortality declined significantly (27%, 25%, 21%, P<0.001) with a 40% decline in mortality unique to blood group O patients (relative to background decline for all blood groups); infant VAD mortality declined by 36% (P<0.01). In Era 3, RCM and re-transplant patients not eligible for status 1A without exception have higher mortality than 1A DCM patients on LVAD support (12% vs. 4.3%, P<0.01). CONCLUSION: Pediatric HT waitlist mortality has declined significantly over the past 20 years. There is evidence to suggest that greater VAD use, revisions to organ allocation, refinements in patient selection, and ABO-I transplant may all contribute. Organ allocation inefficiencies persist under the current allocation system, suggesting opportunities for allocation improvement may still exist.

Original languageEnglish (US)
Pages (from-to)S86
JournalThe Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation
Volume39
Issue number4
DOIs
StatePublished - Apr 1 2020
Externally publishedYes

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine
  • Transplantation

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