Too early for cardiac transplantation—the right decision?

In 109 out of 479 patients who were referred for cardiac transplantation it was considered to be too early to put them on the waiting list for a donor heart. The clinical course of these 109 patients was analysed in order to verify whether this decision had been right. The mean age of the patients was 43 years, half of them suffered from ischaemic heart disease. The systolic left ventricular function of the patients was severely depressed (mean left ventricular ejection fraction 21%) and the left ventricular cavitv was markedly dilated (mean echocardiographic end diastolic dimension 73 mm). Functional capacity, measured bv bicycle ergometry, was low: mean maximal workload 62% of the expected load for gender, height and age. The median follow-up duration was 31 months. The survival rate of the patients was better than that of 175 patients who were accepted for transplantation after referral, 92% 87%, 81%, 71% and 73%, 73%, 71%, 68% after 1,2,3 and 4 years respectively. Re-assessment was necessary in 29% of the patients within 1 year and in 52% within 3 years. Twenty patients died: 12 patients died before re-assessment had been initiated (eight sudden deaths), six patients because of progressive heart failure before heart transplantation could be performed and two patients died after heart transplantation. Left ventricular ejection fraction, pulmonary capillary wedge pressure and transpulmonary gradient were not reliable predictors of the course of the patients. In retrospect, a systolic blood pressure rise of less than 20 mmHg during exercise and an echocardiographic ventricular end-diastolic dimension of more than 75 mm helped in defining a subgroup of patients with an increased risk of clinical deterioration, who needed strict medical supervision after the decision to defer transplantation.