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CLINICAL RESEARCH: HEART TRANSPLANTATION

Frequency and impact of delayed decisions regarding heart transplantation on long-term outcomes in patients with advanced heart failure

Eldrin F. Lewis, MD, MPH^*,*, Sui W. Tsang, BS^*, James C. Fang, MD, FACC^*, Gilbert H. Mudge, MD, FACC^*, John A. Jarcho, MD, FACC^*, Carol M. Flavell, MSN^*, Anju Nohria, MD^*, Michael M. Givertz, MD, FACC^*, Gregory S. Couper, MD, John G. Byrne, MD and Lynne Warner Stevenson, MD, FACC^*

^* Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
Cardiovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA

Manuscript received June 16, 2003; revised manuscript received October 15, 2003, accepted October 20, 2003.

^* Reprint requests and correspondence: Dr. Eldrin F. Lewis, Cardiovacular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts 02115, USA.
eflewis{at}partners.org

OBJECTIVES: We sought to characterize decisions regarding listing of heart transplant candidates and to determine the impact of delayed listing for a transplant on survival.

BACKGROUND: Evaluation and listing for heart transplantation have evolved over the past decade, with the complex decision process often extending beyond the time of initial review. Little is known about the current impact of decisions and timing of listing on outcomes.

METHODS: Decisions were prospectively recorded during the initial committee discussions regarding patients referred for heart transplant evaluation. Survival and transplantation rates were assessed.

RESULTS: A total of 214 patients were evaluated for heart transplantation (age 49 ± 11 years, ejection fraction 21 ± 9%, New York Heart Association class III ± I, peak oxygen consumption 13 ± 4 ml/kg/min). At the initial evaluation, 44% of patients were deemed eligible, 25% were potentially eligible, 19% were ineligible, and 12% were deferred. For eligible patients, 37% of patients were listed within 10 days of evaluation, and a total of 71% of patients were ever listed. Regardless of transplantation, the three-year survival rate in eligible patients not listed early was similar to that in patients listed immediately (85% vs. 77%, p = 0.34). Ineligible and potentially eligible patients had a higher three-year mortality rate than did eligible patients if transplantation occurred (51% vs. 17%, p < 0.001) or not (57% vs. 19%, p = 0.04).

CONCLUSIONS: Using current accepted guidelines, many patients referred for transplant evaluation were not considered eligible for transplantation, and those who were eligible were not often listed immediately. Eligible patients not listed initially did well in the long term, and patients with relative contraindications had worse outcomes with or without a transplant.

Abbreviations and Acronyms   AICD = automatic implantable cardioverter-defibrillator   HF = heart failure   LVEF = left ventricular ejection fraction   NYHA = New York Heart Association   UNOS = United Network for Organ Sharing   VAD = ventricular assist device   VO2 = oxygen consumption