THE IMPENDING CRISIS AWAITING CARDIAC TRANSPLANTATION - MODELING A SOLUTION BASED ON SELECTION

Background Each month, the number of transplant candidates added to th e waiting list exceeds the number of transplantations performed, and m any outpatients deteriorate to require transplantation urgently. The c urrent list of 2400 candidates and the average wait of 8 months contin ue to increase. Methods and Results To determine the size at which the outpatient and critical candidate pools will stabilize, population mo dels were constructed using current statistics for donor hearts, candi date listing, sudden death, and outpatient decline to urgent status an d revised to predict the impact of alterations in policies of candidat e listing. If current practices continue, within 48 months the predict ed list will stabilize as the sum of an estimated 270 hospitalized can didates, among whom, together with newly listed urgent candidates, all hearts will be distributed and 3700 outpatient candidates with virtua lly no chance of transplantation unless they deteriorate to an urgent status. Decreasing the upper age limit now to 55 years would reduce th e number listed each month by 30% and result within 48 months in a lis t of only 1490. The list could also be decreased by 30%, however, if i t were possible to list only a candidate group with an 80% chance (com pared with 52% estimated currently) of sudden death or deterioration d uring the next year. With this strategy, the waiting list would equili brate within 48 months to one-third the current size, with 50% of hear ts for outpatient candidates, who would then have an 11% chance each m onth of receiving a heart compared with 0% if recent policies prevail. Total deaths, with and without transplantation, would be minimized by this rigorous selection of outpatient candidates. Conclusions This st udy implies that immediate provisions should be made to limit candidat e listing and revise expectations to reflect the diminishing likelihoo d of transplantation for outpatient candidates. Future emphasis should be on improved selection of candidates at highest risk without transp lantation.