Outcomes with an alternate list strategy for heart transplantation.
BACKGROUND
Heart transplantation (HT) is an effective therapy for end-stage heart failure, but its impact is limited by the scarcity of donor organs and stringent selection criteria for both donors and recipients. The creation of an alternate list to match recipients with contraindications to traditional HT with sub-optimal donor organs has been implemented at some centers, but outcomes using this approach are uncertain.


METHODS
We created an alternate list that matched recipients in whom standard HT was contraindicated with donor organs that had been rejected for use in standard transplantation. Data on patient characteristics and outcomes were compared with a control group of patients transplanted on the standard list over the same time period.


RESULTS
Fifty patients received HT on the alternate list, compared with 195 on the standard list. The most common reasons for recipient listing on the alternate list were age >65 years (n = 28) and diabetes with end-organ dysfunction (n = 9). Alternate-list patients were older and more likely to have an ischemic etiology and diabetes mellitus. The most common reasons for allocation of donor organs to alternate-list patients were coronary artery disease (n = 12), positive hepatitis serology (n = 12) or left ventricular (LV) dysfunction (n = 8). Two-year survival was 70% for alternate-list patients compared with 88% for standard-list patients (p = 0.02). Post-transplant morbidity did not differ significantly between the 2 groups except that alternate-list patients were hospitalized more frequently.


CONCLUSIONS
The use of an alternate list can expand the applicability of HT to patients who would otherwise be denied this therapy. Although associated with greater morbidity and mortality than standard-list HT, alternate-list HT resulted in clinical outcomes that were significantly better than the natural history of end-stage heart failure.
Felker
G Michael
GM
Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA. michael.felker@duke.edu
Milano
Carmelo A
CA
Yager
Jonathan E E
JE
Hernandez
Adrian F
AF
Blue
Laura
L
Higginbotham
Michael B
MB
Lodge
Andrew J
AJ
Russell
Stuart D
SD
D000367:Age Factors; D000368:Aged; D015897:Comorbidity; D000075202:Contraindications; D003920:Diabetes Mellitus / Q000453:epidemiology; D003925:Diabetic Angiopathies / Q000601:surgery; D005260:Female; D016027:Heart Transplantation / Q000401:mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000453:epidemiology / Q000601:surgery; D017063:Outcome Assessment, Health Care; D018579:Patient Selection; D016016:Proportional Hazards Models; D016019:Survival Analysis; D009927:Tissue and Organ Procurement; D014481:United States; D018487:Ventricular Dysfunction, Left / Q000453:epidemiology; D014850:Waiting Lists