Effect of Heart Transplantation on Survival in Ambulatory and Decompensated Heart Failure

BACKGROUND: In the absence of randomized trials comparing heart transplantation (HTx) with medical therapy for the treatment of advanced heart failure (HF), the role of HTx remains uncertain. Using data from a national audit, we examined the effect of HTx on HF mortality in the United Kingdom. METHODS: Two thousand two hundred nineteen adults listed for HTx from April 1995 to October 2003 and followed to June 2007 were analyzed. In a substudy of 627 patients from two centers, ambulatory patients were risk-stratified by the heart failure survival score. A time-dependent nonproportional hazards model was used to estimate the effect of HTx. RESULTS: Fourteen percent of patients were nonambulatory at listing. Death while waiting was higher among nonambulatory patients (19% vs. 14% in the ambulatory group, P<0.001 with 76% vs. 71% being transplanted). Posttransplant survival to 3 years was 78% and 75% in nonambulatory and ambulatory groups, respectively (P=0.68). HTx was found to benefit all groups. For nonambulatory patients, the risk of dying after HTx fell below the risk of dying while waiting after 10 days (95% CI 2-18) with a net survival benefit after 26 days (95% CI 5-53); for the ambulatory group the estimates were 42 days (95% CI 36-47) and 274 days (95% CI 214-359), respectively. In the substudy cohort net survival benefit was seen after 20, 124, 291, and 729 days for the nonambulatory, high, moderate, and low heart failure survival score risk groups, respectively. CONCLUSION: HTx remains an effective treatment of advanced HF. Prioritization of patients with refractory HF is rational, because they are the first to benefit.