Comparison of Post-Heart Transplant Survival between Status 1A versus Status 1-3 Recipients before and after the UNOS Allocation Policy Change

Purpose The October 2018 UNOS heart allocation policy change was implemented in an effort to better prioritize heart transplants for the most critically ill patients. We compare six-month post-transplant survival of HT patients listed at status 1A one year before (PRE) vs. status 1-3 one year after (POST) the allocation policy change. Methods We identified patients (N = 2926) listed at the highest status levels (status 1A vs. status 1-3) that underwent HT between 10/18/2017 to 10/17/2019. There were 1242 status 1A patients in the PRE group and 1684 status 1-3 patients in the POST group. Baseline clinical characteristics were compared using Mann-Whitney U test and Chi-Square test as appropriate. Survival analysis was performed using Kaplan-Meier analysis. Univariate and Multivariate Cox Proportional Hazards (PH) regression analysis was adjusted for policy change, recipient age, donor age, bilirubin, creatinine, dialysis use, ischemic time, ventilator use, and ECMO use. Results There was no significant change in six-month survival in the POST vs. PRE groups (92% vs 93%, p=0.13). Furthermore, the policy change was not a significant predictor of mortality on both univariate Cox PH (HR: 1.24 [0.94-1.63, p=0.13]) and multivariate (HR: 1.13 [0.85-1.50, p=0.40]) analyses. Ischemic time (median and interquartile range: 3.5h [2.9, 4.1] vs. 3.1h [2.4, 3.7], p Conclusion Among patients in the highest acuity status groups, there was no difference in six-month post-HT survival following implementation of the policy change. This outcome was seen despite longer ischemic times, greater distance from donor recipient hospitals, and shorter total waitlist times. Further investigation is warranted to assess longer term outcomes.