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Original Investigation
August 12, 2020

Survival on the Heart Transplant Waiting List

Author Affiliations
  • 1Division of Abdominal Transplantation, Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, Texas
  • 2Aga Khan University, Karachi, Pakistan
  • 3Division of Cardiothoracic Transplantation and Circulatory Support, Baylor College of Medicine, Houston, Texas
  • 4University of Houston College of Medicine, HCA Research Institute, Houston, Texas
JAMA Cardiol. 2020;5(11):1227-1235. doi:10.1001/jamacardio.2020.2795
Key Points

Question  What is the current status of survival of patients on the heart transplantation waiting list?

Findings  In a cross-sectional analysis of 95 323 candidates wait-listed for heart transplantation between 1987 and 2017, associations were consistent with improvements in survival outcomes.

Meaning  Although not a replacement for heart transplant, continued improvement in heart failure therapy outcomes were associated with a survival benefit while patients awaited heart transplantation, although listing practices remain highly variable among centers; this finding may support a future approach of incorporating this survival benefit into the indications for heart transplantation.


Importance  With continuing improvements in medical devices and more than a decade since the 2006 United Network for Organ Sharing (UNOS) allocation policy, it is pertinent to assess survival among patients on the heart transplantation waiting list, especially given the recently approved 2018 UNOS allocation policy.

Objectives  To assess survival outcomes among patients on the heart transplant waiting list during the past 3 decades and to examine the association of ventricular assist devices (VADs) and the 2006 UNOS allocation policy with survival.

Design, Setting, and Participants  A retrospective cross-sectional used the UNOS database to perform an analysis of 95 323 candidates wait-listed for heart transplantation between January 1, 1987, and December 29, 2017. Candidates for all types of combined transplants were excluded (n = 2087). Patients were followed up from the time of listing to death, transplantation, or removal from the list due to clinical improvement. Competing-risk, Kaplan-Meier, and multivariable Cox proportional hazards regression analyses were used.

Main Outcomes and Measures  The analysis involved an unadjusted and adjusted survival analysis in which the primary outcome was death on the waiting list. Because of changing waiting list preferences and policies during the study period, the intrinsic risk of death for wait-listed candidates was assessed by individually analyzing, comparing, and adjusting for several candidate risk factors.

Results  In total, 95 323 candidates (72 915 men [76.5%]; mean [SD] age, 51.9 [12.0] years) were studied. In the setting of changes in listing preferences, 1-year survival on the waiting list increased from 34.1% in 1987-1990 to 67.8% in 2011-2017 (difference in proportions, 0.34%; 95% CI, 0.32%-0.36%; P < .001). The 1-year waiting list survival for candidates with VADs increased from 10.2% in 1996-2000 to 70.0% in 2011-2017 (difference in proportions, 0.60%; 95% CI, 0.58%-0.62%; P < .001). Similarly, in the setting of changing mechanical circulatory support indications, the 1-year waiting list survival for patients without VADs increased from 53.9% in 1996-2000 to 66.5% in 2011-2017 (difference in proportions, 0.13%; 95% CI, 0.12%-0.14%; P < .001). In the decade prior to the 2006 UNOS allocation policy, the 1-year waiting list survival was 51.1%, while in the decade after it was 63.9% (difference in proportions, 0.13%; 95% CI, 0.12%-0.14%; P < .001). In adjusted analysis, each time period after 1987-1990 had a marked decrease in waiting list mortality.

Conclusions and Relevance  This study found temporally associated increases in heart transplant waiting list survival for all patient groups (with or without VADs, UNOS status 1 and status 2 candidates, and candidates with poor functional status).