Survival of patients removed from the heart transplant waiting list

Understanding lung transplant listing practices: Survival in lung transplant candidates who improve clinically to delisting

BACKGROUND

Occasionally, lung transplant candidates improve to the point where they are removed from the transplant list. We sought to determine the characteristics and outcomes of lung transplant candidates who improved to delisting both before and after implementation of the lung allocation score.

METHODS

Using the United Network for Organ Sharing database, we reviewed all adult patients listed for lung transplant between 1987 and 2012. The last permanent status change was classified into transplanted, improved to delisting (improved), or deteriorated to delisting (deteriorated). Survival time was calculated using the linked date of death from the Social Security Administration. Survival analysis was performed via the Kaplan-Meier method, and adjusted multivariable logistic regressions identified characteristics predicting improvement to delisting.

RESULTS

Of 13,688 candidates, 12,188 (89.0%) were transplanted, 454 (3.3%) improved, and 1,046 (7.6%) deteriorated. The 5-year mortality was greater in improved (hazard ratio = 1.21 [1.07-1.38], P = .002) and deteriorated (hazard ratio = 3.36 [3.11-3.64], P < .001) candidates relative to those transplanted; however, 1-year survival was greater in improved versus transplanted candidates (75.9% vs 67.2%, log rank P < .001). Older, female patients listed for primary pulmonary hypertension and retransplantation were more likely to improve to delisting. The proportion of improved patients varied by hospital quartile volume (P < .001) and the United Network for Organ Sharing geographic region (P < .001). The number of patients improving to delisting decreased after implementation of the lung allocation score.

CONCLUSION

Lung transplant candidates improving to delisting faced less short-term but greater long-term mortality relative to transplanted candidates. Given that the improved population decreased dramatically after implementation of the lung allocation score, redefining patient listing criteria appears to have improved patient appropriateness for transplant.

Durable Mechanical Circulatory Support versus Organ Transplantation: Past, Present, and Future

For more than 30 years, heart transplantation has been a successful therapy for patients with terminal heart failure. Mechanical circulatory support (MCS) was developed as a therapy for end-stage heart failure at a time when cardiac transplantation was not yet a useful treatment modality. With the more successful outcomes of cardiac transplantation in the 1980s, MCS was applied as a bridge to transplantation. Because of donor scarcity and limited long-term survival, heart transplantation has had a trivial impact on the epidemiology of heart failure. Surgical implementation of MCS, both for short- and long-term treatment, affords physicians an opportunity for dramatic expansion of a meaningful therapy for these otherwise mortally ill patients. This review explores the evolution of mechanical circulatory support and its potential for providing long-term therapy, which may address the limitations of cardiac transplantation.

Psychosocial and behavioural factors in heart transplant candidates – an overview

Mortality among heart transplant (HTX) candidates remains high. This review of the literature shows that psychosocial characteristics like depression, social isolation and coping strategies contribute to morbidity and mortality in heart failure (HF) patients, and may also be relevant to the prognosis of HTX candidates. Based on the research to date, physical activity favourably affects subjective and objective parameters not only in HF patients, but also in HTX candidates. Depression is prevalent among HTX candidates, especially in ischaemic patients, and seems to be related to earlier transplantation. Findings on the effects of depression on pretransplant mortality are conflicting. Not much is known concerning social isolation, coping, nutrition, or weight loss in this patient group. Identification of modifiable psychosocial and behavioural variables related to clinical status in this patient group is clearly needed and will aid the development of behavioural interventions to supplement medical therapies.

Long-Term Outcome in Heart Failure Patients Evaluated for Heart Transplantation But Considered Too Well

Patients referred for heart transplantation evaluation may be accepted for transplantation, or denied due to existing contraindications or judged to be too well. There is little knowledge about long-term outcome in patients considered too well for transplantation. Ninety-five patients (mean age 47 +/- 12 years, 73% men) judged "too well" at evaluation were included in this study. Acceptance for transplantation followed international guidelines. The follow-up (mean 4.5 years) was complete. Twenty of the 95 patients (21%) were eventually accepted for transplantation during the follow-up period. Twenty-one patients (22%) died, 13 without preceding acceptance for transplantation, 4 on the waiting list for transplantation, and 4 after transplantation. Cumulative and transplant-free survival at 1, 5, and 10 years were 91%, 82%, and 65%, and 90%, 70%, and 50%, respectively. In conclusion, long-term survival in patients considered too well for transplantation is better than in most contemporary series of heart transplant recipients, which suggests that the guidelines for acceptance are appropriate. However, almost one fifth of the patients die without preceding acceptance for transplantation or while on the waiting list, which illustrates the need for frequent reevaluation and tools to identify heart failure patients with an increased risk for sudden death.

Psychosoziale Aspekte und Gesundheitsverhalten bei Herzinsuffizienz

Zusammenfassung. Für die steigende Zahl von Patienten mit Herzinsuffizienz stehen verschiedene medizinische Behandlungsansätze zur Verfügung, darunter als letzte Option die Herztransplantation (HTX). Ergänzende psychosoziale und behaviorale Interventionen erscheinen aus verschiedenen Gründen auch für Patienten auf der HTX-Warteliste sinnvoll. Unser Literaturüberblick zeigt, dass bekannte psychosoziale koronare Risikofaktoren wie Depressivität und soziale Isolation auch bei Herzinsuffizienz Morbidität und Mortalität erhöhen. Körperliche Aktivität wirkt sich dagegen günstig auf subjektive und objektive Parameter aus. Diese Faktoren stellen erste Ansatzpunkte für verhaltensorientierte Interventionen dar. Welche Rolle andere koronare Risikofaktoren (z.B. Feindseligkeit, Ärger, Ernährung und Gewichtsreduktion) spielen, ist bislang ungeklärt. Ausblickend werden einige viel versprechende Forschungsansätze skizziert.

Should UNOS Status 2 Patients Undergo Transplantation?

BACKGROUND

With recent improvements in medical and device therapy, the benefit of cardiac transplantation for UNOS Status 2 patients has been questioned. No randomized trial has been performed to compare transplantation versus contemporary medical therapy.

METHODS

Between January 1996 and December 2003, 203 patients were listed at our institution for heart transplantation as UNOS Status 2. We performed a retrospective review to determine outcomes in these patients.

RESULTS

Demographics of this cohort revealed a mean age of 52 years, female sex in 28%, and ischemic etiology in 47%. Eighty-one patients (40%) had an implantable cardiac defibrillator. A total of 64 patients (32%) had to be upgraded in their UNOS status, with 9 requiring a left ventricular assist device. Of the entire group, 95 (47%) underwent transplantation at a mean time of 303 days, 45 (22%) died while waiting at a mean time of 397 days, and 24 (12%) were removed from the waiting list due to deterioration in medical condition such that transplantation was no longer an option. The remaining patients continue to wait or have been removed from consideration due to improved condition. Survival at 1- and 3-years postlisting was 94% and 87% for patients who received transplants compared to 81% and 57% for patients who did not receive transplants (P < .01).

CONCLUSION

A significant number of patients listed as Status 2 are upgraded in UNOS status or die while on the waiting list. Early and midterm survival is significantly better with transplantation. Identification of variables associated with deterioration may allow for better risk stratification in the future. At this point, transplantation offers the best outcome.