Circulation, Vol 89, 450-457, Copyright © 1994 by American Heart Association
LW Stevenson, SL Warner, AE Steimle, GC Fonarow, MA Hamilton, JD Moriguchi, JA Kobashigawa, JH Tillisch, DC Drinkwater and H Laks
BACKGROUND: Each month, the number of transplant candidates added to the
waiting list exceeds the number of transplantations performed, and many
outpatients deteriorate to require transplantation urgently. The current
list of 2400 candidates and the average wait of 8 months continue to
increase. METHODS AND RESULTS: To determine the size at which the
outpatient and critical candidate pools will stabilize, population models
were constructed using current statistics for donor hearts, candidate
listing, sudden death, and outpatient decline to urgent status and revised
to predict the impact of alterations in policies of candidate listing. If
current practices continue, within 48 months the predicted list will
stabilize as the sum of an estimated 270 hospitalized candidates, among
whom, together with newly listed urgent candidates, all hearts will be
distributed and 3700 outpatient candidates with virtually no chance of
transplantation unless they deteriorate to an urgent status. Decreasing the
upper age limit now to 55 years would reduce the number listed each month
by 30% and result within 48 months in a list of only 1490. The list could
also be decreased by 30%, however, if it were possible to list only a
candidate group with an 80% chance (compared with 52% estimated currently)
of sudden death or deterioration during the next year. With this strategy,
the waiting list would equilibrate within 48 months to one-third the
current size, with 50% of hearts for outpatient candidates, who would then
have an 11% chance each month of receiving a heart compared with 0% if
recent policies prevail. Total deaths, with and without transplantation,
would be minimized by this rigorous selection of outpatient candidates.
CONCLUSIONS: This study implies that immediate provisions should be made to
limit candidate listing and revise expectations to reflect the diminishing
likelihood of transplantation for outpatient candidates. Future emphasis
should be on improved selection of candidates at highest risk without
transplantation.
ARTICLES
The impending crisis awaiting cardiac transplantation. Modeling a solution based on selection
Ahmanson-UCLA Cardiomyopathy Center.
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