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Decreasing survival benefit from cardiac transplantation for outpatients as the waiting list lengthens
L W Stevenson1, M A Hamilton, I H Tillisch
1Ahmanson-UCLA Cardiomyopathy Center, School of Medicine, University of Californis-Los Angeles 90024-1736.
Insights
Cardiac transplant candidates awaiting surgery face prolonged waits. Survival on medical therapy is high, questioning the urgency of transplantation for some patients after six months.
Area of Science:
- Cardiology
- Transplantation Medicine
Background:
- Many patients are accepted for cardiac transplantation during clinical instability.
- Outpatient waiting lists are lengthening, with priority based on waiting time.
Purpose of the Study:
- To determine the impact of current waiting times and priority systems on the benefit of cardiac transplantation.
- To reevaluate the indication for transplantation in outpatients surviving extended waiting periods.
Main Methods:
- Recalculated 1-year actuarial survival without transplantation for 214 outpatients discharged on tailored medical therapy.
- Compared these data with 1-year survival data of 88 outpatients who underwent transplantation.
Main Results:
- 1-year actuarial survival was 67% on tailored therapy versus 88% after transplantation (p = 0.009).
- For outpatients surviving 6 months without transplantation, 1-year survival was 83% without transplantation.
- The expected survival improvement after transplantation for patients waiting 6 months was only 5%.
Conclusions:
- The survival benefit of cardiac transplantation is diminished for outpatients with prolonged waiting times.
- Patients waiting 6 months or more without transplantation should be reevaluated for continued indication.
Abstract:
Many patients are accepted for cardiac transplantation during a period of clinical instability associated with a high risk of death, even though most can be discharged home to await transplantation. As the waiting lists lengthen, priority is awarded solely on the basis of the waiting time of outpatients, who now usually undergo transplantation after they have already survived a major period of jeopardy. To determine the impact of the current waiting times and priority system on the previously expected benefit offered by transplantation, 1-year actuarial survival without transplantation was recalculated after each month without transplantation for 214 potential candidates with an ejection fraction of 0.17 +/- 0.05 discharged on tailored medical therapy after evaluation. These data were compared with the 1-year survival data of 88 outpatients who underwent transplantation. Actuarial survival after 1 year was 67% on tailored therapy compared with 88% after transplantation (p = 0.009). Death without transplantation was sudden in 43 of 51 patients, resulting from hemodynamic decompensation in 8. For outpatients already surviving 6 months without transplantation, actuarial survival over the next 12 months was 83% without transplantation. Thus, the expected improvement in survival after transplantation would be only 5% over the subsequent year for patients waiting 6 months, which is the waiting time for many outpatients. Such patients should be reevaluated to determine whether transplantation remains indicated during the next year.