Should UNOS Status 2 Patients Undergo Transplantation?
DOI:
https://doi.org/10.1532/HSF98.20061061Abstract
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 defib-rillator. 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.
References
Abraham WT. 2000. Rationale and design of a randomized clinical trial to assess the safety and efficacy of cardiac resynchronization therapy in patients with advanced heart failure: the Multicenter InSync Randomized Clinical Evaluation (MIRACLE). J Card Fail 6:369-80.nBristow MR, Feldman AM, Saxon LA. 2000. Heart failure management using implantable devices for ventricular resynchronization: Comparison of Medical Therapy, Pacing, Defibrillation in Chronic Heart Failure (COMPANION) trial. COMPANION Steering Committee and COMPANION Clinical Investigators. J Card Fail 6:276-85.nCampana C, Gavazzi A, Berzuini C, et al. 1993. Predictors of prognosis in patients awaiting heart transplantation. J Heart Lung Transplant 12:756-65.nCopeland JG, McCarthy M. 2001. University of Arizona, cardiac transplantation: changing patterns in selection and outcomes. Clinical Transplants 203-7.nDeng MC, De Meester JM, Smits JM, Heinecke J, Scheld HH. 2000. Effect of receiving a heart transplant: analysis of a national cohort entered on to a waiting list, stratified by heart failure severity. Comparative Outcome and Clinical Profiles in Transplantation (COCPIT) Study Group. BMJ 321:540-5.nDeng MC, Smits JM, Young JB. 2003. Proposition: the benefit of cardiac transplantation in stable outpatients with heart failure should be tested in a randomized trial. J Heart Lung Transplant 22:113-7.nFrigerio M, Gronda EG, Mangiavacchi M, et al. 1997. Restrictive criteria for heart transplantation candidacy maximize survival of patients with advanced heart failure. J Heart Lung Transplant 16:160-8.nHaywood GA, Rickenbacher PR, Trindade PT, et al. 1996. Analysis of deaths in patients awaiting heart transplantation: impact on patient selection criteria. Heart 75:455-62.nJimenez J, Bennett Edwards L, Higgins R, Bauerlein J, Pham S, Mallon S. 2005. Should stable UNOS Status 2 patients be transplanted? J Heart Lung Transplant 24:178-83.nKao W, McGee D, Liao Y, et al. 1994. Does heart transplantation confer additional benefit over medical therapy to patients who have waited >6 months for heart transplantation? J Am Coll Cardiol 24:1547-51.nLewis EF, Tsang SW, Fang JC, et al. 2004. Frequency and impact of delayed decisions regarding heart transplantation on long-term outcomes in patients with advanced heart failure. J Am Coll Cardiol 43:794-802.nMoss AJ, Zareba W, Hall WJ, et al. 2002. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 346:877-83.nMudge GH, Goldstein S, Addonizio LJ, et al. 1993. Task Force 3: recipient guidelines/prioritization. J Am Coll Cardiol 22:21-31.nOechslin E, Brunner-LaRocca HP, Solt G, et al. 1998. Prognosis of medically treated patients referred for cardiac transplantation. Int J Cardiol 64:75-81.nRickenbacher PR, Trindade PT, Haywood GA, et al. 1996. Transplant candidates with severe left ventricular dysfunction managed with medical treatment: characteristics and survival. J Am Coll Cardiol 61:570-5.nSaxon LA, Stevenson WG, Middlekauff HR, et al. 1993. Predicting death from progressive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy. Am J Cardiol 72:62-5.nShah NR, Rogers JH, Ewald GA, et al. 2004. Survival of patients removed from the heart transplant waiting list. J Thorac Cardiovasc Surg 127:1481-5.nUnited Network for Organ Sharing Policy (section 3.7.3). Available at http://www.unos.org'>http://www.unos.orgnUpadya S, Lee FA, Saldarriaga C, et al. 2004. Home continuous positive inotropic infusion as a bridge to cardiac transplantation in patients with end-stage heart failure. J Heart Lung Transplant 23:466-72.n
