No Survival Benefit Associated with Waiting for Non-Lung Donor Heart Transplants for Recipients with Adult Congenital Heart Disease

PURPOSE Adults with congenital heart disease (CHD) awaiting heart transplant (HT) have higher mortality and waitlist removal due to clinical worsening compared to those without CHD. Reviews and consensus statements have supported the use of harvesting donor pulmonary vasculature to assist in graft implantation which require a non-lung donor (NLD). However, the impact of this practice on waitlist times or mortality has yet to be evaluated. METHODS We analyzed the United Network for Organ Sharing (UNOS) Registry to identify 1271 adults age ≥18 with CHD that underwent HT between January 1, 1987 and December 31, 2016. Baseline characteristics, mean waitlist time, 1-year survival, and overall survival by Cox proportional hazard models were compared between HT recipients receiving donor hearts from NLDs or donor hearts from concomitant lung donors. RESULTS Over the study period, 32% of CHD recipients received HTs from concomitant lung donors; this practice increased from 6% between 1987-1991, to 45% between 2012-2016. Prior to HT, recipients from NLDs were significantly more likely to have undergone prior cardiac surgery, and less likely to be listed UNOS Status 1A, or require mechanical ventilation or intra-aortic balloon pump support. There was no difference in mean time on the waitlist (262 vs. 254 days, p=0.31), crude 1-year survival (82% vs. 80%, p=0.81), nor overall unadjusted risk of survival (hazard ratio 1.01, 95% confidence interval 0.83-1.24, p=0.86) (Figure 1) between CHD HT recipients from NLDs and concomitant lung donors. Results were unchanged after covariate adjustment. CONCLUSION Adult CHD patients who are less critically ill or listed at a lower status are more likely to receive HTs from NLDs. However, there is no overall mortality benefit associated with this practice. While specific cases may necessitate waiting for NLDs, longer wait times may result in worsening clinical status.