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Survival Benefit From Transplant in Patients Listed for Heart Transplantation in the United States
Study Questions:
What is the survival benefit from orthotopic heart transplant (OHT) in those listed for heart transplant?
Methods:
The study cohort was comprised of patients ≥18 years old listed for OHT in the United States from 2007-2010. The investigators developed a model to predict the risk of wait-list mortality within 90 days and stratified listed patients into 10 risk groups. They followed all groups for 1 year to assess cumulative 1-year mortality on the wait-list. Using recipient data, they developed models of 90-day and 1-year post-transplant mortality and estimated these risks at listing in all listed candidates.
Results:
The authors found that of 10,159 patients listed for OHT, 5.9% (n = 596) died within 90 days and 10.4% (n = 1,054) within 1 year without receiving transplant. Of 5,720 OHT recipients with 1-year follow-up, 10.1% (n = 576) died within 1 year. The risk of mortality on the wait-list within 90 days increased from 1.6% to 19% across the 10 risk groups (i.e., risk of death varies by >10-fold). The survival benefit from OHT increased progressively with higher risk of mortality without transplant (p < 0.001 for trend); however, there was no benefit in the first six risk groups.
Conclusions:
The authors concluded that there is substantial variability in the risk of wait-list mortality among those who are OHT candidates—with no measurable benefit in many candidates at low risk of wait-list mortality and increasing survival benefit from OHT with increasing risk of wait-list mortality.
Perspective:
This is an important study because it suggests that the ‘biggest bang for the buck’ for OHT is in patients with the highest risk on the wait-list. Given that the donor heart is a scarce resource, this study suggests that the current model of allocation may need to incorporate similar risk predictors to improve current outcomes following OHT. Prospective data are, however, required before the current clinical practice of allocation of donor hearts is modified to include such prediction models.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Heart Transplant
Keywords: Survival, United States, Heart Transplantation
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