Outcomes of Status 4 Heart Transplant Candidates: A Nationwide Analysis
University Hospitals of Cleveland
Cleveland, OH
United States - Contact Me
Dr. Craig Jarrett joined University Hospitals in 2018 as a fellow in cardiothoracic surgery. After finishing fellowship, he completed an additional fellowship in structural heart disease focused on transcatheter aortic valve replacement (TAVR), and transcatheter mitral valve repair (TMVr) and replacement (TMVR). Dr. Jarrett is a native Ohioan who received his Doctor of Medicine degree from the Cleveland Clinic Lerner College of Medicine (CCLCM) of Case Western Reserve University (CWRU) and Masters in Business Administration from the Weatherhead School of Management of CWRU. He completed a general surgery residency at Massachusetts General Hospital, and completed a fellowship in Health Policy and Management with the Massachusetts General Physician Organization (MGPO) focused on appropriateness of care. He has additional Masters education in Biostatistics at CWRU and is pursuing a Doctor of Philosophy degree in Biomedical and Health Informatics at CWRU. Dr. Jarrett has authored numerous manuscripts and book chapters, has received a number of internal and external research grants, is a statistical reviewer for multiple journals, and is currently mentoring medical, graduate, and undergraduate students at multiple universities in the United States and abroad on all aspects of clinical research. Dr. Jarrett is currently Head of Clinical Research for the Division of Cardiac Surgery.
Description
Methods: We included all adults (ageā„18) in the UNOS STAR file who were listed for heart transplant from 10/18/2018-3/30/2024 with any time as status 4 with the primary focus on patients initially listed as status 4. Primary endpoints were percent of patients and transplants, time to transplant, and survival on the waitlist stratified by indication. Survival was estimated using the Kaplan-Meier method and compared using the log-rank test.
Results: A total of 11,966 unique patients were listed as status 4 with 66.7% (7,983/11,966) as initial status 4. Most (96.3%, 7,687/7,983) initial status 4 patients had no change in the indication for status 4 while listed. Overall, 65.5% (5,232/7,983) of patients were transplanted with a median 70 days (IQR: 24-194) to transplant. For initial status 4 patients, 19.9% were transplanted at 1 month, 38.1% at 3 months, 50.1% at 6 months, 61.8% at 12 months, 67.5% at 18 months, 71.1% at 24 months, 75.0% at 36 months, 77.3% at 48 months, and 77.9% at 60 months (Figure). Percent of total patients, percent of total transplants, and median days to transplant by indication were: 38.8% (3,098/7,983), 33.3% (1,741/5,232), and 135 for LVAD; 20.0% (1,598), 23.4% (1,223), and 31 for IV inotropes; 15.3% (1,218), 16.4% (860), and 60 for exceptions; 10.5% (837), 12.1% (635), and 57 for cardiomyopathy; 8.0% (636), 7.3% (381), and 105 for congenital heart disease; 5.4% (435), 5.4% (283), and 70 for re-transplant; and 2.0% (161), 2.1% (109), and 46 for ischemic heart disease, respectively. Median survival on the waitlist was: 48 months for LVAD, 47 for congenital heart disease, 40 for cardiomyopathy, 38 for ischemic heart disease, 33 for re-transplant, 31 for exceptions, and 24 for IV inotropes. At 5 years, waitlist survival was highest with LVAD indications, and lowest with re-transplant and inotrope dependent indications (p<0.0001).
Conclusions: For status 4 patients, half will be transplanted within 6 months and two-thirds will be transplanted within 18 months of initial status 4 listing. Waitlist survival for status 4 patients is heterogeneous with patients on LVADS having twice the median survival compared to patients on IV inotropes. These results should be considered in advanced heart failure shared decision making.
Figure Legend: Alluvial plot of 7,983 initial status 4 patients showing status changes, deaths on the waiting list, delistings, and transplants at specific time points. Flows of less than 20 patients are not shown for clarity. Dec denotes deceased; Del, delisted; and Tra, transplanted.
Authors
Craig Jarrett (1), Kelsey Gray (1), Yakov Elgudin (1), Chantal ElAmm (1), Marc Pelletier (1), Yasir Abu-Omar (1)
Institutions
(1) University Hospitals, Cleveland, OH