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Heart

OPTN/SRTR 2018 Annual Data Report: Heart

Abstract

The new adult heart allocation policy was approved in 2016 and implemented in October 2018, so its effect was not yet evident in 2018 data. However, the more granular data being collected are anticipated to allow for improved analyses. In 2018, new listings continued to increase; 3883 new adult and 685 new pediatric candidates were added. In 2018, 3440 heart transplants were performed, an increase of 167 over 2017; 473 transplants occurred in pediatric recipients and 2967 in adult recipients. Short-term and long-term posttransplant mortality improved. Overall 1-year survival for adults who underwent heart transplant in 2011-2013 was 90.3%, 3-year survival was 84.7%, and 5-year survival was 79.6%. Mortality rates for pediatric recipients were 4.5% at 6 months and in 5.9% at 1 year posttransplant, 12.5% at 3 years for transplants in 2014-2015, 14.8% at 5 years for transplants in 2012-2013, and 29.8% at 10 years for transplants performed in 2008-2009.

Introduction

The new adult heart allocation policy was approved in 2016 and implemented in October 2018. Its goal is to better stratify heart transplant candidates and to broaden sharing for higher urgency statuses to reduce waitlist mortality. While it is too early to discern the impact of the new policy, the more granular data being collected as part of the new system are anticipated to allow for improved analyses of outcomes and risk factors, which will contribute to a more dynamic policy. The current Annual Data Report provides an early glimpse into the distribution of patients under the new allocation system.

Adult Heart Transplant

Waitlist Trends

Between 2009 and 2018, the number of new active listings for heart transplant increased by 33.7%, from 2810 to 3756 (Figure HR 1). The number of candidates actively awaiting heart transplant increased by 39.7% since 2009, from 1858 to 2596 (Figure HR 2); however, since 2015, the number of active patients on the list at the end of the year declined, and the number of inactive patient declined then increased slightly. Some remarkable demographic trends in heart transplantation include the following: a continued increase in the proportion of heart transplant candidates aged 65 years or older to 18.7% in 2018 (Figure HR 3); stable proportions of racial/ethnic minorities, with black candidates comprising a slightly smaller proportion of waitlist candidates, 24.8%, and whites candidates a slightly higher proportion, 62.4% (Figure HR 5); and a slight increase in patients with congenital heart disease (Figure HR 6). In 2018, 63% of candidates had been on the waiting list for less than 1 year, a slight increase since 2008. In 2008, 12.9% of candidates had been on the waiting list 5 years or longer; this proportion gradually declined to 4.0% in 2018, the lowest in the past decade (Figure HR 7). The proportion of candidates awaiting transplant as status 1A continued to increase, 48.1% in 2018 (Figure HR 8). The proportion of status 1B candidates increased similarly but reached a plateau over the past 4 years, while the proportion waiting as status 2 declined from 25.7% in 2008 to 14.2% in 2018. Note that new status groups in use as of October, 2018 were converted to former status 1A, 1B and 2 equivalents for the 2018 data point (see Preface). The proportion of candidates with ventricular assist devices (VADs) at listing increased from 11.8% in 2008 to 32.6% in 2018 (Figure HR 9). Sex distribution has not changed appreciably: in 2018, women comprised 26% of heart transplant candidates (Figure HR 4). In 2018, 85.5% of candidates resided in a metropolitan area (Table HR 1).The proportion of candidates within 50 miles of the transplant program increased from 56.3% in 2008 to 62.1% in 2018, and proportions of those at greater distances decreased. Candidates with a prior heart transplant declined from 4.3% in 2008 to 2.9% in 2018 (Table HR 3). In 2018, 206 candidates were listed for heart-kidney transplant, a substantial increase since 2008, while those listed for heart-lung transplants decreased to only 42 (1.23%) in 2018 (Table HR 3).

The distribution of candidates by status on December 31 in 2017 and 2018 is shown in Table HR 4. At the end of 2018, 47.8% of candidates were listed as new status 4, similar to the proportion listed as former status 1B at the end of 2017. Only 7 patients, or 0.2%, were listed as new status 1 (Table HR 4). The number of patients receiving any life support prior to transplant increased from 1791 in 2013 to 2402 in 2018 (Table HR 7). Of these, 43.6% had left VADs (LVADs), an increase of 342 over the 5-year period. While the proportion of LVADs and inotropes declined slightly since 2013, intra-aortic balloon pump (IABP) use increased from 5.7% to 9.1% and extracorporeal membrane oxygenation (ECMO) use increased from 0.7% to 2.0%. In 2018, 270 candidates used IABP, compared with 123 in 2013, and 58 used ECMO, compared with 15 in 2013. Candidates with total artificial hearts and right VADs declined to just 1% and 1.6%, respectively (Table HR 7).

Between 2008 and 2018, heart transplant rates fluctuated, reaching a nadir of 61.5 per 100 waitlist-years in 2015, followed by an increase to a decade high of 82.0 per 100 waitlist-years in 2018 (Figure HR 14). This trend was similar for all age groups, blood types, and status groups (Figure HR 11, Figure HR 13, Figure HR 14). For most groups, transplant rates since 2007 reached a nadir in 2014 and 2015 and have increased since. Trends were similar for black and Hispanic candidates, but transplant rates did not recover at the same magnitude as for other groups and overall declined since 2008. The transplant rate for blacks declined from 82.0 per 100 waitlist-years in 2008 to 69.2 in 2018, and for Hispanics from 90.2 per 100 waitlist-years to 80.Transplant rates increased in all age groups since 2015, but to a greater extent for candidates aged 65 or older. The transplant rate for these candidates exceeded that for all the other age groups, at 109.4 per 100 waitlist-years. Despite the overall increase, the transplant rate remained lowest for candidates aged 35-49 years, 69.6 per 100 waitlist-years.

Transplant rates have consistently been highest for candidates with blood type AB (199.4 per 100 waitlist-years) and for those listed as status 1A (302.2 per 100 waitlist-years). In 2018, blood type O candidates underwent transplant at a rate of 58.0 per 100 waitlist-years, nearly half the rate of blood type A and B candidates and 29% of the rate of blood type AB candidates. Candidates with blood type A underwent transplant at a rate of 106.1 per 100 waitlist-years, higher than in previous years, and higher than candidates with blood type B. Despite a decline in transplant rates between 2007 and 2015, since then, rates have increased for nearly all groups. In 2018, candidates residing in non-metropolitan areas underwent transplant at slightly higher rates than those in metropolitan areas, 84.6 per 100 waitlist-years vs. 81.7 (Figure HR 15). Although trends based on candidate distance from the donor hospital have been similar over the past decade, in 2018, candidates residing 100-<250 nautical miles (NM) from the donor hospital underwent transplant at the highest rate, 85.7 per 100 waitlist-years, and those residing 50-<100 NM away at the lowest rate, 80.4 per 100 waitlist-years (Figure HR 16).

The median waiting time in 2017-2018 was 6.9 months (Figure HR 18). The lowest median time to transplant of the decade occurred in 2007-2008. A peak of 11.6 months occurred in 2013-2014, followed by a gradual decline. In 2017-2018, median waiting time was longest for blood type O candidates, 13.5 months (Figure HR 19); status 2 candidates, 16.72 months; and candidates with body mass index ? 31 kg/m2, 11.2 months (Figure HR 20, Figure HR 21). Waiting time decreased for all status groups and was lowest for status 1A, 1.97 months. Women waited on average 4.9 months, and men 7.9 months (Figure HR 18). Median waiting time was lowest of all groups for candidates with blood type AB, 1.5 months. Since 2007, the proportion of candidates undergoing transplant within 1 year of listing declined overall, but increased from 48.6% in 2014 to 57.2% in 2017. Of candidates listed in 2017, 33.3% underwent transplant within 3 months and 45.5% within 6 months (Figure HR 22). When stratified by donation service area (DSA), the proportion of candidates undergoing transplant within 1 year of listing in 2017 varied from 23.1% to 94.1% (Figure HR 23). Similar variability occurred by state, ranging from 25.0% to 100% (n = 3) (Figure HR 24).

Among candidates listed in 2015, 51.5% underwent transplant during the first year on the waiting list, 31.9% were still waiting, 9.4% were removed from the list, and 7.2% had died (Figure HR 17). At 3 years, 66.0% had undergone transplant, 8.1% were still waiting, 17.4% had been removed from the list, and 8.5% had died.

Since 2007-2008, pretransplant mortality declined from 16.6 to 10.8 deaths per 100 waitlist-years in 2017-2018 (Figure HR 25). Pretransplant mortality declined for all groups except candidates with valvular heart disease, unknown etiology, and unknown ethnicity. Pretransplant mortality was lowest for candidates aged 18-34 years and those listed as status 2, 7.3 deaths per 100 waitlist-years. Pretransplant mortality declined by more than 50% for candidates aged 18-34 years, from 15.4 per 100 wait-list deaths in 2007-2008 to 7.3 in 2017-2018 (Figure HR 25, Figure HR 29). Pretransplant mortality declined substantially over the past decade for black, Hispanic, and Asian candidates. In 2017-2018, pretransplant mortality was lowest for blacks, 9.2 deaths per 100 waitlist-years (Figure HR 26). In 2007-2008, pretransplant mortality for LVAD candidates was more than twice that for non-LVAD candidates, 38.3 vs. 15.0 deaths per 100 waitlist-years. However, pretransplant mortality declined substantially for LVAD candidates, to 10.2 deaths per 100 waitlist-years in 2017-2018. Pretransplant mortality for non-VAD candidates was 11.1 deaths per 100 waitlist-years in 2017-2018. Since 2013-2014, pretransplant mortality has been lower in VAD than in non-VAD candidates (Figure HR 30). Pretransplant mortality rates remained highest among candidates listed as status 1A, as might be expected, but declined dramatically between 2007-2008 and 2009-2010, from 71.9 deaths per 100 waitlist-years to 49.3 (Figure HR 29), followed by a gradual decline to 30.1 in 2017-2018. Similarly, pretransplant mortality among candidates listed as status 1B declined from 32.5 to 8.7 deaths per 100 waitlist-years. Pretransplant mortality was slightly higher for candidates residing in nonmetropolitan areas than for those in metropolitan areas (Figure HR 31), and varied by DSA from 3.3 to 25.1 deaths per 100 waitlist-years (Figure HR 34).

Among candidates removed from the waiting list for reasons other than transplant, 16.9% died within 6 months of removal in 2018, although data from only the first half of 2018 were available. The overall trend showed a decline in patients who died within 6 months of removal from the waiting list, despite fluctuation and an increase to 33.2% in 2013 (Figure HR 35). In 2017, 172 patients died within 6 months of removal from the waiting list. In 2017, 47.9% of candidates listed as status 1A died within 6 months of removal. The percentage of candidates aged 18-34 years who died within 6 months followed a similar trend and decreased to 7.7% in 2017, but increased to 19.5% in 2018 (Figure HR 36).

Donor Trends

The number of deceased heart donations continued to increase; 3443 deceased donors in 2018 was the highest number to date, and an increase of 52% since 2007. While the number of donors increased in all age groups over the past decade, the greatest increase was donors aged 18-34 years, from 1039 in 2008 to 1706 in 2018 (Figure HR 37); the highest proportion of donors, 50%, were in this age group (Figure HR 38). Among donors 2014-2018, the number of pediatric heart donors in a DSA ranged from 2 to 164. The proportion of pediatric donor hearts that were transplanted into adults varied by DSA from 0% to 64% (Figure HR 41). The rate of discards, that is, the proportion of recovered hearts that were not transplanted, has fluctuated over the past decade and in 2018 was 0.8% (Figure HR 42). Although discards were highest in age group 50 years or older, they declined in this age group from 3.3% in 2015-2016 to 1.8% in 2017-2018. The discard rate for Public Health Service (PHS) high risk donors was 1.0% compared with 0.7% for non-PHS high risk donors (Figure HR 43).

Head trauma as cause of donor death continued to decline in prevalence and in 2018 was 43.0%. Conversely, anoxia continued to increase in prevalence to 41.6% of donors in 2018, second to head trauma (Figure HR 44). In 2007, anoxia was the cause of death for only 15.0% of donors. The increase in anoxic deaths may be partially attributable to the rise in opioid deaths.

Overall Trends in Heart Transplant

The general trend has been an increase in heart transplants over the past decade (Figure HR 45). In 2018, 3440 heart transplants were performed, an increase of 167 over 2017; 473 transplants occurred in pediatric recipients and 2967 in adult recipients (Figure HR 45). Pediatric heart transplants declined between 2015 and 2017, but increased by 41 since then. In 2018, six fewer transplants were performed in recipients aged 18-34 years, but transplants increased for all other age groups, with the largest number, 1407, in recipients aged 50-64 years (Figure HR 46). In 2018, 2028 heart transplants were performed for cardiomyopathy (Figure HR 49). The number of recipients who underwent transplant at status 1A more than doubled, from 1108 in 2007 to 2439 in 2018, representing 71% of all transplants. The number of status 1B recipients has fluctuated, but decreased from 954 in 2017 to 868 in 2018. Of note, 133 transplants were performed in status 2 patients, the highest since 2011 and an increase of 48 over 2017 (Figure HR 50). Note that new status groups in use as of October, 2018 were converted to former status 1A, 1B and 2 equivalents for the 2018 data point.

In 2018, 84.2% of recipients resided in metropolitan areas, and 61.2% lived within 50 miles of the transplant program (Table HR 8). In 2018, 46.2% of recipients had LVADs. The number of recipients with VADs at the time of transplant increased from 519 in 2013 to 1370 in 2018 (Table HR 9). Although 28.9% of patients underwent transplant within 31 days of listing in 2018, the proportion who waited 1 year or longer increased over the past decade: 18.3% in 2018 vs. 9.5% in 2008 (Table HR 10). Multi-organ transplant accounted for 9.1% of heart transplants; 202 heart-kidney transplants were performed in 2018 compared with 63 in 2008 (Table HR 10).

Use of induction therapy has changed little since 2007. In 2018, 51.7% of adult heart transplant recipients received either IL2-RA or T-cell depleting therapy (Figure HR 51), 96.6% received a tacrolimus-based immunosuppression regimen, and 3.4% received other regimens (Figure HR 52).

In 2018, the median transplant program volume was 19 transplants per year, increased since 2008, but at a plateau since 2015 (Figure HR 54). The percentage transplants performed at low-volume programs (0 to 9 transplants per year) declined to 4.0% in 2018, compared with 10.7% in 2008. The proportion transplants performed at programs with volumes of 60 or more transplants fluctuated, peaking at 21.1% in 2017 and declining to 15.5% in 2018 (Figure HR 55). Overall, however, high-volume programs have increased over the past decade. Between 2007 and 2015, most heart transplants occurred at programs performing 10-29 per year; more recently, this shifted to programs performing 30-59 transplants per year, where 44.6% were performed in 2018 (Table HR 55).

Posttransplant Survival and Morbidity

Overall 1-year survival for patients who underwent heart transplant in 2011-2013 was 90.3%, 3-year survival was 84.7%, and 5-year survival was 79.6% (Figure HR 56). One-year survival in most subgroups was similar, but tended to be lower among recipients aged 65 years or older (Figure HR 56) and Hispanic recipients (Figure HR 57). Survival tended to be better for Asian recipients at all time-points. Survival at 1 year was similar for recipients with VADs, IABPs, and without circulatory support; however, survival was lower at 3 and 5 years for recipients with IABPs, 79.9% and 74.6%, respectively (Figure HR 59). Early survival was lower for re-transplant recipients, but by 5 years was similar to those undergoing a first transplant (Figure HR 60). Survival tended to be worse for recipients residing 250 miles or farther from the transplant program than for those residing closer at 1, 3, and 5 years, and was the lowest 1-, 3-, and 5-year survival of all groups (Figure HR 63). Since 2001, short- and long-term death rates have declined. Among recipients who underwent transplant In 2017, 7.0% died at 6 months and 9.0% died at 1 year (Figure HR 64). Ten-year mortality remained high at 38.2% among those who underwent transplant in 2008, although this has declined from 43.0% among those who underwent transplant in 2001. The number of heart transplant survivors has increased by over 11,000 since 2007. On June 30, 2018, 33,885 heart transplant recipients were alive with a functioning graft, compared with 32,151 in 2017. Most survivors were aged 50 years or older at the time of transplant (Figure HR 65).

The incidence of acute rejection in the first year posttransplant was 27.0% for recipients undergoing transplant in 2016-2017 (Figure HR 66). Rejection occurred more frequently in younger patients, 32.0% of recipients aged 18-34 years compared with 23.1% of those aged 65 years or older. Posttransplant lymphoproliferative disorder (PTLD) occurred in 1.0% of recipients by year 5, but more frequently, 3.5%, in those who were seronegative for Epstein Barr virus (EBV) (Figure HR 68). The most common documented cause of death in the first posttransplant year was cardiovascular/cerebrovascular disease (Figure HR 69), and in years 2 through 5 (Figure HR 70). Malignancy was a relatively infrequent cause of death, 1.4% at 5 years (Figure HR 70).

Pediatric Heart Transplant

Pediatric Waitlist Trends

In 2018, 685 new pediatric candidates were added to the heart transplant waiting list, with few at inactive status (Figure HR 71). At year-end 2018, 395 candidates listed before their eighteenth birthdays were awaiting heart transplant, 73.2% active (Figure HR 72). Over the past decade, the proportion of inactive candidates at year-end decreased from 56.9% in 2007 to 26.8% in 2018. The largest pediatric age group on the waiting list in 2018 was 11-17 years (33.4%), followed by 1-5 years (26.9%), younger than 1 year (26.1%), and 6-10 years (13.6%) (Figure HR 73). Just over half of pediatric heart transplant candidates were white, 20.6% were black, 19.6% were Hispanic, and 4.2% were Asian (Figure HR 74). Over the past decade, the proportion of pediatric heart candidates with congenital defects increased from 41.6% in 2007 to 55.8% in 2018 (Figure HR 75). Considering trends over time, the age and race of waitlisted candidates has remained relatively unchanged (Table HR 13). For candidates waiting on December 31, 2018, congenital defect was the leading cause of heart disease at 62.2%, increased from 48.0% in 2008 (Table HR 14). The proportions of heart transplant candidates listed as status 1B and status 2 increased over the past decade, likely reflecting changes to pediatric heart allocation policy implemented in 2016. The percentage of candidates using VADs at the time of listing remained stable, from 4.0% in 2008 to 6.6% in 2018 (Table HR 14). A smaller proportion of candidates were listed for heart-lung transplant in 2018, 0.6% compared with 5.6 % in 2008 (Table HR 15). Among the 674 candidates removed from the waiting list in 2018, 486 (72.1%) were removed due to undergoing transplant, 77 (11.4%) died, 62 (9.2%) were removed due to improved condition, and 31 (4.6%) were considered too sick to undergo transplant (Table HR 16, Table HR 17).

Just over 70% of pediatric candidates newly listed in 2015 underwent transplant within 3 years, 13.0% died, 11.8% were removed from the list, and 4.2% were still waiting (Figure HR 79). The rate of heart transplants among pediatric waitlist candidates has remained relatively stable over the past decade, and was 117.7 per 100 waitlist-years in 2018 (Figure HR 80). Transplant rates varied by age; rates were highest for candidates aged younger than 1 year, at 183.0 transplants per 100 waitlist-years in 2018, followed by candidates aged 11-17 years, at 117.7 transplants per 100 waitlist-years (Figure HR 80). Pretransplant mortality decreased over the past decade, from 27.6 deaths per 100 waitlist-years in 2007-2008 to 17.6 in 2017-2018 (Figure HR 83). By age, pretransplant mortality rates were highest for candidates aged younger than 1 year, at 41.1 deaths per 100 waitlist-years in 2017-2018, followed by 14.4 deaths per 100 waitlist-years for ages 1-5 years, 11.1 for ages 6-10 years, and 7.1 for ages 11-17 years (Figure HR 83). By medical urgency status, pretransplant mortality was highest for status 1A (46.6 deaths per 100 waitlist-years) and 1B (11.4) candidates, compared with 3.7 for status 2 candidates (Figure HR 85).

Pediatric Trends in Heart Transplant

Pediatric transplant recipients are defined as those aged 18 years or younger at the time of transplant. The number of pediatric heart transplants performed each year continued to increase, to 473 in 2018 from 330 in 2007 (Figure HR 89). In 2018, 27 of 138 total heart transplant programs performed pediatric heart transplants exclusively, 77 performed only adult heart transplants, and 26 performed both adult and pediatric heart transplants (Figure HR 90). In 2018, 7.8% of transplants in recipients aged younger than 10 years were performed at programs with volume of five or fewer pediatric transplants in that year (Figure HR 91). Over the past decade, the age, sex, and race/ethnicity of pediatric heart transplant recipients changed little (Table HR 18).The proportion of recipients with private insurance decreased over the decade and the proportion with Medicaid increased (Table HR 18). Congenital defects remained the most common primary cause of disease, affecting 50.1% of recipients who underwent transplant in 2016-2018 (Table HR 19). The proportion of patients who underwent transplant at status 1A and 1B increased over the decade, and the proportion at status 2 decreased. VAD use at the time of transplant increased from 13.1% of transplant recipients in 2006-2008 to 28.4% in 2016-2018 (Table HR 19). The proportion of ABO-incompatible transplants in 2016-2018 increased 3-fold to 9.9% from 3.3% a decade earlier (Table HR 20).

In 2018, use of T-cell depleting agents for induction continued to increase, to 74.6% of pediatric heart transplant recipients; use of interleukin-2 receptor antagonists decreased to 8.2% (Figure HR 92). The initial immunosuppression regimen used most commonly shifted in 2018 to more recipients using tacrolimus and MMF (47.5%) with a reciprocal decrease in those using tacrolimus, MMF, and steroid (39.0%) (Figure HR 93).

Pediatric Posttransplant Survival and Morbidity

Among pediatric heart transplant recipients 2016-2017, the rate of acute rejection in the first year was 18.8% overall; the highest rate was 23.4% in recipients aged 11-17 years, and the lowest was 15.8% in recipients aged younger than 6 years (Figure HR 96). Among pediatric heart transplant recipients 2016-2018, the combination of a CMV-positive donor and CMV-negative recipient occurred in 28.1% of transplants; for EBV, this combination occurred in 28.7% of transplants (Table HR 22).

Recipient death occurred in 4.5% of patients at 6 months posttransplant and in 5.9% at 1 year posttransplant among pediatric heart transplants performed in 2016-2017, in 12.5% of patients at 3 years posttransplant for transplants performed in 2014-2015, in 14.8% of patients at 5 years posttransplant for transplants performed in 2012-2013, and in 29.8% of patients at 10 years posttransplant for transplants performed in 2008-2009 (Figure HR 99). Overall, 1-year and 5-year patient survival were 90.9% and 81.5%, respectively, among recipients who underwent transplant in 2006-2013 (Figure HR 100). By age, 5-year patient survival was 76.9% for recipients aged younger than 1 year, 82.9% for ages 1-5 years, 87.1% for ages 6-10 years, and 82.4% for ages 11-17 years (Figure HR 100). The leading identified causes of death in the first 12 months posttransplant among recipients from 2016-2017 were infection (1.4%) and cardio/cerebrovascular disease (1.4%) (Figure HR 101). At 5 years posttransplant, the leading causes were graft failure (3.9%) and cardio/cerebrovascular disease (3.7%) (Figure HR 102).

The overall incidence of PTLD was 4.1% at 5 years posttransplant; incidence was 5.3% among EBV-negative recipients and 3.1% among EBV-positive recipients (Figure HR 98).

Figure List

Waiting list

Figure HR 1. New adult candidates added to the heart transplant waiting list
Figure HR 2. Adults listed for heart transplant on December 31 each year
Figure HR 3. Distribution of adults waiting for heart transplant by age
Figure HR 4. Distribution of adults waiting for heart transplant by sex
Figure HR 5. Distribution of adults waiting for heart transplant by race
Figure HR 6. Distribution of adults waiting for heart transplant by diagnosis
Figure HR 7. Distribution of adults waiting for heart transplant by waiting time
Figure HR 8. Distribution of adults waiting for heart transplant by medical urgency
Figure HR 9. Distribution of adults waiting for heart transplant by VAD status at listing
Figure HR 10. Distribution of adults waiting for heart transplant by blood type
Figure HR 11. Deceased donor heart transplant rates among adult waitlist candidates by age
Figure HR 12. Deceased donor heart transplant rates among adult waitlist candidates by race
Figure HR 13. Deceased donor heart transplant rates among adult waitlist candidates by blood type
Figure HR 14. Deceased donor heart transplant rates among adult waitlist candidates by medical urgency
Figure HR 15. Deceased donor heart transplant rates among adult waitlist candidates by metropolitan vs. non-metropolitan residence
Figure HR 16. Deceased donor heart transplant rates among adult waitlist candidates by distance from listing center
Figure HR 17. Three-year outcomes for adults waiting for heart transplant, new listings in 2015
Figure HR 18. Median months to heart transplant for waitlisted adults by sex
Figure HR 19. Median months to heart transplant for waitlisted adults by blood type
Figure HR 20. Median months to heart transplant for waitlisted adults by medical urgency at listing
Figure HR 21. Median months to heart transplant for waitlisted adults by BMI at listing
Figure HR 22. Percentage of adults who underwent deceased donor heart transplant within a given time period of listing
Figure HR 23. Percentage of adults who underwent deceased donor heart transplant within 1 year of listing in 2017 by DSA
Figure HR 24. Percentage of adults who underwent deceased donor heart transplant within 1 year of listing in 2017 by state
Figure HR 25. Pretransplant mortality rates among adults waitlisted for heart transplant by age
Figure HR 26. Pretransplant mortality rates among adults waitlisted for heart transplant by race
Figure HR 27. Pretransplant mortality rates among adults waitlisted for heart transplant by sex
Figure HR 28. Pretransplant mortality rates among adults waitlisted for heart transplant by diagnosis
Figure HR 29. Pretransplant mortality rates among adults waitlisted for heart transplant by medical urgency
Figure HR 30. Pretransplant mortality rates among adults waitlisted for heart transplant by VAD at listing
Figure HR 31. Pretransplant mortality rates among adults waitlisted for heart by metropolitan vs. non-metropolitan residence
Figure HR 32. Pretransplant mortality rates among adults waitlisted for heart, by distance from listing center
Figure HR 33. Pretransplant mortality rates among adults waitlisted for heart, by active/inactive status
Figure HR 34. Pretransplant mortality rates among adults waitlisted for heart transplant in 2017-2018, by DSA
Figure HR 35. Deaths within six months after removal among adult heart waitlist candidates, by status at removal
Figure HR 36. Deaths within six months after removal among adult heart waitlist candidates, by age at removal

Deceased donation

Figure HR 37. Deceased heart donor count by age
Figure HR 38. Distribution of deceased heart donors by age
Figure HR 39. Distribution of deceased heart donors by sex
Figure HR 40. Distribution of deceased heart donors by race
Figure HR 41. Percent of pediatric donor hearts allocated to adult recipients, by DSA of donor hospital, 2014-2018
Figure HR 42. Rates of hearts recovered for transplant and not transplanted by donor age
Figure HR 43. Rates of hearts recovered for transplant and not transplanted, by donor risk of disease transmission
Figure HR 44. Cause of death among deceased heart donors

Transplant

Figure HR 45. Total heart transplants
Figure HR 46. Total heart transplants by age
Figure HR 47. Total heart transplants by sex
Figure HR 48. Total heart transplants by race
Figure HR 49. Total heart transplants by diagnosis
Figure HR 50. Total heart transplants by medical urgency
Figure HR 51. Induction agent use in adult heart transplant recipients
Figure HR 52. Immunosuppression regimen use in adult heart transplant recipients
Figure HR 53. Total HLA A, B, and DR mismatches among adult deceased donor heart transplant recipients, 2014-2018
Figure HR 54. Annual adult heart transplant center volumes, by percentile
Figure HR 55. Distribution of adult heart transplants by annual center volume

Outcomes

Figure HR 56. Patient survival among adult heart transplant recipients, 2011-2013, by age
Figure HR 57. Patient survival among adult heart transplant recipients, 2011-2013, by race
Figure HR 58. Patient survival among adult heart transplant recipients, 2011-2013, by sex
Figure HR 59. Patient survival among adult heart transplant recipients, 2011-2013, by circulatory support
Figure HR 60. Patient survival among adult heart transplant recipients, 2011-2013, by first vs. retransplant
Figure HR 61. Patient survival among adult heart transplant recipients, 2011-2013, by medical urgency
Figure HR 62. Patient survival among adult heart transplant recipients, 2011-2013, by metropolitan vs. non-metropolitan recipient residence
Figure HR 63. Patient survival among adult heart transplant recipients, 2011-2013, by recipients' distance from transplant center
Figure HR 64. Patient death among adult heart transplant recipients
Figure HR 65. Recipients alive with a functioning heart graft on June 30 of the year, by age at transplant
Figure HR 66. Incidence of acute rejection by 1 year posttransplant among adult heart transplant recipients by age, 2016-2017
Figure HR 67. Incidence of acute rejection by 1 year posttransplant among adult heart transplant recipients by induction agent 2016-2017
Figure HR 68. Incidence of PTLD among adult heart transplant recipients by recipient EBV status at transplant, 2012-2016
Figure HR 69. One-year cumulative incidence of death by cause among adult heart recipients, 2016-2017
Figure HR 70. Five-year cumulative incidence of death by cause among adult heart recipients, 2012-2013

Pediatric transplant

Figure HR 71. New pediatric candidates added to the heart transplant waiting list
Figure HR 72. Pediatric candidates listed for heart transplant on December 31 each year
Figure HR 73. Distribution of pediatric candidates waiting for heart transplant by age
Figure HR 74. Distribution of pediatric candidates waiting for heart transplant by race
Figure HR 75. Distribution of pediatric candidates waiting for heart transplant by diagnosis
Figure HR 76. Distribution of pediatric candidates waiting for heart transplant by sex
Figure HR 77. Distribution of pediatric candidates waiting for heart transplant by waiting time
Figure HR 78. Distribution of pediatric candidates waiting for heart transplant by medical urgency
Figure HR 79. Three-year outcomes for newly listed pediatric candidates waiting for heart transplant, 2015
Figure HR 80. Deceased donor heart transplant rates among pediatric waitlist candidates by age
Figure HR 81. Deceased donor heart transplant rates among pediatric waitlist candidates by metropolitan vs. non-metropolitan residence
Figure HR 82. Deceased donor heart transplant rates among pediatric waitlist candidates by distance from listing center
Figure HR 83. Pretransplant mortality rates among pediatrics waitlisted for heart transplant by age
Figure HR 84. Pretransplant mortality rates among pediatrics waitlisted for heart transplant by race
Figure HR 85. Pretransplant mortality rates among pediatrics waitlisted for heart transplant by diagnosis
Figure HR 86. Pretransplant mortality rates among pediatrics waitlisted for heart transplant by medical urgency
Figure HR 87. Pretransplant mortality rates among pediatrics waitlisted for heart transplant by metropolitan vs. non-metropolitan residence
Figure HR 88. Pretransplant mortality rates among pediatrics waitlisted for heart transplant by distance from listing center
Figure HR 89. Pediatric heart transplants by recipient age
Figure HR 90. Number of centers performing pediatric and adult heart transplants by center's age mix
Figure HR 91. Pediatric heart recipients at programs that perform 5 or fewer pediatric transplants annually
Figure HR 92. Induction agent use in pediatric heart transplant recipients
Figure HR 93. Immunosuppression regimen use in pediatric heart transplant recipients
Figure HR 94. Induction use by C/PRA among pediatric heart transplant recipients, 2014-2018
Figure HR 95. Total HLA A, B, and DR mismatches among pediatric deceased donor heart transplant recipients, 2014-2018
Figure HR 96. Incidence of acute rejection by 1 year posttransplant among pediatric heart transplant recipients by age, 2016-2017
Figure HR 97. Incidence of acute rejection by 1 year posttransplant among pediatric heart transplant recipients by induction agent 2016-2017
Figure HR 98. Incidence of PTLD among pediatric heart transplant recipients by recipient EBV status at transplant, 2006-2016
Figure HR 99. Patient death among pediatric heart transplant recipients
Figure HR 100. Patient survival among pediatric deceased donor heart transplant recipients, 2006-2013, by age
Figure HR 101. One-year cumulative incidence of death by cause among pediatric heart recipients, 2016-2017
Figure HR 102. Five-year cumulative incidence of death by cause among pediatric heart recipients, 2012-2013

Table List

Waiting list

Table HR 1. Demographic characteristics of adults on the heart transplant waiting list on December 31, 2008 and December 31, 2018
Table HR 2. Clinical characteristics of adults on the heart transplant waiting list on December 31, 2008 and December 31, 2018
Table HR 3. Listing characteristics of adults on the heart transplant waiting list on December 31, 2008 and December 31, 2018
Table HR 4. Status of adults on the heart waiting list on December 31, 2017 and December 31, 2018
Table HR 5. Heart transplant waitlist activity among adults
Table HR 6. Removal reason among adult heart transplant candidates

Transplant

Table HR 7. Adult heart recipients on circulatory support before transplant
Table HR 8. Demographic characteristics of adult heart transplant recipients, 2008 and 2018
Table HR 9. Clinical characteristics of adult heart transplant recipients, 2008 and 2018
Table HR 10. Transplant characteristics of adult heart transplant recipients, 2008 and 2018
Table HR 11. Status of adult heart transplant recipients, November-December 2017 and 2018
Table HR 12. Adult heart donor-recipient serology matching, 2016-2018

Pediatric transplant

Table HR 13. Demographic characteristics of pediatric candidates on the heart transplant waiting list on December 31, 2008 and December 31, 2018
Table HR 14. Clinical characteristics of pediatric candidates on the heart transplant waiting list on December 31, 2008 and December 31, 2018
Table HR 15. Listing characteristics of pediatric candidates on the heart transplant waiting list on December 31, 2008 and December 31, 2018
Table HR 16. Heart transplant waitlist activity among pediatric candidates
Table HR 17. Removal reason among pediatric heart transplant candidates
Table HR 18. Demographic characteristics of pediatric heart transplant recipients, 2006-2008 and 2016-2018
Table HR 19. Clinical characteristics of pediatric heart transplant recipients, 2006-2008 and 2016-2018
Table HR 20. Transplant characteristics of pediatric heart transplant recipients, 2006-2008 and 2016-2018
Table HR 21. Pediatric heart recipients on circulatory support before transplant
Table HR 22. Pediatric heart donor-recipient serology matching, 2016-2018

A line plot for new adult candidates added to the heart transplant waiting list; the active category increases by 50.8% from 2490 candidates at 2007 to 3756 candidates at 2018; the inactive category increases by 12.4% from 113 candidates at 2007 to 127 candidates at 2018; and the all category increases by 49.2% from 2603 candidates at 2007 to 3883 candidates at 2018.

Figure HR 1. New adult candidates added to the heart transplant waiting list
A new candidate is one who first joined the list during the given year, without having been listed in a previous year. Previously listed candidates who underwent transplant and subsequently relisted are considered new. Candidates concurrently listed at multiple centers are counted once. Active and inactive patients are included.


A line plot for adults listed for heart transplant on december 31 each year; the active category increases by 98.5% from 1308 candidates at 2007 to 2596 candidates at 2018; the inactive category decreases by 27.1% from 1109 candidates at 2007 to 808 candidates at 2018; and the all category increases by 40.8% from 2417 candidates at 2007 to 3404 candidates at 2018.

Figure HR 2. Adults listed for heart transplant on December 31 each year
Candidates concurrently listed at multiple centers are counted once. Those with concurrent listings and active at any program are considered active.


A line plot for distribution of adults waiting for heart transplant by age; the 18 to 34 category is 11.4 percent at 2007 and remains relatively constant with a value of 10.7 percent at 2018; the 35 to 49 category is 23.9 percent at 2007 and remains relatively constant with a value of 22.4 percent at 2018; the 50 to 64 category is 51.6 percent at 2007 and remains relatively constant with a value of 48.1 percent at 2018; and the  greater than or equal to 65 category increases by 43.3% from 13.1 percent at 2007 to 18.7 percent at 2018.

Figure HR 3. Distribution of adults waiting for heart transplant by age
Candidates waiting for transplant at any time in the given year. Candidates listed concurrently at multiple centers are counted once. Age is determined at the later of listing date or January 1 of the given year. Active and inactive candidates are included.


A line plot for distribution of adults waiting for heart transplant by sex; the male category is 75.7 percent at 2007 and remains relatively constant with a value of 74 percent at 2018; and the female category is 24.3 percent at 2007 and remains relatively constant with a value of 26 percent at 2018.

Figure HR 4. Distribution of adults waiting for heart transplant by sex
Candidates waiting for transplant at any time in the given year. Candidates listed concurrently at multiple centers are counted once. Active and inactive patients are included.


A line plot for distribution of adults waiting for heart transplant by race; the white category decreases by 12.8% from 71.5 percent at 2007 to 62.4 percent at 2018; the black category increases by 41.5% from 17.5 percent at 2007 to 24.8 percent at 2018; the hispanic category increases by 14.8% from 7.6 percent at 2007 to 8.8 percent at 2018; the asian category increases by 34.7% from 2.5 percent at 2007 to 3.3 percent at 2018; and the other/unknown category is 0.8 percent at 2007 and remains relatively constant with a value of 0.8 percent at 2018.

Figure HR 5. Distribution of adults waiting for heart transplant by race
Candidates waiting for transplant at any time in the given year. Candidates listed concurrently at multiple centers are counted once. Active and inactive candidates are included.