Impact of allocation rules on outcome after heart transplantation in Germany

Before 2000, high urgency (HU) listing for heart transplantation (HTx) was only possible in cases of acute retransplantations; special urgency requests were limited to 15% of the listed patients. Since August 23, 2000, each center can submit for all patients fulfilling specific HU criteria unlimited, but audited HU requests to Eurotransplant. This study examines the impact of the preferential urgency allocation on transplantation outcome.

Methods: Based on the Eurotransplant- (1997–2007) and the BQS-data (2004–2007), one year survival rates (1ysr) were compared, considering donor and recipient risk factors as well as the percentage of transplants performed through HU-listings.

Results: Between 1997 and 2007, the number of HTx/year decreased continuously from 526 to 366. 1ysr improved from 69% in 1997 to 79% in 2002, but decreased to 62% (Eurotransplant) until 2007. The percentage of retransplantations was consistently around 2% during the entire period. Between 2002 and 2007, mean donor age increased slightly (36 vs. 39 years) while mean ischemic time (3.4 hours) and percentage of ischemic cardiomyopathies (28%) remained stable. The percentage of HU patients transplanted was 30% and 43% in 2001 and 2002, respectively, increasing to 74% in 2007.

Conclusions: Todate, three quarters of the patients undergoing HTx are HU-listed. Preconditions are e.g. inotropic therapy, beginning multi organ failure and/or complications on assist devices, all relevant risk factors for survival according to the ISHLT statistics. Accumulation of risk factors contributes to unacceptable 1ysr in Germany. Besides urgency, outcome predictors should be included into the allocation algorithm for HTx.