Trends in Survival on the Pediatric Heart Transplant Waiting List

Introduction : Advancements in pediatric heart failure management and mechanical circulatory support devices necessitate evaluating survival outcomes for children on the heart transplant waiting list. This study examines survival rates of pediatric patients (ages 0-18) on the heart transplant waiting list from 1987-2023. Methods : A retrospective analysis of the UNOS database was conducted for survival of pediatric candidates (ages 0-18) listed for heart transplant from 1987 to 2023. Patients over 18 and combined transplant candidates were excluded, resulting in a total of 18,536 candidates studied. These candidates were followed from listing to death, transplantation, or clinical improvement warranting removal from the waitlist. Analysis : Analysis involved unadjusted and adjusted survival rates, with Kaplan-Meier survival curves and competing risk analysis models used to assess survival. For competing risk analysis, the primary outcome was waitlist mortality, while transplantation and removal from the waiting list due to improvement were competing outcomes. Variables analyzed include demographic data, BMI, dialysis, extracorporeal membrane oxygenation (ECMO), use of ventricular assist devices (VADs), and functional status at listing. Results & Conclusions : One-year survival for pediatric waitlist candidates improved from 21.1% in 1987-1990 to 70.5% in 2021-2023 (P<.05). Adjusted analyses showed a reduction in mortality risk across eras. Survival for pediatric heart transplant candidates has significantly improved over time. Policy changes in allocation and mechanical support advancements have contributed to enhanced outcomes. Future research should refine pediatric transplant criteria and further investigate assist devices' role in improving waitlist survival.