Factors Influencing Access to Transplant, Waitlist Mortality, and Post-Transplant Survival in the Italian National Heart Transplant Database

Purpose: Candidate selection and donor allocation should promote equitable access to heart transplantation (HTX) according to patients’ needs, avoiding HTX in patients (pts) who are too well or too sick to get benefit. The national HTX database was analyzed to identify which variables were related to the competing events of getting HTX or dying on the waiting list (WL), and to post-transplant survival. Methods: Pts aged 14 years or more, who were listed for primary HTX from May 2012 and December 2016, were followed until January 2018, death or delisting for worsening. The incidence of death on the WL or of HTX were analyzed according to Aalen-Johansen method. Post-HTX survival was evaluated with Kaplan-Meyer method. Univariate and multivariate cause-specific Cox proportional hazard model was used to identify candidates’ variables related to access to HTX or death on the WL, and preoperative recipients’ variables related to post-HTX mortality. Results: Of 1611 listed pts (males 78%, median age 54 y), 10% died and 45% received HTX within 1 year. At the end of follow-up 932 pts (males 73%, median age 53y) had undergone HTX: 13% were bridged with LVAD, 17% were on short-term mechanical circulatory support (MCS), 28% received HTX with emergency heart allocation, and 42% were medically treated outpatients. One-, 3- and 5-years post-HTX survival was 78%, 72% and 69% respectively. Variables which were significantly related to study outcomes at univariate and multivariate analysis are shown in the Table. Conclusion: The higher risk of WL mortality associated with variables that reflect disease severity and medical urgency is limited by allocation rules. Blood type 0 pts are disadvantaged in the current system. 1-y probability of both getting HTX and dying on the WL was lower in LVAD pts. Short term MCS and emergency HTX were associated with higher rate of death after HTX only at univariate analysis: predictors of post-HTX death should be analyzed separately in these high-risk subgroups