Pretransplant survival of patients with end-stage heart failure under competing risks

Heart transplantation is the gold standard of care for end-stage heart failure in the United States. Donor hearts are a scarce resource, however the current allocation policy—proposed in 2016 and implemented in 2018—has not addressed certain disparities. Between 2005 and 2016, the number of active candidates increased 127%, whereas transplant rates decreased 27.8%. Pretransplant mortality rates declined steadily for that period from 14.6 to 9.7, especially for candidates with mechanical circulatory assistive devices (MCSDs). This study reports survival analyses of candidates for heart transplantation list under competing events of transplantation and MCSD implantation. We queried the transplant data for a cohort of adult patients (age ≥ 16) without MCSDs prior to listing for transplantation between 2005 and 2014 (n = 23,373). We used cause-specific and subdistribution hazards models as multivariate regressions for all competing events. Patients listed as low priority for transplantation are less likely to require implantation but less likely to survive after 1,000 days of listing than patients listed at higher priorities. The current policy does not address this disparity as it focuses on stratifying patients with different types of MCSD. Clinical characteristics must be considered in prioritization.