Impact of 2016 UNOS pediatric heart allocation policy changes on VAD utilization, waitlist, and post-transplant survival outcomes in children with CHD versus Non-CHD.

AIMS: We analyzed the impact of the revised pediatric heart allocation policy on types of ventricular assist device (VAD) utilization, and waitlist (WL) and post-heart transplant (HT) survival outcomes in congenital heart disease (CHD) versus non-CHD patients before (Era-1) and after (Era-2) pediatric heart allocation policy implementation. METHODS: We retrospectively reviewed the UNOS database from December 16, 2011, through March 31, 2021, for patients < 18 years old and listed for primary HT. We compared the differences observed between Era-1 and Era-2. RESULTS: 5551 patients were listed for HT, of whom 2447(44%) were in Era-1 and 3104(56%) were in Era-2. CHD patients were listed as status 1A unchanged, but the number of patients listed as status 1B decreased in Era-2, whereas the number of non-CHD patients listed as status 1A decreased, but status 1B increased. In Era-2 compared to Era-1, both temporary (1% to 4%, p < .001) and durable VAD (13.6% to 17.8%, p < .001) utilization increased, and the transplantation rate per 100-patient years increased in both groups. The median WL period for CHD patients increased marginally from 70 to 71 days (p = .06), whereas for non-CHD patients it decreased from 61 to 54 days (p < .001). Adjusted 90-day WL survival increased from 84% to 88%, p = .016 in CHD, but there was no significant change in non-CHD patients (p = .57). There was no significant difference in 1-year post-HT survival in CHD and non-CHD patients between Era-1 and Era-2. CONCLUSIONS: In summary, after the revised heart allocation policy implementation, temporary and durable VAD support increased, HT rate increased, waitlist duration marginally increased in the CHD cohort and decreased in the non-CHD cohort, and 90-day WL survival probability improved in children with CHD without significant change in 1-year post-HT outcomes. Future studies are needed to identify changes to the policy that may further improve the listing criteria to improve WL duration and post-HT survival.

UNOS listing status-related changes in mechanical circulatory support utilization and outcomes in adult congenital heart disease patients.

BACKGROUND: The aim of this study was to investigate the impact of the new United Network for Organ Sharing (UNOS) listing criteria on mechanical circulatory support (MCS) utilization and outcomes in adult congenital heart disease (ACHD) patients. METHODS: We identified all ACHD and non-ACHD heart transplant candidates in the Scientific Registry of Transplant Recipients database listed during the 590 days prior to (historical cohort) or following (recent cohort) the UNOS allocation revision on October 18, 2018. Patients were grouped based on whether they received central temporary MCS (tMCS), peripheral tMCS, durable MCS, or no MCS. RESULTS: A total of 535 ACHD (242 historical, 293 recent) and 12,188 non-ACHD (6,258 historical, 5,930 recent) patients were included in our study. For ACHD patients, we found no differences in the historical versus recent cohort in utilization of central tMCS (3.31% vs 3.07%, p = .88) or durable MCS (3.31% vs 3.41%, p = .95), whereas the rate of peripheral tMCS increased (2.07% historical vs 6.83% recent, p = .009). Across both cohorts, ACHD patients supported with peripheral tMCS had shorter time-to-transplant than non-supported patients (25.7 vs 121.7 days, p = .002). ACHD patients supported with central tMCS had greater rates of post-transplant mortality relative to other ACHD patients (40.0% vs 12.6%, p = .006), while those supported with durable or peripheral temporary MCS had no differences in waitlist or post-transplant mortality compared to non-supported ACHD patients. CONCLUSIONS: The 2018 UNOS allocation changes increased utilization of peripheral temporary MCS in ACHD patients, decreasing waitlist time without impact on post-transplant outcomes.

Hepatocellular Carcinoma and Liver Transplantation: Changing Patterns and Practices.

OPINION STATEMENT: Benefits of liver transplantation (LT) for patients with hepatocellular carcinoma (HCC) are well established. However, there is debate regarding optimal and equitable selection of patients best served by LT, particularly in the face of limited organ availability. Herein, we discuss topics regarding LT selection criteria for patients with HCC. Recent change in UNOS policy currently mandates a 6-month observation period prior to priority listing and institutes a cap of 34 MELD exception points for patients with HCC. Additionally, two further proposed changes to UNOS policy include (1) requiring locoregional therapy for those with small (2-3 cm) unifocal HCC prior to applying for exception points and (2) allowing downstaging in select patients with UNOS T3 lesions. These policies move beyond simply using tumor burden to using markers of tumor biology for selecting patients who have the lowest risk of post-transplant recurrence and best chance at long-term post-transplant survival. Given increasing time on transplant waiting lists and shortage of donor grafts, LT should be reserved for patients who may achieve significant benefit compared to non-transplant therapies. Potential benefit to HCC patients must be weighed against the harm from delaying or precluding LT for non-HCC patients on the waiting list, particularly in regions with limited donor availability. The relative benefit of LT in patients with small (<3 cm) HCC is likely limited; surgical resection (in absence of portal hypertension) and local ablative therapy (if portal hypertension present) are both efficacious and more cost-effective and should likely be regarded as first line therapies for these patients. Salvage LT can be considered as a rescue option for those with recurrent disease. Downstaging for selected patients with UNOS T3 lesions may identify those with good tumor biology and acceptable post-transplant outcomes; however, current studies have had a wide variation in reported outcomes. While awaiting more data, a standardized downstaging protocol including a priori inclusion criteria and a mandatory waiting time prior to LT to observe tumor biology likely yields the best outcomes.