Do Stable Patients Supported with Long-Term Mechanical Circulatory Support Device Have Equitable Access to Donor Hearts in the New French Allocation System?

Abstract

The new French allocation system grants priority to patients on long-term mechanical circulatory support (MCS) with device complications but does not prioritize stable long-term MCS candidates. Some experts expressed concerns regarding waiting time of long-term MCS candidates without complication. The aim of this study was to evaluate the access to transplantation of long-term MCS candidates. The study included all candidates on long-term MCS without complication registered on the French heart transplant waiting list between January 2018 and March 2019 (group 1, n=65) and those ambulatory without circulatory support(group 2, n=220). The main outcomes were 6-month cumulative incidence (CI) of transplantation, and, of waitlist mortality or delisting for worsening medical condition. The CI were estimated using the competing risk analyses and compared using Gray's test. In addition, the restricted mean survival was used to estimate the difference in access to transplantation between the 2 groups. Among the 65 stable long-term MCS candidates, 37 were on support at listing and 28 were implanted while listed. The 6-month CI of transplantation was significantly lower in patients on long-term MCS than in ambulatory candidates (25% vs 49%; p<0.01). The difference of restricted mean survival between the groups was 37 days. The 6-month CI of waitlist mortality was higher in long-term MCS candidates implanted while listed (19%) than in patients on MCS at listing (8 %) and in ambulatory patients (1%). Access to transplantation was lower in stable long-term MCS patients than in ambulatory candidates. The increased waitlist mortality was only observed in candidates implanted while listed. The French allocation system is being revised with a new version granting a provision in stable long-term MCS candidates.