Impact of 2016 UNOS pediatric heart allocation policy changes on VAD utilization, waitlist, and post-transplant survival outcomes in children with CHD versus Non-CHD.

Abstract

We analyzed the impact of the revised pediatric heart allocation policy on types of ventricular assist device (VAD) utilization, and waitlist (WL) and post-heart transplant (HT) survival outcomes in congenital heart disease (CHD) versus non-CHD patients before (Era-1) and after (Era-2) pediatric heart allocation policy implementation. We retrospectively reviewed the UNOS database from December 16, 2011, through March 31, 2021, for patients<18 years old and listed for primary HT. We compared the differences observed between Era-1 and Era-2. 5551 patients were listed for HT, of whom 2447(44%) were in Era-1 and 3104(56%) were in Era-2. CHD patients were listed as status 1A unchanged, but the number of patients listed as status 1B decreased in Era-2, whereas the number of non-CHD patients listed as status 1A decreased, but status 1B increased. In Era-2 compared to Era-1, both temporary (1% to 4%, p<.001) and durable VAD (13.6% to 17.8%, p<.001) utilization increased, and the transplantation rate per 100-patient years increased in both groups. The median WL period for CHD patients increased marginally from 70 to 71 days (p=.06), whereas for non-CHD patients it decreased from 61 to 54 days (p<.001). Adjusted 90-day WL survival increased from 84% to 88%, p=.016 in CHD, but there was no significant change in non-CHD patients (p=.57). There was no significant difference in 1-year post-HT survival in CHD and non-CHD patients between Era-1 and Era-2. In summary, after the revised heart allocation policy implementation, temporary and durable VAD support increased, HT rate increased, waitlist duration marginally increased in the CHD cohort and decreased in the non-CHD cohort, and 90-day WL survival probability improved in children with CHD without significant change in 1-year post-HT outcomes. Future studies are needed to identify changes to the policy that may further improve the listing criteria to improve WL duration and post-HT survival.