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Prognosis of Patients Removed from a Transplant Waiting List for Medical Improvement: Implications for Organ Allocation and Transplantation in Status 2 Patients
K. J. Hoercher, E. H. Blackstone, E. Nowicki, J. Alster, G. Gonzalo-Stawinski, N. G. Smedira. Cleveland Clinic, Cleveland, OH,
Objectives: In the current era of medical and device therapy, importance of appropriate patient selection for heart transplant (HTx) is crucial. Decision-making for stable heart failure has become more complex as survival benefit of HTx has been questioned. We investigated medically improved patients listed as status 2 and subsequently removed from the waiting list (delisted) to 1) assess long term outcomes and 2) identify modes of death and interventions to improve outcomes.
Methods: From 1985_2005, 100 patients (82% male, mean age 51.4± 11.6, all status 2 at listing) were delisted due to medical improvement (mean waiting list time 1.24yrs. Subsequent risks of mortality and modes of death were determined from follow-up (mean 4.4± 3.5 yrs). Hazard function modeling, competing risks analyses, and simulation were used to analyze outcomes and predict benefit of interventions.
Results: Survival was 96%, 70%, and 40% at 1, 5, and 10 yrs. Freedom from return of heart failure, defined by Class IV symptoms, relisting, need for left ventricular assist device, or transplant, was 50% at 5 yrs (Fig1). Sudden cardiac death (SCD) was the most common mode of death beginning in year 2 (4%/y)and peaking at 3 yrs (10%/year) following delisting. Simulation demonstrated that implantable cardioverter-defibrillators (ICD) could have improved survival to 100%,78% and 50% at 1, 5, and 10 yrs (Fig2).
Conclusion: Because patients removed from the waiting list for medical improvement demonstrate survival comparable to transplantation, we propose that patients with optimally managed stable heart failure (equivalent to status 2) should not undergo HTx. However, patients delisted because of medical improvement, remain at high risk for SCD. Aggressive application of ICDs and resynchronization therapy in such patients should further improve outcomes and avoidance of HTx. These findings suggest that the survival benefit of HTx in stable Status 2 patients remains questionable and allocation of scarce organs should be reserved for the most critically ill pts awaiting HTx. 
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