Intensified medical therapy and regional donor allocation in the management of patients with end stage heart failure [Stellenwert von therapieintensivierung und regionalisierter spenderherzallokation in der versorgung terminal herzinsuffizienter patienten]

Summary Background and objective: The medical management of heart failure improved greatly during the last decade. Heart transplantation (HTx) as surgical alternative is an established measure but operation numbers stagnated due to the lack of donor organs and still the 1 year mortality is about 20%. Rising numbers of new registrations led to long waiting lists with a high mortality rate. Solutions are intensified therapeutic concepts and improvements in organ allocation. This study was done to show if a combined intensified medical management and a regional donor allocation system may improve outcome in heart transplant candidates. Patients and methods: A cohort of 396 elective candidates for heart trans plantation from the years 1984-1997 without contraindications and at least in NYHA stage III at entry were investigated for total mortality, modes of death and the probability of heart transplantation. Patients were divided in two groups (group A: submitted from 1984-1994, n = 256, group B: 1995-1998, n = 150). Results: The groups were comparable in clinical and hemodynamic baseline characteristics. Patients of group B had a better long-term prognosis after 2 years (87% versus 73.5%, p = 0.009) and had a significantly lower rate of heart transplantation (HTX rate in group A and B after 2 years: 35% and 15%, p = 0.002). Only two patients died due to heart failure in the years 1995-1998 compared to 20 heart failure death from 1984-1994. The waiting time for a donor heart fell from 81.8 γ 80 days in group A to 22.1 γ 21 days in group B. The main problem is the unchanged sudden death rate in patients with stable hemodynamics prior to the event. Conclusions: A combination of tailored medical therapy for heart failure plus regionalization of donor heart allocation with short waiting time seems to be the best way to treat patients with end-stage heart failure. A specialized cardiomyopathy program is necessary for such an approach. Sudden death in heart transplant candidates has to be studied more intensively.