Pediatric heart transplant waiting list mortality in the era of ventricular assist devices

Background Earlier reviews have reported unacceptably high incidence of pediatric heart transplant (PHT) waiting list mortality. An increase in ventricular assist devices (VAD) suggests a potential positive effect. This study evaluated PHT waiting list mortality in the era of pediatric VADs. Methods United Network of Organ Sharing (UNOS) database from 1999 to 2012 showed 5,532 pediatric candidates (aged ≤ 18 years) actively listed for PHT: 2,191 were listed in 1999 to 2004 (Era 1) and 3,341 were listed in 2005 to 2012 (Era 2). Results Waiting list mortality was lower in Era 2 (8%) vs Era 1 (16%; p < 0.001). VAD therapy was used more frequently in Era 2 (16%) than in Era 1 (6%; p < 0.001) and was associated with better waiting list survival ( p < 0.001). There were more UNOS Status 1A patients in Era 2 (80%) vs Era 1 (68%; p < 0.001). Independent predictors of waiting list mortality included weight < 10 kg (odds ratio [OR], 2.7 95% confidence interval [CI], 1.1–6.9), congenital heart disease diagnosis (OR, 2.4; 95% CI, 1.9–3.0), blood type O (OR, 2.2; 95% CI, 1.8–2.8)], extracorporeal membrane oxygenation (OR, 1.5; 95% CI, 1.1–2.2), mechanical ventilation (OR, 1.8; 95% CI, 1.4–2.3), and renal dysfunction (OR 1.6; 95% CI, 1.2–2.0). Independent predictors of survival on the waiting list included VAD therapy (OR 4.2; 95% CI, 2.4–7.6), cardiomyopathy diagnosis (OR 3.3; 95% CI, 2.4–4.6), blood type A (OR, 2.2; 95% CI, 1.8–2.8), UNOS list Status 1B (OR, 1.9; 95% CI, 1.2–3.0), listed in Era 2 (OR 1.8; 95% CI, 1.4–2.2), and white race (OR 1.3; 95% CI, 1.1–1.6). Conclusions Despite an increase in the number of children listed as Status 1A, there was more than a 50% reduction in waiting list mortality in the new era. Irrespective of other factors, patients supported with a VAD were 4 times more likely to survive to transplant.