Exception Statuses Used In Transplantation For LVAD Patients. A OPTN Database Analysis

Purpose Patients supported by left ventricular assist device (LVAD) listed for heart transplant (HT) have a decreased frequency of transplantation, and increased frequency of exception status requests. The purpose of our study was to understand the reason for exception requests and their impact on post-transplant outcomes. Methods Adult patients who received HT while on durable LVAD support between October 18, 2018, and December 31, 2020, were included in this study. Patients were stratified according to the request of an exception status at the time of HT. Clinical characteristics at the time of transplant and post-transplant outcomes were compared between groups. The narratives for exceptions status requests were reviewed.* Results A total of 1120 patients were included in the analysis. Of these, 170 (15.2%) had an exception status at the time of HT. There were significant differences between Non-Exception and Exception LVAD patients (Table 1). In summary, LVAD-Exception patients were more likely to be male, blood type O, on inotropic support, have higher pulmonary artery and pulmonary capillary wedge pressures, and more likely to be supported on HM-2 or HVAD. They were more likely to receive a heart from a younger, male, and undersized donor. In addition, ischemic time and distance from donor hospital were greater in these patients (Table). The most common cause for exception request was right ventricular failure (34.1%), followed by arrhythmia (20%), infection (17.1%), thrombosis (14.7%), device malfunction (5.3%), bleeding (2.9%), aortic regurgitation (2.4%), stroke (1.8%), and multiple causes (1.8%). The 1-year post-transplant survival was similar between exception and non-exceptions status (89.8% vs. 88.2%, p=0.517). Conclusion The current HT allocation system does not appropriately prioritize a significant proportion of patients, thus requiring an exception status. LVAD patients who received HT under an exception status share multiple characteristics associated with prolonged waitlist. Right ventricular failure and arrhythmias are the most common causes for exception request. Patients supported by left ventricular assist device (LVAD) listed for heart transplant (HT) have a decreased frequency of transplantation, and increased frequency of exception status requests. The purpose of our study was to understand the reason for exception requests and their impact on post-transplant outcomes. Adult patients who received HT while on durable LVAD support between October 18, 2018, and December 31, 2020, were included in this study. Patients were stratified according to the request of an exception status at the time of HT. Clinical characteristics at the time of transplant and post-transplant outcomes were compared between groups. The narratives for exceptions status requests were reviewed.* A total of 1120 patients were included in the analysis. Of these, 170 (15.2%) had an exception status at the time of HT. There were significant differences between Non-Exception and Exception LVAD patients (Table 1). In summary, LVAD-Exception patients were more likely to be male, blood type O, on inotropic support, have higher pulmonary artery and pulmonary capillary wedge pressures, and more likely to be supported on HM-2 or HVAD. They were more likely to receive a heart from a younger, male, and undersized donor. In addition, ischemic time and distance from donor hospital were greater in these patients (Table). The most common cause for exception request was right ventricular failure (34.1%), followed by arrhythmia (20%), infection (17.1%), thrombosis (14.7%), device malfunction (5.3%), bleeding (2.9%), aortic regurgitation (2.4%), stroke (1.8%), and multiple causes (1.8%). The 1-year post-transplant survival was similar between exception and non-exceptions status (89.8% vs. 88.2%, p=0.517). The current HT allocation system does not appropriately prioritize a significant proportion of patients, thus requiring an exception status. LVAD patients who received HT under an exception status share multiple characteristics associated with prolonged waitlist. Right ventricular failure and arrhythmias are the most common causes for exception request.