Impact of the New French Heart Allocation System on Post-Transplant Mortality

Abstract

<h3>Purpose</h3> The goal of the new French heart allocation system launched on January 2018 was to minimize death on the waiting list without detrimental effect on post-transplant outcome. The new system is based on the candidate risk score (CRS) considering donor-recipient matching and post-transplant risk of death as well as the distance between procurement and transplant centers. Exceptions to the score have been implemented for adults for whom the CRS does not accurately predict waitlist mortality. This study aimed to compare recipients' profile and survival under the old and new allocation systems. <h3>Methods</h3> The study included all patients undergoing transplantation between January 2014 and June 2019 (n=2520) listed on the national registry CRISTAL. The main outcome was 6-month post-transplant mortality. Survival curves were estimated using the Kaplan-Meier method and compared between the old allocation system (2014-2017, N=1838) and the new system (2018-2019, N=682) using the log-rank test. To evaluate the independent effect of the period on post-transplant mortality, we used a multivariable Cox proportional hazard model adjusting on post-transplant mortality risk factors. <h3>Results</h3> Recipients from the new system (n=682) were more likely to be supported with VA-ECMO (29.6% vs 18.3%, p=0.01) and ventilator (10.6% VS 7.6%, p=0.02) and less likely to be on inotrope infusion (13.2% vs 26.2%, p<0.01). Six-month post-transplant survival rate did not differ between 2018-2019 and 2014-2017 (81.0% vs 81.8%, p=0.8) (Figure 1). In a multivariable Cox model including post-transplant mortality risk factors (recipient age, indication, mechanical ventilation, GFR, Inotropic infusion, history of cardiac surgery, diabetes mellitus and donor age), no association was found between period and 6-month post-transplant mortality (HR=1.0 95%CI : 0.8-1.2; p=0.9). <h3>Conclusion</h3> The new French heart allocation system has resulted in higher rate of recipients supported with VA-ECMO without change in 6-month post-transplant Survival.