Comparison of survival by allocation to medical therapy, surgery, or heart transplantation for ischemic advanced heart failure.
BACKGROUND
To ascertain survival of ischemic advanced heart failure patients by treatment allocation, we examined the outcome of transplant assessment patients allocated to medical therapy, high-risk conventional surgery, or transplantation.


METHODS
Patients were identified from the Papworth transplant database and excluded if primary etiology was not ischemic. Grouping was undertaken according to treatment allocation at initial assessment, and analysis was performed by intention to treat. Survival was computed from the time of assessment and Cox regression used to stratify patients according risk with the Heart Failure Survival Score.


RESULTS
From May 1993 to September 2001, a total of 755 patients were admitted for transplant assessment, with 348 (46.1%) identified as having heart failure of ischemic origin. Variables required for calculation of the Heart Failure Survival Score was available in 273 patients (78.4%), and 20 patients (7.3%) were lost to follow-up. Of the remaining 253 patients, 89 (35.2%) were allocated to medical therapy, 32 (12.6%) to surgery, and 132 (52.2%) to transplantation. The relative risk (95% confidence limit) of death compared with medical therapy was 0.62 (0.28, 1.40) for surgery and 0.38 (0.24, 0.61) for transplantation in medium- to high-risk patients. For low-risk patients, the relative risks for death compared with medical therapy were 1.87 (0.63, 5.60) for surgery and 1.97 (0.79, 4.96) for transplantation.


CONCLUSIONS
Transplantation improved survival of medium- and high-risk patients compared with medical therapy. In the low-risk group, this was not evident. However, repeated assessment of risk is required because the hazard for death rises steadily after the third year in these patients.
Lim
Eric
E
Transplant Unit, Papworth Hospital, Cambridge, UK.
Ali
Ziad
Z
Ali
Ayyaz
A
Motalleb-Zadeh
Reza
R
Jackson
Christopher
C
Ong
Seok Ling
SL
Halstead
James
J
Sharples
Linda
L
Parameshwar
Jayan
J
Wallwork
John
J
Large
Stephen R
SR
D006348:Cardiac Surgical Procedures / Q000379:methods / Q000401:mortality*; D002316:Cardiotonic Agents / Q000627:therapeutic use*; D002423:Cause of Death; D015331:Cohort Studies; D005260:Female; D006333:Heart Failure / Q000209:etiology / Q000401:mortality* / Q000628:therapy*; D016027:Heart Transplantation / Q000379:methods / Q000401:mortality*; D006801:Humans; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000150:complications / Q000175:diagnosis; D018579:Patient Selection; D011336:Probability; D011379:Prognosis; D011788:Quality of Life; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis
D002316:Cardiotonic Agents