In Reply A new adult heart transplant allocation system was initiated in the US in 2018, with a primary goal to reduce waiting list mortality caused by overcrowding in the top-priority tiers. Under the new system, patients supported by a left ventricular assist device (LVAD) were largely assigned to lower-priority tiers, reflecting improvements in survival over the preceding decade. Patients supported by venoarterial extracorporeal membrane oxygenation (VA-ECMO), who have historically had higher waiting list mortality, retained the highest-priority listing status. One consequence of these changes, highlighted in our recent publication in JAMA Cardiology,1 has been a significant increase in VA-ECMO utilization and decrease in durable LVAD utilization as a bridge to transplant. Thus, within the constraints delineated by the new status justification criteria, there appears to be some exchangeability between the 2 mechanical support platforms that is at the discretion of treating physicians, and the trend toward increased VA-ECMO utilization seems to be driven by new allocation incentives.
Hanff TC, Goldberg LR, Birati EY. Venoarterial Extracorporeal Membrane Oxygenation to Heart Transplant—An Inflamed Bridge?—Reply. JAMA Cardiol. 2021;6(3):362–363. doi:10.1001/jamacardio.2020.6127
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