ABSTRACT
Background The current United States donor heart allocation system prioritizes patients receiving temporary mechanical circulatory support over those with durable left ventricular assist devices (d-LVADs), but the impact on post-transplant survival remains unclear.
Objectives To evaluate post-transplant outcomes in patients bridged with d-LVAD versus t-LVAD before and after the 2018 United Network for Organ Sharing (UNOS) allocation policy change.
Methods Using the UNOS database, we analyzed 24,795 adult first-time HT recipients from 2011–2023, stratified by device type at transplant: d-LVAD (43.3%), t-LVAD (6.4%), or no LVAD. Outcomes included survival at 30 days, 90 days, 1 year, and 2 years. Risk-adjusted analyses were performed using Cox proportional hazards models. Subgroup analysis examined time on LVAD and the impact of organ preservation on outcomes.
Results Compared to t-LVAD and no-LVAD recipients, d-LVAD recipients had significantly higher adjusted mortality rates at all time points (hazard ratios ranged from 1.44 at 30 days to 1.18 at 2 years; p < 0.001). The mortality gap was more pronounced under the current allocation era. In patients with device duration data, ≥2 years on LVAD was associated with a 39% higher 1-year mortality risk (HR 1.39, 95% CI 1.15–1.68). No significant differences in 1-year mortality were observed between DCD donor and machine-perfused donor transplant subgroups by LVAD status.
Conclusions Post-transplant survival is worse with d-LVAD bridging, particularly under current allocation rules, and prolonged LVAD support further elevates risk. These findings underscore the need to reevaluate LVAD strategy and transplant prioritization, considering evolving allocation policies.
Condensed Abstract In a UNOS analysis of 24,795 heart transplants (2011–2023), patients bridged with durable LVADs (43.3%) consistently experienced worse post-transplant survival than those with temporary LVADs (6.4%) or no device. Adjusted mortality was higher at all time points (HR 1.44 at 30 days to 1.18 at 2 years; p<0.001), with disparities becoming more pronounced after the 2018 allocation change. Prolonged LVAD use (≥2 years) further increased the risk. These findings highlight the need to reevaluate durable LVAD strategies and transplant prioritization.
Preprint Server None
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
No funding was received
Author Declarations
I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.
Yes
The details of the IRB/oversight body that provided approval or exemption for the research described are given below:
Exemption for the research due to use of publicly available deidentified data
I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.
Yes
I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).
Yes
I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.
Yes
Footnotes
Source of funding: none.
Financial disclosure: Dr. Jaiswal is on the speaker bureau of Bristol-Myers Squibb and has received funds (modest) for consulting with Cytokinetics. Dr. Baran has received funds (modest) for consulting the following firms: steering Committee Procyrion, CareDx, XVIVO, NirSense. All other authors have reported no relationships with industry relevant to the contents of this paper to disclose.
Data Availability
All data is publicly available upon request by UNOS
