A Comparison of the LVAD Population 1-Year Clinical Outcomes Before and After the Transplant Allocation System Change

Abstract

<h3>Purpose</h3> In October 2018, the transplant allocation system deprioritized left ventricular assist devices (LVAD) as an indication for heart transplant. After the allocation system change, the majority of LVADs are implanted as destination therapy. As a greater proportion of LVAD patients are implanted as destination therapy, we hypothesized that the overall population of patients implanted after the allocation system change will experience less favorable 12-month outcomes and decreased rates of progression to transplant as compared to those implanted prior. <h3>Methods</h3> The data cohort includes patients implanted with LVADs at an academic high volume transplant center since 2005. The overall cohort was divided into two groups- those implanted prior to the allocation system change and those implanted after. Baseline characteristics and one-year outcomes were compared; survival curves were constructed using the Kaplan-Meier method and compared using the log-rank test. <h3>Results</h3> 50 patients were implanted with a LVAD between November 1^st, 2018 and July 1^st, 2020, and 181 patients received an implant between 2005 and before November 1^st, 2018. After the allocation system change, 86% of patients received a LVAD as destination therapy, compared to 45.4% implanted prior to allocation system change (p<0.0001). Patients who were implanted prior to the allocation system change had a lower pre-implant INTERMACS status than those implanted after the change (p=0.0001), and had a higher rate of device malfunction and pump thrombosis (p=0.02). The log-rank test comparing the survival curves for the combined outcome of death and rehospitalization did not demonstrate a significant difference (p=0.63). We did not find a significant difference in time from implant to transplantation nor in the rate of transplantation. <h3>Conclusion</h3> While there were important differences in baseline characteristics and outcomes, patients implanted with a LVAD after the allocation system change did not clearly have poorer pre-implant health, 1 year outcomes, or lower rates of transplantation at 1 year than patients implanted after. Furthermore, the practice patterns of transplanting patients with a LVAD did not change significantly at this academic high volume transplant center.