Valvular heart failure is a distinct heart transplant phenotype with comparable adjusted survival to other heart failure etiologies.

PURPOSE: Valvular heart failure (VHF) accounts for 1-5% of heart transplant listings. Comparative outcomes relative to other heart failure etiologies remain poorly characterized. This study defines the VHF phenotype and compares waitlist and transplant outcomes to other heart failure recipients. METHODS: This retrospective cohort study uses the UNOS thoracic transplant database to analyze adult, first-time, heart-only listings with a diagnosis of heart disease. Patients were grouped by diagnosis as VHF or non-VHF. The primary outcome was waitlist events; post-transplant survival and outcomes were secondary analyses. Subgroup analysis was performed in the post-2018 allocation era. RESULTS: VHF recipients were older (55.3 vs 54.0 years, P = 0.004), more frequently female (36.1% vs 25.0%, P < 0.001), and had higher rates of prior cardiac surgery (P < 0.001) with greater pulmonary vascular burden. At time of listing, VHF recipients had higher ECMO rates (4.9% vs 2.5%, P < 0.001) and lower VAD use (17.3% vs 31.7%, P < 0.001). VHF diagnosis was not independently associated with transplantation rates (SHR 0.979, P = 0.749) but was associated with a 23% higher rate of waitlist death/too sick to transplant (SHR 1.233, P = 0.005). Post-transplant survival was not significantly different between groups (P = 0.812). Post guideline changes, the waitlist mortality difference was attenuated. CONCLUSION: VHF represents a distinct but transplantable phenotype of heart failure. Although VHF patients faced higher waitlist mortality risk, allocation framework revisions attenuated this difference, and post-transplant survival is comparable to non-VHF recipients. Independent predictors of mortality are patient-level risk factors, supporting early referral and optimization as the primary strategy for outcome improvement in this phenotype.