Outcomes of Multiple Listing for Heart Transplantation

Study Questions:

What is the association of multiple listing with waitlist outcomes and post-heart transplantation (HT) survival?

Methods:

The study cohort was comprised of 33,928 adult candidates for a first single-organ HT between January 1, 2000 and December 31, 2013 in the Organ Procurement and Transplantation Network (OPTN) database. The study authors utilized a multivariable regression model which included 13 baseline variables: age, race, sex, ABO blood type, cardiac diagnosis, initial primary listing status, United Network for Organ Sharing (UNOS) region, year of initial listing, initial urgency status of primary listing, education level, insurance status, socioeconomic status index, crossmatch requirement, and ventricular assist device. They performed competing outcome analyses for R to compare waitlist outcomes of multiple-listing (ML) and single-listing patients. The Kaplan-Meier analysis and the log-rank test were used to compare post-HT survival.

Results:

The study authors identified 679 ML candidates (2.0%), who were younger (median age 53 years [interquartile range, 43-60] vs. 55 [45-61], p < 0.0001), more often white (76.4% vs. 70.7%, p = 0.0010), and privately insured (65.5% vs. 56.3%, p < 0.0001), and lived in zip codes with higher median incomes (90,153 [25,471-253,831] vs. 68,986 [19,471-219,702], p = 0.0015). Likelihood of ML increased with the primary center’s median waiting time. ML candidates had lower initial priority (39.0% 1A or 1B vs. 55.1%, p < 0.0001) and predicted 90-day waitlist mortality (2.9% [2.3-4.7] vs. 3.6% [2.3-6.0], p < 0.0001), but were frequently upgraded at secondary centers (58.2% 1A/1B; p < 0.0001 vs. ML primary listing). ML candidates had a higher HT rate (74.4% vs. 70.2%, p = 0.0196) and lower waitlist mortality (8.1% vs. 12.2%, p = 0.0011). Compared to a propensity-matched cohort, the relative ML HT rate was 3.02 (95% confidence interval, 2.59-3.52; p < 0.0001). There were no post-HT survival differences.

Conclusions:

The study authors concluded that ML policy should be overturned because it may give advantage to patients with the means to participate rather than the most medically needy.

Perspective:

This is an important study because it suggests that a better job could be done regarding organ allocation so that the most medically needy are first in line. ML may have a place in those who are ‘knocking on death’s door,’ but their chances of getting an organ sooner are low because of characteristics such as type-O blood, larger body sizes, congenital heart disease, and residency in UNOS region 9. This paper should result in a review of current procedures for organ allocation so that the most medically needy are first in line.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and CHD & Pediatrics, Cardiac Surgery and Heart Failure, Congenital Heart Disease, CHD & Pediatrics and Interventions, Heart Transplant, Mechanical Circulatory Support , Interventions and Structural Heart Disease

Keywords: Blood Grouping and Crossmatching, Cardiac Surgical Procedures, Heart Defects, Congenital, Heart Transplantation, Heart-Assist Devices, Insurance Coverage, Tissue and Organ Procurement, Waiting Lists


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