364 - Postoperative Outcomes of Patients Initially Deferred for Heart Transplantation Compared to Those with Initial Acceptance

Abstract

Introduction: Heart transplantation (HT) is the definitive treatment for end stage heart failure. Candidates for HT are presented at an interdisciplinary transplant committee (TC). The TC considers factors affecting postoperative success, including medical, financial, and psychosocial comorbidities. Outcomes of presentation include: accepted and listed for HT or left ventricular assist device (LVAD), deferred for later decision, or rejected from both strategies. Deferred patients often have modifiable comorbidities and may be presented again at a later date, but outcomes for patients initially deferred are unknown. We sought to characterize the impact of delayed listing for HT on postoperative outcomes. Hypothesis: We hypothesized that delay in listing for HT to modify comorbidities would not adversely affect postoperative outcomes. Methods: Patients evaluated for HT at a single institution from January 2013 to October 2016 were retrospectively reviewed. We compared postoperative measures of patients undergoing HT, including one-year mortality, postoperative length of stay (LOS), rejection, dialysis need, number of rehospitalizations, and ICU stay on readmission in these groups. Results: A total of 202 patients were presented and decisions were as follows: 104 listed for HT or LVAD (51.5%), 62 rejected (30.7%), and 36 deferred (17.8%). Of the 36 deferred: 20 were never represented, 11 were represented and listed, 3 were rejected, and 2 were deferred again (1 was presented a third time and listed). In the cohort of initially rejected patients, 2 were presented again and 1 was listed. Ultimately, 107 patients were listed for HT or LVAD; of these, 73 underwent HT (65 of whom were initially accepted, 7 deferred, and 1 rejected). There was a trend toward significance (P = .07) in time to HT from initial presentation to TC in accepted (190 ± 228 days) compared to delayed (302 ± 143 days) cohorts. There was no difference in postoperative LOS (22.8 days, 33.4 days, P = .37), one year survival (99.41%, 100%, P = .53%), average rejection (25.4%, 25.0%, P = .98), or dialysis need (13.9%, 12.5%, P = .25) in the accepted compared to delayed cohorts, respectively. There was also no difference in readmission (1.7%, 2.9%, P = .422) or ICU stay on readmission (23.1%, 25.0%, P = .25). Conclusion: Our experience suggests that less than half of patients who are deferred at TC are ever represented (44.4%), and even fewer of these patients are ever listed for HT (33.3%). Of these patients, just a small fraction (19.4%) ultimately underwent HT. Outcomes of those who are deferred and transplanted are identical to those initially accepted. These data suggest that criteria for deferring HT may need refinement to focus resources on patients with truly modifiable goals, and not cause needless uncertainty in very sick patients who cannot meet HT criteria. In those initially deferred patients in whom goals are achieved, outcomes are excellent.