Selection of Cardiac Transplantation Candidates in 2010

Heart failure is a progressive disease that now affects >5 million patients in the United States. Recent estimates suggest that between 5% and 10% of all patients with heart failure (HF) have advanced, or stage D, disease, which is associated with a very high mortality and very poor quality of life.1 In the most advanced phase of HF, heart transplantation (HT) has been the only means of improving the quality of life and survival in these patients. With the advances in immunosuppression therapy, 1-year survival after cardiac transplantation approaches 90%, with 50% of patients surviving >11 years.2 With the improving results of cardiac transplantation, more patients are referred for transplantation evaluation. Moreover, patients with comorbidities who in the past would not be suitable transplantation candidates are now often considered for transplantation.3Unfortunately, this life-saving therapy is available to only a fraction of those who need it because of the constant shortage of available donors. Over the last 2 decades, only 2200 patients underwent HT annually in the United States. This has resulted in increasing number of patients awaiting transplants with longer waiting times. Efforts to modify the US heart allocation scheme to prioritize organ allocation to those candidates who are the least likely to survive was first introduced by the US United Network of Organ Sharing (UNOS) in 1989 as a high-priority UNOS status 1 listing. In 1999, this evolved into a 2-tiered system with UNOS status 1A and 1B.4 These changes resulted in a shorter waiting time and a significant improvement in survival on the HT waiting lists.5 Median time to cardiac transplantation has declined from 359 days in 1999 to 113 days in 2007. With the decline in waiting time, the absolute mortality rate for status 1A has declined from 21.7% in 1999 …