Transplant Registrants With Implanted Left Ventricular Assist Devices Have Insufficient Risk to Justify Elective Organ Procurement and Transplantation Network Status 1A Time

Objectives The goal of this research was to identify disparities in risk within heart transplant urgency designations. Background Patients with left ventricular assist devices (LVADs) are given 30 days of elective status 1A time. This allowance may create competition for organs between stable LVAD-supported registrants and less stable registrants listed status 1A or 1B. Methods The Scientific Registry of Transplant Recipients database was analyzed for all status 1A and 1B listings between 2005 and 2010. Cox models were used to estimate the relative and absolute risk of adverse events (death or delisting as too ill) during status 1A or 1B listing. Results Status 1A registrants supported with dual inotropes and right heart monitoring had a higher risk of adverse events compared to those supported with implanted LVADs using elective 1A time (hazard ratio: 3.2; 95% confidence interval: 1.8 to 5.7). The 30-day risk of events was 1% (95% confidence interval: 0.1% to 3%) for implanted LVADs using elective 1A time and 6% (95% confidence interval: 4% to 8%) for dual inotrope support. Registrants listed with paracorporeal ventricular assist devices had a higher risk of adverse events (hazard ratio: 9.1; p < 0.0001) compared with registrants with implanted LVADs using elective 1A time. The odds of transplant were higher for implanted LVADs (odds ratio: 1.5; p < 0.0001) compared with dual-inotrope and intra-aortic balloon pump support. Conclusions The historic allowance for 30 days of elective status 1A time for implanted LVADs creates disparities in risk among status 1A registrants. The allowance of 30 days of elective status 1A time should not be allocated to stable registrants with implanted LVADs. Registrants supported with paracorporeal ventricular assist devices should be listed status 1A indefinitely. (J Am Coll Cardiol 2012;60:36-43) (C) 2012 by the American College of Cardiology Foundation