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LVAD implants don’t justify top status on transplant list, study says

NEW YORK (Reuters Health) – Patients who receive left ventricular assist devices (LVADs) should not automatically be granted the top status (1A) for receiving heart transplants, according to a new report.

Patients who receive LVADs currently receive 30 days of elective status 1A time, which may create competition for organs between stable LVAD-supported registrants and less stable registrants with status 1A or 1B, researchers write in the July 3 issue of the Journal of the American College of Cardiology.

“Our study results suggest that organs could be allocated inefficiently with respect to the risk of mortality while waiting,” Dr. Todd Dardas from the University of Washington in Seattle told Reuters Health by email.

“Further studies of the current system would clarify how frequently organs are allocated to those at the highest risk of death versus those at lower risk listed in the same status,” he added.

Dr. Dardas and colleagues used the Scientific Registry of Transplant Recipients to assess the risk among status 1A and 1B registrants who were actively listed for transplant.

Among people registered as status 1A, the risk death or delisting as too ill for transplant within 30 days was 1% for those with a LVAD, 6% for those with a ventricular assist device (VAD) with complication, 6% for medical therapy, and 15% for paracorporeal VAD.

The trend was similar for status 1B registrants, whose risk was 3% for people with VADs, 9% for single inotrope support, and 26% for paracorporeal VAD support.

Over the course of observation, the likelihood of transplantation for patients supported with an implanted LVAD using status 1A elective time increased from 11% to 27%. The likelihood of transplantation dropped from 38% to 35% for those with medical support and from 27% to 14% for those with paracorporeal support.

Among status 1A patients who received transplants, post-transplant mortality was significantly higher among ventilator-dependent registrants compared with those receiving medical support, whereas post-transplant outcomes were similar for patients with an implanted LVAD, paracorporeal VADs, and VADs with complications.

For status 1B patients, post-transplant prognosis did not differ significantly among those with paracorporeal VADs, implanted LVADs, and low-dose inotropes.

“On the basis of our analysis, allowing elective status 1A time for implanted LVAD patients creates a disparity in what should be equal risk among status 1A registrants,” the researchers conclude.

“The improvement in LVAD technology and clinical results with LVADs has been very rapid,” Dr. Dardas said. “The transplant urgency system will need to carefully consider changes that balance the risk of patients with and without LVADs waiting for transplants.”

He added that “Changes to the policy are being considered.”

Minutes from a meeting this year of the Organ Procurement and Transplantation Network’s Thoracic Organ Transplantation Committee indicate that the Heart Subcommittee continues to consider improvements to the current adult medical urgency statuses.

SOURCE: http://bit.ly/JMgbah

J Am Coll Cardiol 2012;60:36-43.