Durable Left Ventricular Assist Device as a Bridge to Heart Transplantation Under the New Donor Heart Allocation System

The new donor heart allocation system prioritizes candidates supported by temporary devices. However, waitlist and posttransplant outcomes in candidates with durable left ventricular assist device (LVAD) remain to be elucidated. The United Network for Organ Sharing database was queried for adults listed from October 2015 to March 2020 for a single-organ, first-time heart transplant (HTx) with a durable LVAD. Waitlist removal within 1 year because of death or clinical deterioration and HTx was analyzed using competing risks regression. Candidates who underwent HTx within 1 year of listing were identified for examination of post-HTx survival using the Kaplan-Meier method and Cox proportional hazards models. Compared with candidates listed under the old system (n = 2,122), candidates listed under the new system (n = 1,562) were slightly younger (p = 0.04) but had higher body mass index (p < 0.01). Those listed under the new system were significantly less likely to experience waitlist removal because of death or clinical deterioration (subhazard ratio [HR] 0.68, 95% CI 0.52-0.90) but were also less likely to undergo HTx (sub-HR 0.91, 95% CI 0.83-0.998). Those who survived to HTx were more likely to experience death or need for re-HTx within 1 year of HTx under the new system (adjusted HR 1.50, 95% CI 1.11-2.03). Candidates with durable LVAD experience favorable waitlist outcomes under the new allocation system, although those who undergo HTx may be at increased mortality risk. Thus, candidates with a durable LVAD should be carefully selected for HTx listing under the new allocation system.