Effect of the 2018 heart allocation system on patients with durable left ventricular assist devices

Objective: In this study we report trends and survival of durable left ventricular assist device (LVAD) patients who underwent heart transplantation under the 2018 allocation system. Methods: The United Network for Organ Sharing database was queried for adult recipients of heart transplants after durable LVAD implantation from January 1, 2016, to December 31, 2020. We excluded patients with additional mechanical support, multiorgan transplants, previous heart transplants, or loss to follow-up. Results: One thousand seven hundred eighty-three patients with durable LVADs received heart transplants under the new allocation system (new), and 3445 under the old (old). New recipients were more likely hospitalized at transplant (n = 376 [22.4%] vs n = 446 [13.6%]; P <.001) and inotrope-dependent (n = 134 [7.5%] vs n = 206 [6.0%]; P =.038). Donors of the new cohort were more likely to have history of smoking (n = 234 [13.4%] vs n = 373 [11.0%]; P =.013), cocaine use (n = 506 [29.0%] vs n = 829 [24.4%]; P <.001), Centers for Disease Control and Prevention high risk status (n = 656 [36.8%] vs n = 1046 [30.4%]; P <.001), with ejection fraction <45% (n = 15 [0.8%] vs n = 10 [0.3%]; P =.012), and higher donor sequence numbers (mean 22.3 vs 12.0; P <.001)—trends that are not observed in non-LVAD transplants. Distances were further (mean 240 vs 144 miles; P <.001) and ischemic times longer (3.41 vs 3.04 hours; P <.001). Kaplan–Meier curves show worse survival in new recipients in unadjusted analysis (P =.005), and trends toward worse survival on propensity matching (P =.058). Similarly, increased mortality risk in the new era was shown in univariable Cox regression (hazard ratio, 1.27; 95% CI, 1.07-1.49; P =.005), but not multivariable analysis (P =.090). Conclusions: Durable LVAD patients are more likely to accept marginal donor organs under the new system because of difficulty in receiving offers. Worse survival trends might be attributed to recipient conditions and donor organ differences.