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. 2018 Mar;11(3):e004665.
doi: 10.1161/CIRCHEARTFAILURE.117.004665.

Mechanical Circulatory Support Device Utilization and Heart Transplant Waitlist Outcomes in Patients With Restrictive and Hypertrophic Cardiomyopathy

Lakshmi Sridharan  1 , Brian Wayda  1 , Lauren K Truby  1 , Farhana Latif  1 , Susan Restaino  1 , Koji Takeda  1 , Hiroo Takayama  1 , Yoshifumi Naka  1 , Paolo C Colombo  1 , Mathew Maurer  1 , Maryjane A Farr  1 , Veli K Topkara  2
Affiliations

Mechanical Circulatory Support Device Utilization and Heart Transplant Waitlist Outcomes in Patients With Restrictive and Hypertrophic Cardiomyopathy

Lakshmi Sridharan et al. Circ Heart Fail. 2018 Mar.

Abstract

Background: Patients with restrictive cardiomyopathy (RCM) and hypertrophic cardiomyopathy (HCM) generally are considered poor candidates for mechanical circulatory support devices (MCSDs) and often not able to be bridged mechanically to heart transplantation. This study characterized MCSD utilization and transplant waitlist outcomes in patients with RCM/HCM under the current allocation system and discusses changes in the era of the new donor allocation system.

Methods and results: Patients waitlisted from 2006 to 2016 in the United Network for Organ Sharing registry were stratified by RCM/HCM versus other diagnoses. MCSD utilization and waitlist duration were analyzed by propensity score models. Waitlist outcomes were assessed by cumulative incidence functions with competing events. Predictors of waitlist mortality or delisting for worsening status in patients with RCM/HCM were identified by proportional hazards model. Of 30 608 patients on the waitlist, 5.1% had RCM/HCM. Patients with RCM/HCM had 31 fewer waitlist days (P<0.01) and were ≈26% less likely to receive MCSD (P<0.01). Cumulative incidence of waitlist mortality was similar between cohorts; however, patients with RCM/HCM had higher incidence of heart transplantation. Predictors of waitlist mortality or delisting for worsening status in patients with RCM/HCM without MCSD support included estimated glomerular filtration rate <60 mL/min per 1.73 m2, pulmonary capillary wedge pressure >20 mm Hg, inotrope use, and subjective frailty.

Conclusions: Patients with RCM/HCM are less likely to receive MCSD but have similar waitlist mortality and slightly higher incidence of transplantation compared with other patients. The United Network for Organ Sharing RCM/HCM risk model can help identify patients who are at high risk for clinical deterioration and in need of expedited heart transplantation.

Keywords: cardiomyopathies; heart failure; mortality; pulmonary wedge pressure; transplantation.

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Figures

Figure 1
Figure 1. CIF Model - Incidence of Waitlist Death and Heart Transplantation by Diagnosis, All Patients: UNOS Registry 2006–2016
Competing risks of waitlist death, heart transplantation, and waitlist removal for other reasons were modeled. The incidence of waitlist death did not differ in RCM/HCM vs. non-RCM/HCM patients. The incidence of transplant was significantly higher for RCM/HCM patients compared to non-RCM/HCM patients (B).
Figure 2
Figure 2. UNOS RCM/HCM Risk Score – Predictors of Waitlist Death in the RCM/HCM Population: UNOS Registry 2009–2016
Predictors of waitlist death significant in the multivariate proportional hazards model were weighted equally (A). Distribution of the risk score within the UNOS population (B). Patients with complete data numbered 1155 or 88% of all RCM/HCM patients.
Figure 3
Figure 3. ROC Curve Analysis of UNOS RCM/HCM Risk Score: UNOS Registry 2006–2016
ROC curves for all RCM/HCM patients derived from the validation cohort (AUC = 0.75) and derivation cohort (AUC = 0.79) (A). ROC curves for HCM patients only (n=538, AUC= 0.71) and RCM patients only (n = 770, AUC = 0.80) in the full cohort of patients (B). AUC = area under the curve; AUC > 0.7 is generally considered to indicate a good model.
Figure 4
Figure 4
Kaplan-Meier Curves for Waitlist Death or Delisting for Worsening Clinical Status by UNOS RCM/HCM Risk Model Score: UNOS Registry 2006–2016
See this image and copyright information in PMC

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