EART FAILURE ACCOUNTS DIrectly for 55 000 deaths and indirectly for an additional 230 000 deaths in the United States each year. 1 Despite advances in care, the prognosis for patients with symptomatic heart failure remains poor, with median life expectancy of less than 5 years. 2 For those with the most advanced disease, 1-year mortality rates approach 90%. 3,4 About half of these deaths are due to progressive pump failure, while the remainder are sudden. 5 Prognosis is highly dependent on a multitude of patient characteristics, and a number of prognostic models have been developed to help predict survival in patients with heart failure. 6-9 Given the progressive nature of heart failure, its high mortality rate, and its predilection for affecting elderly persons, end-of-life issues should be at the forefront of heart failure management. In recognition of this, practice guidelines from major cardiovascular societies include sections on end-oflife considerations, which advocate ongoing patient and family education regarding prognosis for quality of life and survival. 10-12 Despite these guidelines, data on end-of-life issues in heart fail-For editorial comment see p 2566.

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24 weeks after transplantation in DCM patients only (pϽ0.01 vs. post-transplant weeks 6 and 12). Conclusions: These data indicate a significant PAI-1 upregulation associated with uPA downregulation in DCM independent of VEGF-A which was corrected by cardiac transplantation temporarily. However, reoccurring upregulated myocardial PAI-1 levels at 6 months following transplantation indicate a persistent PAI-1-related molecular pathology in DCM.Background: Heart transplantation (HT) is an effective therapy for end-stage heart failure, but its impact is limited by scarcity of donor organs and stringent criteria for donors and recipients. The creation of an alternate list (AL) to match recipients with contraindications to traditional HT with sub-optimal donor organs has been proposed, but outcomes with this approach are uncertain. Methods: We created an AL that matched recipients with contraindications to traditional HT with donor organs that had been rejected for use in standard transplantation. Baseline characteristics and outcomes were compared to a group of patients transplanted on the standard list (SL) over the same time period. Results: Since 2000, 46 patients received HT on the AL, compared to 189 on the SL. The most common reasons for recipient listing on the AL were ageϾ65 years (nϭ26) and diabetes with end organ damage (nϭ7). The most common reasons for allocation of donor organs to AL patients were positive hepatitis serology (nϭ12), LV dysfunction (nϭ10), and CAD (nϭ10). AL patients were older (62 vs. 51 years, pϽ0.001) and more likely to have ischemic heart failure (72% vs. 40%, pϽ0.001) and diabetes (39% vs. 21%, pϭ0.02). Differences in outcomes are shown in the table.