Heart transplantation in women with dilated cardiomyopathy.

BACKGROUND: Dilated cardiomyopathy (DCM) is responsible for over half of all heart transplants. Fewer women with DCM undergo heart transplants than men with DCM; the reasons for this state of affairs are unclear. METHODS AND RESULTS: We analyzed prospectively a cohort of 698 DCM patients who were referred to our heart transplant center. Only 15.5% of them were women. Women and men did not differ in age or ejection fraction (24%). Women were more frequently in New York Heart Association class III-IV, had lower exercise tolerance, worse pulmonary function, and poorer kidney function (all P<0.05) than men. Women were less commonly diabetic (14% vs. 23%; P<0.05). Similar percentages of women and men who were referred were transplanted; the women spent less time on the waiting list (153+/-37 days for women and 314+/-29 days for men; P<0.05). The 10-year survival rate of women and men after transplantation was similar (57% and 45%, respectively; P<0.203). We compared our current data to our overall experience from 1985 till date (n=972), and also with the Eurotransplant heart dataset. Similar to our current findings, far lower percentages of DCM patients in both cohorts were women, although the 10-year survival of female and male DCM patients after transplantation was not different. CONCLUSIONS: Because women were referred with more severe heart failure but fewer relative contraindications, it seems that the option of transplantation is less intensely considered for women, particularly for those with comorbidities, by the referring physicians. Because women with DCM do as well as men after transplantation, efforts should be undertaken to improve referral of women.

Proposition: the benefit of cardiac transplantation in stable outpatients with heart failure should be tested in a randomized trial.

Recent data suggest that cardiac transplantation is associated with a survival benefit only in patients at high risk for dying of advanced heart failure without this procedure. To test the hypothesis that survival and quality of life advantages associated with cardiac transplantation exist in stable outpatients, a 3-stage approach is proposed: 1). to establish a database within the International Society for Heart and Lung Transplantation/United Network for Organ Sharing/Eurotransplant infrastructure that will provide an estimate of the survival benefit of heart transplantation in various heart failure risk strata by prospectively following cohorts of patients listed for heart transplantation; 2). to organize an international consensus conference that will define, based on the review of the Stage 1 data, the feasibility of a prospective randomized trial; and 3). pending consensus, to perform a clinical trial, perhaps with an augmented, randomized design that allocates cardiac transplantation to all patients at high risk for dying of heart failure while randomizing patients at low risk to either conventional treatment or cardiac transplantation. Generating such scientific evidence is important in light of today's donor organ crisis and the associated difficulties of equitable resource allocation.

Which ABO-matching rule should be the decisive factor in the choice between a highly urgent and an elective patient?

ABO blood group matching policy between donor and recipient is a key element of organ allocation. Unequal distribution of the ABO blood groups in the population can lead to inequities in the distribution of organs to potential recipients. Furthermore, High Urgency liver transplant candidates might compromise the chances of transplantation for the elective patients. To compare the influence of the various ABO blood group matching policies on the transplantation rate of HU patients and on the subsequent donor liver availability for elective patients, a simulation study was undertaken. The study shows that in the Eurotransplant liver allocation program, a restricted ABO-compatible matching policy for HU liver patients offers the highest probability of acquiring a liver transplant, for both High Urgency- and elective patients, irrespective of their ABO blood group. A simulation study once again proved to be an elegant tool for objectively analysing various options in a complex organ allocation algorithm.