Assessment of Heart Transplant Waitlist Time and Pre- and Post-transplant Failure

Abstract

Background Over the past two decades there have been increasingly long waiting times for heart transplantation. We studied the relationship between heart transplant waiting time and transplant failure (removal from the waitlist, pre-transplant death, or death or graft failure within one-year) to determine the risk that conservative donor heart acceptance practices confer in terms of increasing the risk of failure among patients awaiting transplantation. Methods We studied a cohort of 28,283 adults registered on the United Network for Organ Sharing (UNOS) heart transplant waiting list between 2000 and 2010. We used Kaplan-Meier methods with inverse probability censoring weights to examine the risk of transplant failure accumulated over time spent on the waiting list (pre-transplant). In addition, we used transplant candidate blood type as an instrumental variable to assess the risk of transplant failure associated with increased wait time. Results Our results show that those who wait longer for a transplant have greater odds of transplant failure. While on the waitlist, the greatest risk of failure is during the first 60 days. Doubling the amount of time on the waiting list was associated with a 10% (1.01, 1.20) increase in the odds of failure within one year after transplantation. Conclusions Our findings suggest a relationship between time spent on the waiting list and transplant failure, thereby supporting research aimed at defining adequate donor heart quality and acceptance standards for heart transplantation.

Donor selection in the modern era

“…To date, a number of consensus statements (4,5) and risk models (6,7) have been published in an attempt to codify knowledge around donor heart selection. What we know is that more patients are waiting for heart transplantation every year, that there is a positive association between time spent on the waitlist and mortality (8) and that the criteria used for donor heart selection must be questioned, challenged, and expanded in order to meet the evergrowing demand for heart transplantation. This Perspective discusses recent advances in the field that should help guide and expand use of available donor hearts in the modern era.…”

How to obtain and maintain favorable results after heart transplantation: keys to success?

“…Even nowadays it can be lifesaving for patient that is not a candidate for an MCS, such as those with hypertrophic cardiomyopathy or some complex forms of congenital heart disease and those needing a re-transplantation. As has been shown in several countries dealing with growing waitlists, a prolonged waiting time negatively impacts post-transplant survival (11). Many patients that were good candidates at the moment of listing, may turn out poor recipients 2 years later.…”

“…This has not only resulted in scientific output, but has also likely lowered the threshold for patients to contact the transplant nurses and physicians in case of questions or problems. It may have also assisted in creating a culture where patients and their families form a team together with Primary graft failure [16] Acute rejection [7] Late graft failure (HFrEF) [6] [Non] STEMI [4] Post-PCI/CABG [3] Technical problems during HTx [3] Stroke/intracranial bleeding [12] Aortic rupture [4] Intestinal ischemia [3] Malignancy 78 [32] Lung [35] GI tract [10] PTLD [9] Kidney-bladder [6] Pancreas [4] Blood [4] Prostate [3] Skin [3] Primary tumor unknown [3] Brain [1] Infection 43 [18] Pneumonia [22] Sepsis [15] Other [6] Other 27 [11] Old age [8] Dementia [5] Suicide [4] Therapy withdrawal [3] Trauma [3] Respiratory failure [1] Bleeding [1] ALS [1] Euthanasia [1] Finally, we pay a lot of attention to cardiovascular prevention and screening for malignancies. The significant and consistent decreases in age-adjusted cardiovascular mortality shown in European and US registries was attributed to better prevention and better treatment of cardiac disease (29).…”

Cost‐effectiveness of left ventricular assist devices for patients with end‐stage heart failure: analysis of the French hospital discharge database

“…• Reducing the HTx referrals to 1% (transplant rates) every month, as donor hearts are expected to become scarce. 21 • Improved survival to reflect improved LVAD performance, as recent studies showed that long-term performance of LVAD had improved in the recent era. 22,23 • Higher costs for the management of 'no LVAD' group because of prolonged intensive care unit (ICU) stay (mean ICU costs €42 000/month).…”