Waitlist mortality and post transplant survival amongst non-extracorporeal membrane oxygenation high-urgency heart transplant recipients before and after the 2018 policy change.
7 affiliations
- 1David Geffen School of Medicine, UCLA, Los Angeles, Calif.
- 2Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa.
- 3Drexel University College of Medicine, Philadelphia, Pa.
- 4Department of Surgery, Stamford Hospital, Stamford, Conn.
- 5Division of Cardiac Surgery, Department of Surgery, UCLA, Los Angeles, Calif.
- 6Department of Biostatistics, UCLA, Los Angeles, Calif.
- 7Division of Pediatric Cardiology, Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, Calif.
Abstract
Objective
The adult heart allocation policy changed from a 3- to 6-tiered system in 2018, more precisely stratifying high-urgency patients. Many studies examined the effects on patients classified as Status 1 or those with implantable devices, especially extracorporeal membrane oxygentation (ECMO), however, few have analyzed other high-urgency cohorts. This study's purpose is to compare waitlist and midterm outcomes of non-ECMO high-urgency patients before and after the policy change.Methods
All high-risk (Status 1A, 1, 2, 3) non-ECMO adult patients listed for isolated heart transplantation were identified using the United Network for Organ Sharing database and split based on the October 18, 2018, policy change date into era 1 (7/2014-7/2018) and era 2 (1/2019-1/2023). Categorical and continuous variables were assessed using χ² and t tests, respectively. Waitlist mortality was analyzed using competing risk regression whereas Kaplan-Meier curves assessed posttransplant survival.Results
Candidates from era 2 demonstrated greater rates of comorbidities like pulmonary hypertension (65% vs 67%, P = .007) and greater need for support with inotropes (39% vs 47%, P < .001) and intra-aortic balloon pump (12% vs 42%, P < .001). Yet, candidates from era 2 had significantly decreased waitlist time (71 vs 19 days, P < .001) and waitlist mortality (19% vs 7%, P < .001) whereas Kaplan-Meier 3-year survival (86% vs 85%, P = .42) remained similar.Conclusions
Among non-ECMO high-urgency heart transplant recipients, candidates from era 2 demonstrated greater clinical acuity but improved waitlist mortality and equivalent midterm survival. These findings reassure that the 2018 policy change did not compromise outcomes amongst this high-urgency cohort, despite favoring patients bridged with ECMO.
Related
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- Extracorporeal Membrane Oxygenation (ECMO) Prediction of Mortality and Integrated Complication with Infection Risk Assessment by Machine Learning: Structured Narrative Review.
- Low Dietary Bromide Intake and Sex-Specific Mortality in Kidney Transplant Recipients
BibTeX
@article{white2026waitlist,
title = {{Waitlist mortality and post transplant survival amongst non-extracorporeal membrane oxygenation high-urgency heart transplant recipients before and after the 2018 policy change.}},
author = {John P White and Joseph Song and Samuel T Kim and Hedwig Zappacosta and Peter D Cho and Stephanie McKay and Akanksha Girish and Alexey Abramov and Malini Daniel and Donatello Telesca and Majid Husain and Abbas Ardehali},
journal = {JTCVS open},
year = {2026},
month = jun,
doi = {10.1016/j.xjon.2026.101936},
url = {https://europepmc.org/article/MED/42948479},
note = {CC BY},
}
RIS
TY - JOUR
TI - Waitlist mortality and post transplant survival amongst non-extracorporeal membrane oxygenation high-urgency heart transplant recipients before and after the 2018 policy change.
AU - John P White
AU - Joseph Song
AU - Samuel T Kim
AU - Hedwig Zappacosta
AU - Peter D Cho
AU - Stephanie McKay
AU - Akanksha Girish
AU - Alexey Abramov
AU - Malini Daniel
AU - Donatello Telesca
AU - Majid Husain
AU - Abbas Ardehali
PY - 2026
DA - 2026/06/20
JO - JTCVS open
DO - 10.1016/j.xjon.2026.101936
UR - https://europepmc.org/article/MED/42948479
AB - Objective The adult heart allocation policy changed from a 3- to 6-tiered system in 2018, more precisely stratifying high-urgency patients. Many studies examined the effects on patients classified as Status 1 or those with implantable devices, especially extracorporeal membrane oxygentation (ECMO), however, few have analyzed other high-urgency cohorts. This study's purpose is to compare waitlist and midterm outcomes of non-ECMO high-urgency patients before and after the policy change.Methods All high-risk (Status 1A, 1, 2, 3) non-ECMO adult patients listed for isolated heart transplantation were identified using the United Network for Organ Sharing database and split based on the October 18, 2018, policy change date into era 1 (7/2014-7/2018) and era 2 (1/2019-1/2023). Categorical and continuous variables were assessed using χ² and t tests, respectively. Waitlist mortality was analyzed using competing risk regression whereas Kaplan-Meier curves assessed posttransplant survival.Results Candidates from era 2 demonstrated greater rates of comorbidities like pulmonary hypertension (65% vs 67%, P = .007) and greater need for support with inotropes (39% vs 47%, P < .001) and intra-aortic balloon pump (12% vs 42%, P < .001). Yet, candidates from era 2 had significantly decreased waitlist time (71 vs 19 days, P < .001) and waitlist mortality (19% vs 7%, P < .001) whereas Kaplan-Meier 3-year survival (86% vs 85%, P = .42) remained similar.Conclusions Among non-ECMO high-urgency heart transplant recipients, candidates from era 2 demonstrated greater clinical acuity but improved waitlist mortality and equivalent midterm survival. These findings reassure that the 2018 policy change did not compromise outcomes amongst this high-urgency cohort, despite favoring patients bridged with ECMO.
SN - 2666-2736
ER -