OBJECTIVES: In 2018, the United Network for Organ Sharing modified their heart allocation policy to reduce waitlist mortality and prioritize patients with the greatest acuity. Considering declining rates of combined heart-lung transplantation, this study sought to investigate the impact of the new allocation system on waitlist and post-transplant outcomes of patients listed for combined heart-lung transplantation. METHODS: Adult patients listed for combined heart-lung transplant between 2012 and 2021 were included. Patients were stratified according to listing era. Competing risk regression was used to assess waitlist outcomes. Cox proportional hazards regression was used to establish risk factors for post-transplant mortality. RESULTS: A total of 511 patients were included, of whom 295 (57.8%) were listed in era 1 and 216 (42.2%) in era 2. Era 2 was associated with increased likelihood of transplant (adjusted standard hazard ratio (aSHR): 1.60 [1.23–2.07]; P < 0.01) and decreased waitlist mortality (aSHR: 0.43 [0.25–0.73]; P < 0.01). Despite longer ischaemic times and increased use of preoperative veno-arterial extracorporeal membrane oxygenation (ECMO) in era 2, early post-transplant survival was equivalent. Predicted heart mass ratio <0.8 (Hazard ratio (HR); 3.24; P = 0.01), ventilator support (HR: 3.83; P < 0.01) and greater ischaemic times (HR: 1.80; P < 0.01) independently predicted the mortality. Procedures at high centre volumes (HR: 0.36; P = 0.04) were associated with decreased mortality. Use of ECMO was not predictive of mortality in the modern era. CONCLUSIONS: The allocation policy change has led to improvements in waitlist outcomes in patients listed for heart-lung transplantation. Despite increased ischaemic times and use of ECMO, early post-transplant survival was equivalent.

Background: Little is known regarding the impact of donor COVID‐19 status on recipient outcomes after heart transplantation. In this study, we characterize outcomes of the first 110 heart transplants from organ donors positive for COVID‐19 (COVID‐19+) in the United States. Methods and Results: Retrospective analysis of the United Network for Organ Sharing database was performed for single‐organ adult heart transplants from January 2020 to March 2022. Donor COVID‐19+ status was defined as a positive nucleic acid amplification, antigen, or other COVID‐19 test within 7 days of transplant. Nearest‐neighbor propensity score matching used to adjust for differences between recipients of COVID‐19+ and nonpositive donor hearts. Overall, 7251 heart transplants were included in analysis, with 110 using COVID‐19+ donor hearts. Recipients of COVID‐19+ allografts were younger (54 [interquartile range, 41–61]) versus 57 [46–64] years; P =0.02) but had similar rates of female sex and non‐White race compared with those receiving allografts from negative donors. Nearest‐neighbor propensity score matching resulted in 100 well‐matched pairs of recipients of COVID‐19+ versus nonpositive donor organs. The 2 matched groups had similar median lengths of stay (15 [11–23] days versus 15 [13–23] days; P =0.40), rates of graft failure (1% versus 0%; P =0.99), 30‐day death (3% versus 3%; P =0.99), and 3‐month survival (88% versus 94%; P =0.23) compared with recipients of nonpositive donors. No deaths occurred due to COVID‐19 infection among the 8 (7%) total deceased recipients of COVID‐19+ allografts to date. Conclusions: Short‐term outcomes of heart transplant recipients receiving COVID‐19+ donor organs are reassuring. However, continued monitoring for long‐term survival and potential complications are warranted.