Heart Transplant Waiting List Mortality - Impact of HeartMate 3 and the Need for Prioritized Organ Allocation.

Abstract

Background: Japan's heart transplantation system is characterized by an extremely long waiting period, which contributes to significant mortality on the waiting list. The current allocation system may maintain favorable post-transplant outcomes at the expense of high-risk patients, particularly those with severe heart failure or complications following left ventricular assist device (LVAD) implantation. To explore an optimal allocation system for Japan, we investigated risk factors for waiting list mortality.

Methods and results: We analyzed 300 patients registered on the heart transplant waiting list at Osaka University between 2014 and 2024. Cox hazard analysis identified age at registration (hazard ratio [HR] 1.023) and congenital heart disease (HR 4.531) as independent risk factors for mortality. In the LVAD cohort (n=244), right heart failure (HR 4.582), stroke associated with systemic infection (HR 5.175), and sudden stroke without preceding infection (HR 3.158) were significant risk factors. Although the HeartMate 3 significantly reduced sudden stroke (P<0.001), it did not improve right heart failure or infection-related stroke. Patients with these complications had significantly lower proportions of time at home with an LVAD (P<0.001).

Conclusions: Prioritized organ allocation for patients with congenital heart disease, right heart failure, or LVAD-related infections may improve waiting list survival. Reducing hospitalizations in high-risk LVAD patients could also be beneficial from a healthcare economics perspective.