The Fallout of Heart Allocation System Changes: Practice Patterns and Landscape of the Recipient

PURPOSE: The United Network for Organ Sharing (UNOS) implemented a new heart allocation system on October 1, 2018. This has inevitably changed the strategy to position the recipient to receive a donor organ. However, these changes in practice and the condition of the recipient has not been thoroughly evaluated. METHODS: The UNOS database was evaluated from 2006 to 2019 for all adult heart transplant recipients. Patients were excluded if they were listed for multiple organs, re-transplantation, or for a diagnosis of congenital heart disease. This patient population was then analyzed for differences in pre-transplantation characteristics for January, 2006- September, 2018 (Era 1) versus October, 2018 - June, 2019 (Era 2). RESULTS: A total of 25,820 patients were identified with 25,209 and 619 patients in Era 1 and Era 2, respectively. Results from the comparison analysis are summarized in Table 1. Overall, patients spent fewer days on the waiting list in Era 2, but were more likely to have a temporary support device with extracorporeal membrane oxygenation or intra-aortic balloon pump. Additionally, distance traveled for donors was significantly farther in era 2. Consequently, patients were more likely to have a permanent mechanical circulatory support device implanted prior to the policy changes. CONCLUSION: The new status classification for recipients has resulted in more patients receiving transplant on ECMO and IABP compared to long-term durable devices. In addition, patients have a significantly shorter waiting time and distance travelled for donors is significantly increased. Major changes are observed in both practice patterns and recipient condition after the allocation changes, and more data are required to correlate this to outcomes and other differences.