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CLINICAL RESEARCH: HEART TRANSPLANTATION

Selection of patients for heart transplantationin the current era of heart failure therapy

Javed Butler, MD, MPH, FACC^*||¶,*, Ghazanfar Khadim, MD^*, Kimberly M. Paul, MD, Stacy F. Davis, MD^*, Marvin W. Kronenberg, MD^*, Don B. Chomsky, MD^*¶, Richard N. Pierson, III, MD^# and John R. Wilson, MD^*

^* Division of Cardiovascular Medicine, Department of Medicine, Nashville, TennesseeUSA
Center for Health Services Research, Nashville, TennesseeUSA
Center for Education and Research in Therapeutics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Cardiology Division, Emory University, Atlanta, Georgia, USA
^|| Geriatric Research, Education, and Clinical Center, Nashville, TennesseeUSA
^¶ Medicine Service, Nashville Veterans Affairs Medical Center, Nashville, Tennessee, USA
^# Department of Cardiothoracic Surgery, University of Maryland, Baltimore, Maryland, USA

Manuscript received June 3, 2003; revised manuscript received August 23, 2003, accepted August 26, 2003.

^* Reprint requests and correspondence: Dr. Javed Butler, Cardiology Division, 383 PRB, Vanderbilt University Medical Center, Nashville, Tennessee 37232-6300, USA.
javed.butler{at}vanderbilt.edu

OBJECTIVES: We sought to assess the relationship between survival, peak exercise oxygen consumption (VO₂), and heart failure survival score (HFSS) in the current era of heart failure (HF) therapy.

BACKGROUND: Based on predicted survival, HF patients with peak VO₂ <14 ml/min/kg or medium- to high-risk HFSS are currently considered eligible for heart transplantation. However, these criteria were developed before the widespread use of beta-blockers, spironolactone, and defibrillators—interventions known to improve the survival of HF patients.

METHODS: Peak VO₂ and HFSS were assessed in 320 patients followed from 1994 to 1997 (past era) and in 187 patients followed from 1999 to 2001 (current era). Outcomes were compared between these two groups of patients and those who underwent heart transplantation from 1993 to 2000.

RESULTS: Survival in the past era was 78% at one year and 67% at two years, as compared with 88% and 79%, respectively, in the current era (both p < 0.01). One-year event-free survival (without urgent transplantation or left ventricular assist device) was improved in the current era, regardless of initial peak VO₂: 64% vs. 48% for peak VO₂ <10 ml/min/kg (p = 0.09), 81% vs. 70% for 10 to 14 ml/min/kg (p = 0.05), and 93% vs. 82% for >14 ml/min/kg (p = 0.04). Of the patients with peak VO₂ of 10 to 14 ml/min/kg, 55% had low-risk HFSS and exhibited 88% one-year event-free survival. One-year survival after transplantation was 88%, which is similar to the 85% rate reported by the United Network for Organ Sharing for 1999 to 2000.

CONCLUSIONS: Survival for HF patients in the current era has improved significantly, necessitating re-evaluation of the listing criteria for heart transplantation.

Abbreviations and Acronyms   HF = heart failure   HFSS = heart failure survival score   LVAD = left ventricular assist device   UNOS = United Network for Organ Sharing   VO2 = oxygen consumption

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