Abstract
Heart transplantation candidates are often bridged to transplantation with medical therapy (MT) or mechanical circulatory support (MCS). Recent changes were made in the UNOS adult heart allocation system, partly based on bridging strategy, and potential effects remain uncertain. We compared outcomes of patients bridged to OHT with durable VAD (dVAD), intra-aortic balloon pump (IABP), and MT prior to the new allocation system. A retrospective review was performed on 513 consecutive patients listed for OHT between April 2004 and December 2018. Patients were excluded if bridged with extracorporeal ventricular assist devices or multiple concomitant MCS devices. Pre-, intra-, and post-operative characteristics were compared between the BTT strategies. Continuous variables are expressed as mean ± standard deviation or median (Q1-Q3) while categorical variables are expressed as number (%). A total of 501 patients were included (age 54.5(42.5-62.0) years, 104(30%) female). Of these, 348(69.5%) were transplanted (dVAD 175(50.3%), IABP 69(19.8%), and 104(29.9%) MT). Overall, 30-day mortality was 4% and 2-year mortality was 11%. dVAD had longer CPB minutes (dVAD 155.9±42.9, IABP 145.3±65.7, MT 139.7±52.6, p=0.031), but donor ischemic minutes were similar (dVAD 179.9±44.4, IABP 188.2±49.1, MT 179.9±53.7, p=0.44). IABP patients had longer overall LOS (IABP 55.0(31.0-90.0) days, dVAD 16.0(11.0-26.0) days, MT 40.0(20.5-75.0) days, p<0.001), but post-transplantation LOS was similar. Survival rates at 1, 2, 5, and 10 years were similar across groups (p=0.18, Figure). There were 28 deaths on the waiting-list, 13 dVAD, 2 IABP, and 13 MT. In this study, OHT outcomes were similar between the three bridging strategies, but overall LOS was higher in the IABP group. Further study is needed to determine the long-term effects of the new UNOS allocation system in regards to waiting-time, death on waiting list, transplant survival and cost-effectiveness of these bridging strategies.
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