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DOI: 10.1055/s-2002-32408
© Georg Thieme Verlag Stuttgart · New York
Influence of Intensified Medical Treatment and Organ Allocation on Outcome of Transplant Candidates
This paper was presented at the annual meeting of the German Society for Thoracic and Cardiovascular Surgery, Leipzig, February 2001Publikationsverlauf
Publikationsdatum:
21. Juni 2002 (online)
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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.
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