Influence of Intensified Medical Treatment and Organ Allocation on Outcome of Transplant Candidates

Introduction

Accepting a patient as a candidate for cardiac transplantation requires careful evaluation, including balancing the expected individual peri- and postoperative risk of transplantation vs. the prognosis with individualized medical treatment of the advanced stage of heart failure [1] [2] [3]. Whereas international postoperative results following transplantation did not change significantly during the last 15 years with a reported one-year survival rate of 80 % for the transplant period 1986 - 91 vs. 85.6 % 1996 - 99 [4], the success rate of intensified medical treatment improved dramatically during the past 1œ decades: Stevenson reported a one-year mortality of 34 % in patients evaluated for transplantation 1986 to 1988. In 1995, the author presented data with a reduction of one-year mortality to 19 % in the period 1991 to 1993 [5], explaining this improvement in prognosis with changes in medical standard therapy - increasing use of ACE inhibitors, avoiding potential proarrhythmic Class IC drugs, and increasing use of amiodarone instead. Since then, a number of authors reported comparable success with intensified medical treatment via outpatient clinics specialized in advanced heart failure [6] [7].

Due to these encouraging results, we modified the structure of our pre-transplant outpatient clinic. Instead of pure screening for transplant indication with follow-up visits after 3 to 6 months, an outpatient clinic specialized in advanced heart failure was established in May 1996 to consider all available pharmacological, electrophysiological and interventional options of non-surgical treatment of heart failure in each individual patient. Patients were now followed closely by the heart failure clinic with a continuous opportunity to optimize medical therapy according to the individual patients' clinical status.

The organ allocation modus in Germany has changed at the same time as these changes in the organization of the pre-transplant clinic; prior to 1996, patients listed for cardiac transplantation were transplanted exclusively according to Eurotransplant guidelines, with waiting time being the strongest criterion. As of 1995, transplant centers received the opportunity to form regionally based partnerships with other transplant centers. Four transplant centers in Northern Germany started such a partnership for donor recruitment and allocation in heart transplantation. Donor organs recruited within this regional allocation system could now be used preferentially for the “sickest” suitable recipient independent of waiting time [8].

This paper presents the analysis of the outcome of transplant candidates referred between 4/93 and 4/96 compared to those referred between 5/96 and 7/00 in order to test whether changes in the establishment of a pre-transplant clinic and changes in organ allocation modus influence prognosis of patients with end-stage heart failure referred for evaluation of cardiac transplantation.

References

• 1 Hunt S A. 24^th Bethesda conference: cardiac transplantation.  J Am Coll Cardiol. 1993;  22 1-64
• 2 Deng M C, de Meester J MJ, Smits J MA. et al . Effect of receiving a heart transplant: analysis of a national cohort entered on to a waiting list, stratified by heart failure severity.  BMJ. 2000;  321 540-545
• 3 Stevenson L W, Hamilton M A, Tillisch I H. et al . Decreasing survival benefit from cardiac transplantation for outpatients as the waiting list lengthens.  J Am Coll Cardiol. 1991;  12 159-172
• 4 Hosenpud J D, Leah E B, Keck B M. et al . The Registry of the international society for heart and lung transplantation: 17th official report - 2000.  J Heart Lung Transplant. 2000;  19 909-931
• 5 Stevenson W G, Stevenson L W, Middlekauff H R. Improving survival for patients with advanced heart failure: a study of 734 consecutive patients.  J Am Coll Cardiol. 1995;  26 1417-1423
• 6 Fonarow G C, Stevenson L W, Walden J A. et al . Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure.  J Am Coll Cardiol. 1997;  30 725-732
• 7 Nagele H, Rodiger W. Sudden death and tailored medical therapy in elective candidates for heart transplantation.  J Heart Lung Transplant. 1999;  18 869-876
• 8 Hirt S W, Nitschke F P, Möller F. et al . Multizentrische Analyse der Effizienz eines regionalen Allokationsverbundes in der Herztransplantation.  Transplantationsmedizin. 2000;  12 31-36
• 9 Aaronson K D, Schwartz J S, Chen T MC. et al . Development and prospective validation of a clinical index to predict survival in ambulatory patients referred for cardiac transplant evaluation.  Circulation. 1997;  95 2660-2667
• 10 MERIT-HF Study Group . Effect of Metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF).  Lancet. 1999;  353 2001-2007
• 11 CIBIS II Investigators and Committees . The Cardiac Insufficiency Bisoprolol Study II (CIBIS II).  Lancet. 1999;  353 9-13
• 12 Packer M, Bristow M R, Cohn J N. et al . (for the US Carvedilol Heart failure Study Group) The effect of Carvedilol on morbidity and mortality in patients with chronic heart failure.  N Engl J Med. 1996;  334 1349-1355
• 13 Packer M, Coats A J, Fowler M B. et al . Carvedilol Prospective Randomized Cumulative Survival Study Group. Effect of carvedilol on survival in severe chronic heart failure.  N Engl J Med. 2001;  344 1651-1658