INFLUENCE OF HEART-TRANSPLANTATION ON THE NATURAL-HISTORY OF PATIENTSWITH SEVERE CONGESTIVE-HEART-FAILURE

In an attempt to study the influence of heart transplantation on the n atural history of patients with severe congestive heart failure, we ha ve reviewed our experience with 240 consecutive patients who were New York Heart Association class IV or III/IV, who had left ventricular ej ection fraction less than 35%, who were younger than 65 years of age, and who were assessed for heart transplantation in our hospital since May 1986. Mean age was 47 +/- 12 years. Left ventricular ejection frac tion was 20% +/- 6%. Eighty-seven percent were male. New York Heart As sociation class was IV in 88% and III/IV in 12%. The cause was ischemi c heart disease in 35% of patients, valvular heart disease in 13% of p atients, and primary dilated cardiomyopathy in 52% of patients. At ini tial assessment, heart transplantation was considered to be not indica ted in 30% of patients, indicated in 51% of patients, and contraindica ted in 19% of patients. During a follow-up of 13 +/- 13 months (2 to 6 4 months), 110 patients underwent transplantation (46%). Posttransplan tation actuarial probability of survival was 70% at 3 years. Three-yea r probability of survival free from transplantation was significantly lower for patients older than 55 years of age (p < 0.05), for those wi th left ventricular ejection fraction less than 20% (p < 0.05), ischem ic causes (p < 0.05), New York Heart Association class IV (p < 0.001), and indication/contraindication for transplantation (p < 0.001); no d ifference was noted for gender. Overall probability of being alive and free from transplantation was only 16% at 3 years; when posttransplan tation survival was included, the overall 3-year actuarial survival ro se to 43% (p < 0.01). Heart transplantation also increased by about tw o to three times 3-year survival in all studied subgroups of patients: age less than 55 years (from 14% to 47%, p < 0.01) and more than 55 y ears (from 10% to 25%, p < 0.05); male (from 15% to 43% p < 0.01) and female (from 13% to 35%, p < 0.05); left ventricular ejection fraction less than 20% (from 12% to 37%, p < 0.01) and more than 20% (from 25% to 51%, p < 0.05); ischemic causes (from 6% to 33%, p < 0.01) and pri mary dilated cardiomyopathy (from 26% to 44%, p < 0.05); initial indic ation/contraindication for transplantation (from 13% to 45%, p < 0.01) and initial no indication (from 46% to 73%, p < 0.05); and New York H eart Association class IV (from 12% to 42%, p < 0.01). In conclusion, (1) long-term probability of cardiac death (death or heart transplanta tion) is very high in patients with severe dilated cardiomyopathy (84% at 3 years); and (2) heart transplantation increased long-term surviv al in the entire population and in all studied subgroups of patients b y two to three times.