Impact of the New Heart Allocation System in France on Candidates’ Profile and Waitlist Outcomes

Purpose The new French allocation system (NFAS) based on the candidate risk score has been launched on January 2, 2018. This study aimed to evaluate the effect of implementation of NFAS on newly registered candidates’ profile and their waitlist outcomes. Methods The study included all adults newly registered on the French waiting list for heart transplantation between January and July, 2014-2018 (n=1808). Characteristics and waitlist outcomes of candidates registered during the 7-month period in the 4 years before (n=1401) and the year after (n=407) introduction of NFAS were compared. The access to transplantation was calculated using competing risk estimation and waitlist survival was estimated using the Kaplan-Meier method. Inactive candidates were excluded from those analyses. Results After the new system implementation, new registrations increased by 27% and transplant activity decreased by 14% leading to a rise in organ shortage (candidate per graft ratio: 1.6 vs 1.3). Candidate demographics remained unchanged (75% male, 49±15 years, dilated cardiomyopathy 41%, coronary artery disease 35%). Compared to 2014-2017, the 2018 proportions of new candidates on VA-ECMO (20% vs 17%, p=0.4), long-term MCS (9% vs 8%), mechanical ventilation (13 % vs 11%, p=0.2), inotropic infusion (34% vs 38%, p=0.2) and dialysis (1.8% vs 2.8%, p=0.2) were not significantly different. The proportion of candidates always inactive during their waiting time increased (3% vs 1%, p=0.02). While the 3-month cumulative incidence of transplantation tended to decrease (48% vs 51%, p=0.15), the 3-month waitlist survival remained unchanged (88.5% vs 89.9% respectively in 2018 and 2014-17; p=0.6) (Figure 1). Conclusion The implementation of the new allocation system did not modify candidates’ profile although we observed a significantly higher proportion of candidates always inactive during their waiting time. Despite the increase of organ shortage, waitlist survival did not decrease.