Abstract
The United Network for Organ Sharing (UNOS) recently revised its heart allocation policy to address numerous shortcomings of the previous system. Implemented in 2018, the changes sought to reduce waiting list mortality, clearly define urgency status based on objective physiologic variables, decrease exemption requests, and introduce geographic modifications to ensure organ distribution favors the highest urgency candidates. In large part, UNOS policy revisions were driven by the growing use of continuous flow left ventricular assist devices (CF-LVADs) and the relevant device complications that led to an unacceptably high number of status exemptions. The new 6-tiered system assigns a comparatively lower urgency status to patients supported on CF-LVADs and higher urgency to patients supported on short-term mechanical circulatory assist (MCA) such as extracorporeal membrane oxygenation (ECMO) and intraaortic balloon pump (IABP) counterpulsation. LVAD use as bridge to transplant (BTT) therapy increased steadily throughout the preceding decade due to technological improvements and increased physician familiarity, but the recent policy changes introduce incentives for physicians to withhold this life-saving therapy in order to achieve higher urgency status for their patients. This paper will explore the technological evolution of MCA and the pertinent clinical trials that have led to their FDA approval as BTT and destination therapy. A review of the inception and development of the donor allocation system will be provided before examining available post-policy outcome data. Finally, we will highlight successes and shortcomings of the implemented changes before commenting on areas to potentially expand upon the existing policy.
Highlights
End-stage Heart failure is a devastating clinical syndrome whose prevalence and incidence continue to grow
The goal of this review is to provide a comprehensive overview of how left ventricular assist devices (LVADs) evolution has shaped changes in organ allocation policy, followed by an examination of new trends and future directions
Improvements in device design and durability have led to an increasing number of cardiac transplant candidates being managed with some form of mechanical circulatory assist (MCA), in particular LVADs
Summary
End-stage Heart failure is a devastating clinical syndrome whose prevalence and incidence continue to grow. An insufficient supply of donor hearts persists despite numerous interventions aimed at expanding the available donor pool and has resulted in more time spent on waiting lists and increased attention toward optimizing management strategies for candidates [3]. One-year survival for patients supported on third generation left ventricular assist devices (LVADs) is over 80%, and historically devastating complications such as pump thrombosis and pump failure are scarce events [6]. 2001 REMATCH trial demonstrates superiority of LVAD over optimal medical therapy in New York Heart Association class IV patients erature is a review of how developments in LVAD technologies have paved the way for organ allocation restructuring and how the implemented priority changes are impacting patients supported on these devices. The goal of this review is to provide a comprehensive overview of how LVAD evolution has shaped changes in organ allocation policy, followed by an examination of new trends and future directions
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