Eugene H Blackstone1, Jeevanantham Rajeswaran2, Vincent B Cruz3, Eileen M Hsich4, Marijan Koprivanac5, Nicholas G Smedira6, Katherine J Hoercher6, Lucy Thuita2, Randall C Starling4. 1. Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: blackse@ccf.org. 2. Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio. 3. Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio. 4. Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio. 5. Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. 6. Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio.
Abstract
BACKGROUND: Heart transplant allocation in the United States is made on the basis of coarse tiers, defined by mechanical circulatory devices and therapy for advanced heart failure, updated infrequently as a patient's condition deteriorates. Thus, many patients die awaiting heart transplantation. What is needed is a tool that continuously updates risk of mortality as a patient's condition changes to inform clinical decision making. OBJECTIVES: This study sought to develop a decision aid that aggregates adverse events and measures of end-organ function into a continuously updated waitlist mortality estimate. METHODS: From 2008 to 2013, 414 patients were listed for heart transplantation at Cleveland Clinic, Cleveland, Ohio. The endpoint was waitlist death. Pre-listing patient characteristics and events and laboratory results during listing were analyzed. At each event or measurement change, mortality was recomputed from the resulting model. RESULTS: There were 77 waitlist deaths, with 1- and 4-year survival of 85% and 57%, respectively. When time-varying events and measurements were incorporated into a mortality model, pre-listing patient characteristics became nonsignificant. Neurological events (hazard ratio [HR]: 13.5; 95% confidence interval [CI]: 7.63 to 23.8), new requirement for dialysis (HR: 3.67; 95% CI: 1.88 to 7.14), more respiratory complications (HR: 1.79 per episode; 95% CI: 1.23 to 2.59), and higher serum bilirubin (p < 0.0001) and creatinine (p < 0.0001) yielded continuously updated estimates of patient-specific mortality across the waitlist period. CONCLUSIONS: Mortality risk for patients with advanced heart failure who are listed for transplantation is related to adverse events and end-organ dysfunction that change over time. A continuously updated mortality estimate, combined with clinical evaluation, may inform status changes that could reduce mortality on the heart transplant waiting list.
BACKGROUND: Heart transplant allocation in the United States is made on the basis of coarse tiers, defined by mechanical circulatory devices and therapy for advanced heart failure, updated infrequently as a patient's condition deteriorates. Thus, many patients die awaiting heart transplantation. What is needed is a tool that continuously updates risk of mortality as a patient's condition changes to inform clinical decision making. OBJECTIVES: This study sought to develop a decision aid that aggregates adverse events and measures of end-organ function into a continuously updated waitlist mortality estimate. METHODS: From 2008 to 2013, 414 patients were listed for heart transplantation at Cleveland Clinic, Cleveland, Ohio. The endpoint was waitlist death. Pre-listing patient characteristics and events and laboratory results during listing were analyzed. At each event or measurement change, mortality was recomputed from the resulting model. RESULTS: There were 77 waitlist deaths, with 1- and 4-year survival of 85% and 57%, respectively. When time-varying events and measurements were incorporated into a mortality model, pre-listing patient characteristics became nonsignificant. Neurological events (hazard ratio [HR]: 13.5; 95% confidence interval [CI]: 7.63 to 23.8), new requirement for dialysis (HR: 3.67; 95% CI: 1.88 to 7.14), more respiratory complications (HR: 1.79 per episode; 95% CI: 1.23 to 2.59), and higher serum bilirubin (p < 0.0001) and creatinine (p < 0.0001) yielded continuously updated estimates of patient-specific mortality across the waitlist period. CONCLUSIONS: Mortality risk for patients with advanced heart failure who are listed for transplantation is related to adverse events and end-organ dysfunction that change over time. A continuously updated mortality estimate, combined with clinical evaluation, may inform status changes that could reduce mortality on the heart transplant waiting list.
Authors: M Colvin-Adams; M Valapour; M Hertz; B Heubner; K Paulson; V Dhungel; M A Skeans; L Edwards; V Ghimire; C Waller; W S Cherikh; B L Kasiske; J J Snyder; A K Israni Journal: Am J Transplant Date: 2012-09-13 Impact factor: 8.086
Authors: M Colvin; J M Smith; M A Skeans; L B Edwards; K Uccellini; J J Snyder; A K Israni; B L Kasiske Journal: Am J Transplant Date: 2017-01 Impact factor: 8.086
Authors: Eiran Z Gorodeski; Eric C Chu; Chen H Chow; Wayne C Levy; Eileen Hsich; Randall C Starling Journal: Circ Heart Fail Date: 2010-08-26 Impact factor: 8.790
Authors: Eileen M Hsich; Lucy Thuita; Dennis M McNamara; Joseph G Rogers; Maryam Valapour; Lee R Goldberg; Clyde W Yancy; Eugene H Blackstone; Hemant Ishwaran Journal: Am J Transplant Date: 2019-02-13 Impact factor: 8.086
Authors: Eileen M Hsich; Eugene H Blackstone; Lucy W Thuita; Dennis M McNamara; Joseph G Rogers; Clyde W Yancy; Lee R Goldberg; Maryam Valapour; Gang Xu; Hemant Ishwaran Journal: JACC Heart Fail Date: 2020-06-10 Impact factor: 12.035