Impact of left ventricular assist device complications on heart transplant outcomes under the 2018 heart transplant allocation policy

Objective: The study objective was to determine the impact of left ventricular assist device complications on post–heart transplant survival before and after the 2018 US heart transplant allocation policy change. Methods: Adult patients (age >18 years) supported by left ventricular assist devices at the time of listing or transplantation in the United Network for Organ Sharing between October 18, 2015, and December 31, 2021, were included. Left ventricular assist device complications were defined by status at transplant (nonelective 1A in the prior era or new era status 2 or 3). Post-transplant survival (primary analysis) and baseline characteristics were compared among those with and without left ventricular assist device complications and by allocation era using multivariable Cox regression analyses. Results: The primary analysis included 4160 patients with left ventricular assist devices who underwent heart transplant (prior era n = 2458, new era n = 1702). Patients who underwent heart transplant with left ventricular assist device complications were on left ventricular assist device support longer under the new era (498 days vs 423 days P < .001). Post-transplant survival was highest in the prior era among those without left ventricular assist device complications. Patients who underwent transplantation in the prior era with a complication and in the new era without complications were not statistically different. Left ventricular assist device complications in the new era were associated with the highest post-transplant mortality (status 2 adjusted hazard ratio, 1.87, 95% confidence interval, 1.31-2.67, P < .001, status 3 adjusted hazard ratio, 1.50, 95% confidence interval, 1.11-2.04, P = .009). Conclusions: Left ventricular assist device complications in the new era are associated with increased post-transplant mortality. As a heart allocation score is being considered, modeling time on left ventricular assist device support to promote heart transplant before development of left ventricular assist device–related complications may improve outcomes for patients with left ventricular assist devices.