Heart Transplant Waitlist Outcomes and Wait Time by Center Volume: Where Should You List?

Abstract

Purpose With new devices and policy changes in the heart transplantation, patients are faced with increasingly complex management options. Among one of the decisions they must make is which transplant center they can and should list under. Here we explored waitlist outcomes by transplant center volume. Methods We performed a retrospective analysis of adults listed for primary heart transplantation from 2008 to 2018 using the UNOS Database. Transplant centers were split into low ( 30 HTx/year) volume. Multivariable Cox Proportional Hazards analysis identified predictors of death prior to transplantation; Cox model was adjusted for age at listing, transpulmonary gradient, and use of LVAD while on the waitlist. Results Of the 37,779 patients included in our study, only 24,285 (64.3%) underwent transplantation. Of the remaining 13,494, 6,687 (49.6% of non-transplanted patients) died before receiving transplantation. Of the 140 centers, 51 were low volume (1,412 HTx), 64 were medium volume (11,687 HTx), and 25 were high volume (11,186 HTx); 118 patients were listed at centers which did not perform any transplants in the years analyzed. LVAD utilization (at listing or while listed) was 20.2% for low, 31.8% for medium, and 25.1% for high volume centers. Of the 3,192 patients listed in low-volume centers, only 1,412 (44.2%) underwent transplantation, while 800 (25.1%) died prior to transplant; of the 18,538 listed in medium volume centers, 11,687 (63.0%) underwent transplantation, while 3,343 (18.0%) died prior to transplant; of the 15,931 listed in high volume center, 11,186 (70.2%) underwent transplantation, while 2,503 (15.7%) died prior to transplant. Average time on waitlist was 328.7 + 453.7 days for low-volume, 358.5+469.8 for medium-volume, and 313.7+484.6 for high-volume centers (p = NS). Cox proportional hazards analysis demonstrated listing at a higher volume center to be an independent predictor of lower death rate while on transplant waitlist (HR 0.89, P Conclusion Survival to transplantation was higher for patients listed in higher volume centers. This may be associated with higher utilization rates of LVADs which was also associated with improved waitlist outcomes, or possibly better management of advanced heart failure in centers more experienced with this patient population.