Complications and Status Upgrades among Adult Heart Transplant Candidates with Durable LVADs: Waiting 6 to 8 Years for Status Escalation Is Too Long.

Abstract

Introduction: After the 2018 allocation policy change, the rate of listings and transplants with durable LVADs has decreased significantly in favor of bridging patients from temporary mechanical circulatory support to heart transplant. The Organ Procurement and Transplantation Network (OPTN) recently approved a policy, to be implemented in September 2026, stipulating that patients supported by durable LVADs for 6 and 8 years will obtain statuses 3 and 2, respectively.

Methods: Using OPTN data, we identified all adult heart transplant candidates with a durable LVAD implanted between October 18, 2018 and May 31, 2025. We estimated the cumulative incidence of status upgrades and durable LVAD-related complications, treating transplantation and waitlist removal before experiencing complications as competing events. We also assessed how the composition of the adult heart transplant waitlist on June 1, 2025 would have changed based on the upcoming policy change.

Results: During the study period, 3,881 adult patients were listed for heart transplant with a durable LVAD. 3,182 (82.0%) of the durable LVADs were Abbott HeartMate 3, 568 (14.6%) were Medtronic Heartware HVAD, and 91 (2.3%) were Abbott HeartMate II. Transplant centers submitted a total of 6,924 justifications for status upgrades due to LVAD-related complications (6.3% status 1, 34.3% status 2, and 59.4% status 3) for 1,500 (38.6%) of these patients, with a median of 3 per patient. The cumulative incidence of complications or status upgrades was 38.6% [95% CI (37.1%, 40.2%)]. Nearly all of the 2,381 patients who did not experience any complication or status upgrade during listing were removed from the waitlist by 6 years. Had the upcoming OPTN policy change been implemented on June 1, 2025, the proportion of the waitlist that would have achieved higher priority status instantaneously was 0.06%.

Conclusions: The cumulative incidence of status upgrades and complications among heart transplant candidates with durable LVADs was nearly 40% within 6 years of device implantation. The upcoming OPTN policy to escalate patients to statuses 3 and 2 after 6 and 8 years of durable LVAD support, respectively, is unlikely to make a meaningful impact on waitlist priority status.