1 heart
waiting list ....................... deceased donation ......... transplant ....................... donor-recipient matching outcomes ........................ pediatric transplant ......... transplant center maps....
6 11 12 15 16 19 25
M. Colvin-Adams1,2 , J. M. Smith1,3 , B. M. Heubner1 , M. A. Skeans1 , L. B. Edwards4,5 , C. D. Waller4,5 , E. R. Callahan4,5 , J. J. Snyder1,6 , A. K. Israni1,6,7 , B. L. Kasiske1,7
1
Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
2
Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
3
Department of Pediatrics, University of Washington, Seattle, WA
4
Organ Procurement and Transplantation Network, Richmond, VA
5
United Network for Organ Sharing, Richmond, VA
6
Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
7
Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
OPTN/SRTR 2013 Annual Data Report:
heart
ABSTRACT The number of heart transplants performed annually continues to increase gradually, and the number of adult candidates on the waiting list increased by 34.2% from 2003 to 2013. The heart transplant rate among active adult candidates peaked at 149.0 per 100 waitlist years in 2007 and has been declining since then; in 2013, the rate was 87.4 heart transplants per 100 active waitlist years. Increased waiting times do not appear to be correlated with an overall increase in waitlist mortality. Since 2008, the proportion of patients on life support before transplant increased from 53.4% to 65.8% in 2013. Medical urgency categories have become less distinct, with most patients listed in higher urgency categories. Approximately 500 pediatric candidates are added to the waiting list each year; the number of pediatric transplants performed each year increased from 293 in 2003 to 411 in 2013. Patient survival among pediatric recipients continues to improve; 5-year patient survival for transplants performed from 2001 through 2008 was 70% to 80%. Medicare paid for some or all of the care for 42.2% of all heart transplant recipients in 2012.
KEY WORDS End-stage heart failure, heart transplant, transplant outcomes, ventricular assist device.
It will be two years in September that our 19 year old daughter received her new heart. While camping two weeks ago she rode her bike: no breathlessness. I almost cried. Thank you to the donor families who make this possible for other families to experience moments like this. Jody, recipient mother
2
OPTN/SRTR 2013 Annual Data Report
Introduction Although 2013 did not bring major changes in heart transplant, progress was made in perioperative management, patient selection, desensitization, management of rejection, and management of candidates with ventricular assist devices (VADs). Complications of VADs and their effect on candidacy and allocation policies remain major areas of concern, and defining a policy that further stratifies urgency remains of interest. The number of candidates listed for heart transplant continues to increase more rapidly than the number of donors suitable for heart donation. Since 2002, the number of heart transplants performed also increased, but not at the same pace as the number of candidates being listed. The proportion of candidates with VADs remains high and continues to increase. Transplant rates and donation rates continue to show marked regional variability. Increasing proportions of older candidates and ethnic minorities are being listed, and the number of heart-kidney transplants has more than doubled since 2003. The Organ Procurement and Transplantation Network/United Network for Organ Sharing Thoracic Committee is developing heart allocation policy that will better stratify risk of waitlist mortality.
Adult Heart Transplant Waitlist Trends: New Listings, Time to Transplant, and Waitlist Mortality
In 2013, 3293 new candidates were listed for heart transplant, representing a 34.2% increase since 2003 (Figure HR 1.1). The most notable waitlist trends include the following: The proportion of candidates aged 65 years or older continues to
increase; in 2013, 18.2% of candidates were aged 65 years or older, compared with 10.8% in 2003. The proportion of black candidates has increased over the past decade by approximately 8%, to 22.8% of candidates in 2013. The prevalence of cardiomyopathy as the reason for listing has increased to more than 50%, while prevalence of coronary artery disease as a reason for listing decreased to 35.8% in 2013. Fewer candidates than in previous spend long times on the waiting list. In 2003, 14.8% of candidates spent 5 or more years on the waiting list, compared with only 5.4% in 2013. The proportion of candidates with VADs at listing increased dramatically, from 7.5% in 2003 to 27.4% in 2013. Over the past 5 years alone, the prevalence of VADs at listing more than doubled. The distribution of medical urgency categories has shifted to a higher prevalence of status 1A and 1B. Over the past decade, the proportion of patients awaiting heart transplant as status 1A during the year increased from 21.6% to 43.9%, and the proportion awaiting heart transplant as status 1B increased from 15.8% to 27.4% (Figure HR 1.2). Heart transplant rates were highest among candidates aged 65 years or older, those with blood type AB, those listed as status 1A, and those with VADs (Figure HR 1.4). In general, few candidates died while awaiting a heart transplant (Figure HR 1.7). In the cohort of transplant candidates listed in 2010, 66.4% underwent transplant within 3 years, 8.9% were still waiting, and 10.0% had died. Some (14.7%) were removed from the list for other reasons, including improved or worsened condition (Figure HR 1.8). Half of all candidates listed in 2012-2013 underwent transplant within 9.3 months, an increase from 5.3 months in 2004-2005 (Figure HR 1.9). Waiting time for candidates listed as status 1A increased slightly from 1.9 months to 2.6 months since 2004-2005; however, median waiting time for candidates listed as status 1B increased notably, from 2.7
3 heart
months to 8.5 months during the same period. The median waiting times for candidates with and without VADs at listing were essentially the same: 9.3 months and 9.4 months, respectively; however, the median waiting time for candidates with VADs increased sharply recently, from 6.2 months for candidates listed in 2010-2011 to 9.3 months for candidates listed in 2012-2013 (Figure HR 1.9). Waiting time to transplant varied notably by geographical area (Figure HR 1.6). When stratified by donation service area (DSA), the occurrence of heart transplant within 1 year of listing ranged from 28.9% to 100.0%. This may reflect local practices in addition to donor availability; however, donor availability by state does not correspond to the trends in waiting times for the DSAs with the highest transplant rates (Figure HR 2.2). Death on the waiting list has steadily declined over the past decade, to 10.7 deaths per 100 waitlist years in 20122013 from 14.8 deaths per 100 waitlist years in 2002-2003. There were no major differences in waitlist mortality among subgroups in 2012-2013, but some trends are worth noting. Waitlist mortality declined by more than half for candidates aged 18 to 34 years; in 2012-2013, waitlist mortality for these candidates was the lowest (8.8 deaths per 100 waitlist years) among the age categories. Waitlist mortality declined in all race categories and for all etiologies except valvular cardiomyopathy, where variability was substantial and a large increase occurred in 2012-2013. When compared by presence of VAD at listing, mortality for candidates with and without VADs was similar. Waitlist mortality was higher for candidates with blood type AB (17.1 deaths per 100 waitlist years) than for the other blood type groups, despite higher transplant rates, and lowest for candidates with blood type O (9.7 deaths per 100 waitlist years). Waitlist mortality remained substantial for the status 1A group, although it declined over the decade. Of note, waitlist mortality for the status 1B group was 4.9 deaths per 100 status 1B waitlist years, which is not substantially higher than mortality for the status 2 group. The mortality rate for inactive patients increased to 25.5 deaths per 100 inactive waitlist years in 2012-2013 (Figure HR 1.10). Donor Trends
In general, heart donation rates have been stable over the past decade; the rate was 3.49 per 1000 patient deaths in 2011. One notable exception is an increase in donation rates of 38.6% since 2006 in the group aged 1 to 15 years. Donors aged 55 years or older have become increasingly rare. Heart donation rates have either plateaued or decreased slightly in all race groups except black race, where rates have steadily increased (Figure HR 2.1). The overall donation rate was 0.94 hearts donated per 1000 deaths in 2009-2011; however, there was great regional variability, and donation rates
were greater than 0.50 per 1000 deaths in most states (Figure HR 2.2). Cerebrovascular accident/stroke was an increasing cause of death in donors aged 50 years or older (data not shown), while head trauma remained the most prevalent cause of death in donors aged younger than 50 years. In all age groups, anoxia was an increasingly prevalent cause of death (Figure HR 2.3). Trends in Heart Transplant
The number of adult heart transplants has increased gradually over the past decade, by 22.4% since 2003 (Figure HR 3.1). Among the age groups, the greatest increase in transplants was among recipients aged 65 years or older. The gradual growth in the number of heart transplants was seen for men and women and among race groups. The number of transplants due to cardiomyopathy and congenital heart disease continued to increase (Figure HR 3.2). Life support, including intravenous inotropes, intra-aortic balloon pumps, ventricular and circulator assist devices, ventilators, inhaled nitric oxide, and prostaglandins, is becoming more common before transplant. In 2013, 65.8% of transplant recipients were on life support before transplant, compared with 53.4% in 2008 (Figure HR 3.3). The major contributor to this trend is the increase in the prevalence of left VADs (LVADs) before transplant. In 2013, 44.0% of transplant recipients used LVADs and 34.3% were receiving intravenous inotropes. This is in striking contrast to 2008, when 46.6% of transplant recipients were receiving inotropes and only 24.6% used LVADs. The number of candidates with a total artificial heart (TAH) before transplant has tripled over the past 5 years, from 18 TAHs in 2008 to 54 in 2013, while ventilator support has decreased by nearly two-thirds (Figure HR 3.3). Recipient Characteristics
The mean age of heart transplant recipients increased from 51.3 years in 2003 to 53.2 years in 2013. The proportion of recipients aged 65 years or older doubled to 20.9% during that same period. Most recipients were white men; however, 21.7% were black, which is a notable increase since 2003. Women comprised 27.4% of recipients. The typical recipient had blood type A or O. The proportion of private payers declined by 10.6% to 48.5% in 2013, mirrored by an increase in Medicare as the primary payer to 35.1% of recipients. Although a waiting time to transplant of less than 31 days was most common, occurring for 23.8% of candidates in 2013, waiting times between 3 months and 2 years became more frequent. Simultaneous heart-kidney and heart-liver transplants increased in frequency, while heart-lung transplants became even rarer; in 2013, only 16 heart-lung transplants were performed (Figure HR 3.4). Since 2003, status 1A and 1B listings (Figure HR 1.3) have increased markedly. This increase
data behind the figures can be downloaded from our website, at srtr.transplant.hrsa.gov
4
OPTN/SRTR 2013 Annual Data Report
in higher urgency listings corresponded to an almost 2-fold increase in the proportion of status 1A recipients, to 65.1%. In contrast, status 1B transplants were less common in 2013, occurring in 31.4% of recipients, and status 2 transplants declined from 26.4% in 2003 to 3.5% of transplants in 2013 (Figure HR 3.4). Survival after Heart Transplant
One-year survival in patients who underwent heart transplant from 2006 through 2008 was 88.1%; 3-year survival was 81.3% and 5-year survival 75.3%. Survival was slightly lower for women, particularly after year 3 posttransplant. Among the age groups, survival during year 1 was lowest for recipients aged 65 years or older; however, after year 1, survival was worst for recipients aged 18 to 34 years. At 5 years, survival was only 67.4% for recipients aged 18 to 34 years, compared with 76.7%, 77.0%, and 73.5% for ages 35 to 49 years, 50 to 64 years, and 65 years or older, respectively (Figure HR 5.1). Although the reason is difficult to determine, this difference may be a result of the etiology of heart failure, possibly immunologic complications (rejection), or psychosocial challenges that may be unique in the younger population. Early survival was similar in all race groups; however, curves diverged at 11 months, at which point survival for black recipients became lower. By year 3, survival was only 75.8% for blacks, compared with 82.7% for whites and 81.6% for other race groups. By year 5, survival was 68.8% for blacks, compared with 77.0% for whites. Survival was slightly lower for recipients with prior VADs than for those without VADs. Survival did not differ meaningfully between the medical urgency categories at any time point (Figure HR 5.1). The number of heart transplant survivors continued to increase. On June 30, 2013, 27,120 heart transplant recipients were alive with a functioning graft, most aged 50 years or older (Figure HR 5.2). Posttransplant morbidity
Rejection remains an important cause of morbidity after heart transplant; the cumulative incidence of rejection at 1 year was 23.6%. Rejection was most prevalent in recipients aged 18 to 34 years. As might be expected, the lowest occurrence of rejection was among the oldest age group, particularly those aged 65 years or older (Figure HR 5.3). Viral serologies were important risk factors for morbidity after transplant. Epstein-Barr virus (EBV) infection is associated with lymphoma and posttransplant lymphoproliferative disorder (PTLD), and cytomegalovirus (CMV) infection is strongly linked to cardiac allograft vasculopathy. Recipients who are EBV negative are more likely to have a positive (11.9% of all matches 2009-2013) than a negative donor (0.7%), due to the frequency of EBV in the general popula-
tion (Figure HR 4.2). The risk of PTLD in EBV-negative recipients was more than twice that in EBV-positive recipients at 5 years, 1.8% vs. 0.7%, respectively (Figure HR 5.4). Overall, the incidence of PTLD was low in this population, only 0.9% at 5 years (Figure HR 5.4). The leading causes of death during year 1 posttransplant were infection, cardiovascular/cerebrovascular disease, and graft failure. After year 1, however, cardiovascular/cerebrovascular disease became a more common cause of death, followed by infection and graft failure (Figure HR 5.7). Summary
Current trends reflect the increasing use of mechanical circulatory support as a bridge to transplant. Listing as status 2 is becoming less common, as most patients are listed in a higher medical urgency category. VADs have had a great impact on the upward trend toward listing patients at higher urgency categories.
Pediatric Heart Transplant Pediatric Waitlist Trends
In 2013, the number of new pediatric candidates added to the heart transplant waiting list increased to 589, with very few added as inactive status. At year-end 2013, almost 350 candidates were awaiting heart transplant, with 64.5% listed as active (Figure HR 6.1). The largest age group of children on the waiting list was 11 to 17 years (33.3%), followed by younger than 1 year (28.1%), 1 to 5 years (24.1%), and 6 to 10 years (14.6%). Almost 55% of heart transplant candidates were white, 20.0% were black, 19.9% were Hispanic, and less than 5% were Asian (Figure HR 6.2). The proportion of waitlist candidates aged younger than 1 year increased from 4.7% in 2003 to 17.4% in 2013 (Figure HR 6.3). Sex and race distribution remained relatively similar in 2003 and 2013. For candidates waiting on December 31, 2013, congenital defect was the leading cause of heart disease (45.6%). Just over half of candidates (57.5%) waiting for a heart transplant on December 31, 2013, had been waiting for less than 1 year, compared with 38.2% in 2003. Almost 30% of candidates were listed as status 1A in 2013, compared with 8.8% in 2003. Another notable change is the increase in the number candidates using VADs at the time of listing, from 0.9% in 2003 to 5.1% in 2013 (Figure HR 6.3). Among candidates removed from the waiting list in 2013, 73.6% underwent transplant, 9.3% died, 8.6% were removed from the list because their condition improved, and 5.3% were considered too sick to undergo transplant (Figure HR 6.4). Almost 75% of patients newly listed in 2010 underwent transplant within 3 years, 9.8% died, 10.8% were removed from the list, and 5.1% were still waiting (Figure HR 6.5).
5 heart
The rate of heart transplants among active pediatric waitlist candidates decreased from a peak of almost 300 per 100 waitlist years in 2006 to 196 per 100 waitlist years in 2013, likely attributable to a growing waiting list. Transplant rates varied by age, with the highest rates for candidates aged less than 1 year, at 317 transplants per 100 waitlist years, followed by candidates aged 11 to 17 years, at 212 transplants per 100 waitlist years. Transplant rates for candidates aged 1 to 5 and 6 to 10 years were similar, at approximately 145 transplants per 100 waitlist years (Figure HR 6.6). Waitlist mortality continues to decrease; rates were almost half the rates observed a decade earlier. The waitlist mortality rate was highest for candidates aged younger than 1 year, at 42 deaths per 100 waitlist years in 2012-2013, almost 2.5 times higher than the rate for candidates aged 1 to 5 years (Figure HR 6.7). Waitlist mortality among candidates with a VAD at the time of listing has declined over time and now almost equals that of candidates without a VAD. Looking at cause of disease, waitlist mortality was highest in candidates with congenital defects or dilated myopathy/myocarditis (Figure HR 6.7). Pediatric Transplant
The number of pediatric heart transplants performed each year increased from 294 in 2002 to 411 in 2013, with the largest increase in candidates aged 11 to 17 years (Figure HR 6.8). Over the past decade, the age, sex, and race of pediatric heart transplant recipients changed little. Congenital defects remain the most common primary cause of disease, affecting 43.4% of recipients in 2011-2013. The proportion of recipients undergoing retransplant has remained stable over the decade at 6% to 7%. The percentage of ABO-incompatible transplants in 2011-2013 was 3.6%, increased from 1.3% a decade earlier. The proportion of recipients with private insurance decreased and Medicaid coverage increased. The proportion of patients who underwent transplant as status 1A increased from 67.9% in 2001-2003 to 89.6% in 2011-2013. VAD use increased from only 8.4% of transplant recipients in 2001-2003 to 23.0% in 2011-2013 (Figure HR 6.9). Among pediatric heart transplant recipients from 2009 to 2013, 56.6% were CMV negative and 41.9% were EBV negative (Figure HR 6.10). The combination of a CMV-positive donor and CMV-negative recipient occurred in 28.8% of
transplants; for EBV, this occurred in 31.1% of transplants (Figure HR 6.10). The incidence of PTLD among EBV-negative recipients was 5.9% at 5 years after transplant, compared with 2.3% among EBV-positive recipients (Figure HR 6.11). Pediatric Immunosuppression and Outcomes
Substantial changes in immunosuppression have occurred in heart transplantation. In 2013, the most common induction therapy was T-cell depleting agents, used in almost half of heart transplant recipients, followed by interleukin-2 receptor antagonists in 20.2%. No induction therapy was reported in 35.0% of recipients. The initial immunosuppression agents used most commonly in 2013 were tacrolimus (86.5%), mycophenolate mofetil (92.1%), and steroids (67.7%). Mammalian target of rapamycin inhibitors were used in only 1.0% of recipients at the time of transplant but use increased to 8.6% at 1 year after transplant. Steroid use at 1 year after transplant was reported in 63.0% of recipients (Figure HR 6.12). Patient survival was 96.9% at 30 days for transplants performed in 2013, 92.7% at 1 year for transplants performed in 2012, 87.1% at 3 years for transplants performed in 2010, 76.5% at 5 years for transplants performed in 2008, and 60.4% at 10 years for transplants performed in 2003 (Figure HR 6.13). Among patients undergoing transplant in 2001-2008, 1-, 3-, and 5-year patient survival was 87.3%, 79.9%, and 74.1%, respectively (Figure HR 6.16). Patient survival was poorest for heart transplant recipients aged younger than 1 year. The leading identified causes of death were graft failure and cardio/cerebrovascular disease, with almost identical rates at 1 year and 5 years after transplant (Figure HR 6.17). The rate of late graft failure is traditionally measured by the graft half-life conditional on 1-year survival, defined as the time to when half of grafts surviving at least 1 year are still functioning. For heart transplants performed in 2011, the 1-year conditional graft half-life was 15.2 years (Figure HR 6.14). The incidence of first acute rejection increases over time after transplant. Interestingly, the age cohort with the highest incidence of acute rejection at all time points was aged 6 to 11 years, with almost half experiencing rejection by 2 years after transplant (Figure HR 6.15).
data behind the figures can be downloaded from our website, at srtr.transplant.hrsa.gov
OPTN/SRTR 2013 Annual Data Report
waiting list
4000
New patients
4000
Patients
3000
Patients on list on Dec 31 each year Active Inactive All
3000 Patients
6
2000 Active Inactive All
1000
2000 1000
0
0 03
05
07 Year
09
11
13
03
05
07 Year
09
11
13
HR 1.1 Adults waiting for heart transplant A new patient is one who first joined the list during the given year, without having been listed in a previous year. Previously listed candidates who underwent transplant and subsequently relisted are considered new. Candidates concurrently listed at multiple centers are counted once. Concurrently listed candidates who are active at any program are considered active; those who are inactive at all programs are considered inactive.
HR 1.2 Distribution of adults waiting for heart transplant Candidates waiting for transplant any time in the given year. Candidates listed concurrently at multiple centers are counted once. Age is determined at the later of listing date or January 1 of the given year. Time on the waiting list is determined at the earlier of December 31 or removal from the waiting list. Medical urgency status is the most severe during the year. Active and inactive patients are included. VAD, ventricular assist device.
7 heart
waiting list Age
Sex Race
Citizenship
Primary diagnosis
Heart tx history Blood type
Waiting time
Medical urgency
VAD at listing Multi-organ
All candidates
18-34 35-49 50-64 65+ Female Male White Black Hispanic Asian Other/unknown US citizen Non-citizen resident Non-citizen non-resident Other/unknown Coronary artery disease Cardiomyopathy Congenital disease Valvular disease Other/unknown First transplant Retransplant A B AB O < 1 year 1-< 2 years 2-< 3 years 3-< 4 years 4-< 5 years 5+ years 1A 1B 2 Inactive Heart only Heart-kidney Heart-lung Other
2003 N % 324 9.9 791 24.2 1,723 52.8 426 13.1 772 23.7 2,492 76.3 2,480 76.0 460 14.1 238 7.3 72 2.2 14 0.4 3,221 98.7 33 1.0 7 0.2 3 0.1 1,390 42.6 1,444 44.2 107 3.3 85 2.6 238 7.3 3,172 97.2 92 2.8 1,036 31.7 321 9.8 49 1.5 1,858 56.9 1,121 34.3 539 16.5 360 11.0 331 10.1 232 7.1 681 20.9 62 1.9 342 10.5 1,365 41.8 1,495 45.8 126 3.9 3,055 93.6 58 1.8 145 4.4 6 0.2 3,264 100.0
2013 N % 341 10.2 716 21.4 1,667 49.9 617 18.5 784 23.5 2,557 76.5 2,212 66.2 782 23.4 242 7.2 82 2.5 23 0.7 3,261 97.6 15 0.4 7 0.2 58 1.7 1,184 35.4 1,791 53.6 143 4.3 48 1.4 175 5.2 3,223 96.5 118 3.5 1,064 31.8 388 11.6 79 2.4 1,810 54.2 1,768 52.9 667 20.0 342 10.2 197 5.9 132 4.0 235 7.0 326 9.8 1,312 39.3 895 26.8 808 24.2 886 26.5 3,125 93.5 142 4.3 42 1.3 32 1.0 3,341 100.0
HR 1.3 Characteristics of adults on the heart transplant waiting list on December 31, 2003, and December 31, 2013 Patients waiting for transplant on December 31, 2003, and December 31, 2013, regardless of first listing date; active/inactive status is on this date, and multiple listings are not counted.
data behind the figures can be downloaded from our website, at srtr.transplant.hrsa.gov
8
OPTN/SRTR 2013 Annual Data Report
waiting list Age
1000 Transplants per 100 wait-list years
Transplants per 100 wait-list years
1000 800
18-34 35-49 50-64 65+
600 400 200 0 05
07 Year
09
11
600 400 200
13
03
Medical urgency
800
1000 Transplants per 100 wait-list years
Transplants per 100 wait-list years
A B AB O
800
0 03
1000
Blood type
Status 1A Status 1B Status 2 All
600 400 200 0
05
07 Year
09
11
13
11
13
VAD at listing
800 Yes No
600 400 200 0
03
05
07 Year
09
11
13
03
05
07 Year
09
HR 1.4 Heart transplant rates among active adult waitlist candidates Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of active waiting in a given year. VAD, ventricular assist device.
No data
47.3 54.6
84.0
124.2
224.5 148.9
No data
34.3 40.9
48.4
57.4
74.0 64.9
HR 1.5 Deceased donor heart transplant rates per 100 waitlist years among active adult candidates, by DSA, 20122013
HR 1.6 Percentage of adult waitlisted candidates who underwent deceased donor heart transplant within 1 year, by DSA, 2012
Transplant rates by DSA of the listing center, limited to candidates with active time on the waiting list in 2012 and 2013; deceased donor transplants only. Maximum time per listing is 2 years. Candidates listed concurrently in a single DSA are counted separately.
Candidates listed concurrently in a single DSA are counted once in that DSA; candidates listed in multiple DSAs are counted separately per DSA.
9 heart
waiting list Patients at start of year Patients added during year Patients removed during year Patients at end of year
2011 2,898 2,811 2,862 2,847
2012 2,843 3,025 2,805 3,063
2013 3,058 3,293 3,019 3,332
Removal reason Deceased donor transplant Patient died Patient refused transplant Improved, tx not needed Too sick for transplant Other
1,948 332 16 165 191 210
2,005 306 21 145 190 138
2,116 338 14 146 223 182
HR 1.7 Heart transplant waitlist activity among adults
HR 1.8 Three-year outcomes for adults waiting for heart transplant, new listings in 2010
Candidates concurrently listed at more than one center are counted once, from the time of earliest listing to the time of latest removal. Candidates who are listed, undergo transplant, and are relisted are counted more than once. Candidates are not considered to be on the list on the day they are removed; counts on January 1 may differ from counts on December 31 of the prior year. Candidates listed for multi-organ transplants are included.
Medical urgency at listing
20 Median months to transplant
Median months to transplant
20
Adults waiting for heart transplant and first listed in 2010. Candidates concurrently listed at more than one center are counted once, from the time of earliest listing to the time of latest removal. DD, deceased donor.
15 Status 1A Status 1B Status 2
10 5 0 02-03
VAD at listing No VAD VAD All
15 10 5 0
04-05
06-07 08-09 Year of listing
10-11
12-13
02-03
04-05
06-07 08-09 Year of listing
10-11
12-13
HR 1.9 Median months to heart transplant for waitlisted adults, by medical urgency and VAD status at listing Observations censored at earliest of December 31, 2013, transfer to another center, or removal from waiting list due to improved condition; otherwise, candidates contribute waiting time until deceased donor transplant. Kaplan-Meier competing risks methods used to estimate time to transplant. Analysis performed per candidate not per listing. Only the first transplant is counted. VAD, ventricular assist device.
data behind the figures can be downloaded from our website, at srtr.transplant.hrsa.gov
10
OPTN/SRTR 2013 Annual Data Report
waiting list 20 15 18-34 35-49 50-64 65+ All
5 0
120
04-05
10-11
12-13
20 15 10
White Black Hispanic Asian
5
No Yes
60 40 20 0
04-05
06-07 08-09 Year
10-11
12-13
06-07 08-09 Year
10-11
12-13
20 15 10
Coronary artery dis. Cardiomyopathy Congential dis. Valvular dis.
5
02-03
Blood type
120
100 A B AB O
80 60 40 20 0
04-05
Primary diagnosis
0
02-03
120
100
02-03
25
0
06-07 08-09 Year
VAD at listing
80
Race
Deaths per 100 wait-list years
10
02-03
Deaths per 100 wait-list years
Deaths per 100 wait-list years
25
Deaths per 100 wait-list years
Age
Deaths per 100 wait-list years
Deaths per 100 wait-list years
25
02-03
04-05
06-07 08-09 Year
10-11
12-13
Medical urgency
100
Status 1A Status 1B Status 2 Inactive
80 60 40 20 0
04-05
06-07 08-09 Year
10-11
12-13
02-03
04-05
06-07 08-09 Year
10-11
12-13
HR 1.10 Pretransplant mortality rates among adults waitlisted for heart transplant Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year range. Candidates concurrently listed at multiple centers are counted once. Deaths after removal from the waiting list are not counted. Rates by status are calculated as the number of transplants for a given status divided by total waiting time in the year at that status. Age is determined at the later of listing date or January 1 of the given year. VAD, ventricular assist device.
11 heart
deceased donation Age
waiting list ....................... deceased donation ......... transplant ....................... donor-recipient matching outcomes ........................ pediatric transplant ......... transplant center maps....
6 11 12 15 16 19 25
M. Colvin-Adams1,2 , J. M. Smith1,3 , B. M. Heubner1 , M. A. Skeans1 , L. B. Edwards4,5 , C. D. Waller4,5 , E. R. Callahan4,5 , J. J. Snyder1,6 , A. K. Israni1,6,7 , B. L. Kasiske1,7
1
Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
2
Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
3
Department of Pediatrics, University of Washington, Seattle, WA
4
Organ Procurement and Transplantation Network, Richmond, VA
5
United Network for Organ Sharing, Richmond, VA
6
Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
7
Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
OPTN/SRTR 2013 Annual Data Report:
heart
ABSTRACT The number of heart transplants performed annually continues to increase gradually, and the number of adult candidates on the waiting list increased by 34.2% from 2003 to 2013. The heart transplant rate among active adult candidates peaked at 149.0 per 100 waitlist years in 2007 and has been declining since then; in 2013, the rate was 87.4 heart transplants per 100 active waitlist years. Increased waiting times do not appear to be correlated with an overall increase in waitlist mortality. Since 2008, the proportion of patients on life support before transplant increased from 53.4% to 65.8% in 2013. Medical urgency categories have become less distinct, with most patients listed in higher urgency categories. Approximately 500 pediatric candidates are added to the waiting list each year; the number of pediatric transplants performed each year increased from 293 in 2003 to 411 in 2013. Patient survival among pediatric recipients continues to improve; 5-year patient survival for transplants performed from 2001 through 2008 was 70% to 80%. Medicare paid for some or all of the care for 42.2% of all heart transplant recipients in 2012.
KEY WORDS End-stage heart failure, heart transplant, transplant outcomes, ventricular assist device.
It will be two years in September that our 19 year old daughter received her new heart. While camping two weeks ago she rode her bike: no breathlessness. I almost cried. Thank you to the donor families who make this possible for other families to experience moments like this. Jody, recipient mother
2
OPTN/SRTR 2013 Annual Data Report
Introduction Although 2013 did not bring major changes in heart transplant, progress was made in perioperative management, patient selection, desensitization, management of rejection, and management of candidates with ventricular assist devices (VADs). Complications of VADs and their effect on candidacy and allocation policies remain major areas of concern, and defining a policy that further stratifies urgency remains of interest. The number of candidates listed for heart transplant continues to increase more rapidly than the number of donors suitable for heart donation. Since 2002, the number of heart transplants performed also increased, but not at the same pace as the number of candidates being listed. The proportion of candidates with VADs remains high and continues to increase. Transplant rates and donation rates continue to show marked regional variability. Increasing proportions of older candidates and ethnic minorities are being listed, and the number of heart-kidney transplants has more than doubled since 2003. The Organ Procurement and Transplantation Network/United Network for Organ Sharing Thoracic Committee is developing heart allocation policy that will better stratify risk of waitlist mortality.
Adult Heart Transplant Waitlist Trends: New Listings, Time to Transplant, and Waitlist Mortality
In 2013, 3293 new candidates were listed for heart transplant, representing a 34.2% increase since 2003 (Figure HR 1.1). The most notable waitlist trends include the following: The proportion of candidates aged 65 years or older continues to
increase; in 2013, 18.2% of candidates were aged 65 years or older, compared with 10.8% in 2003. The proportion of black candidates has increased over the past decade by approximately 8%, to 22.8% of candidates in 2013. The prevalence of cardiomyopathy as the reason for listing has increased to more than 50%, while prevalence of coronary artery disease as a reason for listing decreased to 35.8% in 2013. Fewer candidates than in previous spend long times on the waiting list. In 2003, 14.8% of candidates spent 5 or more years on the waiting list, compared with only 5.4% in 2013. The proportion of candidates with VADs at listing increased dramatically, from 7.5% in 2003 to 27.4% in 2013. Over the past 5 years alone, the prevalence of VADs at listing more than doubled. The distribution of medical urgency categories has shifted to a higher prevalence of status 1A and 1B. Over the past decade, the proportion of patients awaiting heart transplant as status 1A during the year increased from 21.6% to 43.9%, and the proportion awaiting heart transplant as status 1B increased from 15.8% to 27.4% (Figure HR 1.2). Heart transplant rates were highest among candidates aged 65 years or older, those with blood type AB, those listed as status 1A, and those with VADs (Figure HR 1.4). In general, few candidates died while awaiting a heart transplant (Figure HR 1.7). In the cohort of transplant candidates listed in 2010, 66.4% underwent transplant within 3 years, 8.9% were still waiting, and 10.0% had died. Some (14.7%) were removed from the list for other reasons, including improved or worsened condition (Figure HR 1.8). Half of all candidates listed in 2012-2013 underwent transplant within 9.3 months, an increase from 5.3 months in 2004-2005 (Figure HR 1.9). Waiting time for candidates listed as status 1A increased slightly from 1.9 months to 2.6 months since 2004-2005; however, median waiting time for candidates listed as status 1B increased notably, from 2.7
3 heart
months to 8.5 months during the same period. The median waiting times for candidates with and without VADs at listing were essentially the same: 9.3 months and 9.4 months, respectively; however, the median waiting time for candidates with VADs increased sharply recently, from 6.2 months for candidates listed in 2010-2011 to 9.3 months for candidates listed in 2012-2013 (Figure HR 1.9). Waiting time to transplant varied notably by geographical area (Figure HR 1.6). When stratified by donation service area (DSA), the occurrence of heart transplant within 1 year of listing ranged from 28.9% to 100.0%. This may reflect local practices in addition to donor availability; however, donor availability by state does not correspond to the trends in waiting times for the DSAs with the highest transplant rates (Figure HR 2.2). Death on the waiting list has steadily declined over the past decade, to 10.7 deaths per 100 waitlist years in 20122013 from 14.8 deaths per 100 waitlist years in 2002-2003. There were no major differences in waitlist mortality among subgroups in 2012-2013, but some trends are worth noting. Waitlist mortality declined by more than half for candidates aged 18 to 34 years; in 2012-2013, waitlist mortality for these candidates was the lowest (8.8 deaths per 100 waitlist years) among the age categories. Waitlist mortality declined in all race categories and for all etiologies except valvular cardiomyopathy, where variability was substantial and a large increase occurred in 2012-2013. When compared by presence of VAD at listing, mortality for candidates with and without VADs was similar. Waitlist mortality was higher for candidates with blood type AB (17.1 deaths per 100 waitlist years) than for the other blood type groups, despite higher transplant rates, and lowest for candidates with blood type O (9.7 deaths per 100 waitlist years). Waitlist mortality remained substantial for the status 1A group, although it declined over the decade. Of note, waitlist mortality for the status 1B group was 4.9 deaths per 100 status 1B waitlist years, which is not substantially higher than mortality for the status 2 group. The mortality rate for inactive patients increased to 25.5 deaths per 100 inactive waitlist years in 2012-2013 (Figure HR 1.10). Donor Trends
In general, heart donation rates have been stable over the past decade; the rate was 3.49 per 1000 patient deaths in 2011. One notable exception is an increase in donation rates of 38.6% since 2006 in the group aged 1 to 15 years. Donors aged 55 years or older have become increasingly rare. Heart donation rates have either plateaued or decreased slightly in all race groups except black race, where rates have steadily increased (Figure HR 2.1). The overall donation rate was 0.94 hearts donated per 1000 deaths in 2009-2011; however, there was great regional variability, and donation rates
were greater than 0.50 per 1000 deaths in most states (Figure HR 2.2). Cerebrovascular accident/stroke was an increasing cause of death in donors aged 50 years or older (data not shown), while head trauma remained the most prevalent cause of death in donors aged younger than 50 years. In all age groups, anoxia was an increasingly prevalent cause of death (Figure HR 2.3). Trends in Heart Transplant
The number of adult heart transplants has increased gradually over the past decade, by 22.4% since 2003 (Figure HR 3.1). Among the age groups, the greatest increase in transplants was among recipients aged 65 years or older. The gradual growth in the number of heart transplants was seen for men and women and among race groups. The number of transplants due to cardiomyopathy and congenital heart disease continued to increase (Figure HR 3.2). Life support, including intravenous inotropes, intra-aortic balloon pumps, ventricular and circulator assist devices, ventilators, inhaled nitric oxide, and prostaglandins, is becoming more common before transplant. In 2013, 65.8% of transplant recipients were on life support before transplant, compared with 53.4% in 2008 (Figure HR 3.3). The major contributor to this trend is the increase in the prevalence of left VADs (LVADs) before transplant. In 2013, 44.0% of transplant recipients used LVADs and 34.3% were receiving intravenous inotropes. This is in striking contrast to 2008, when 46.6% of transplant recipients were receiving inotropes and only 24.6% used LVADs. The number of candidates with a total artificial heart (TAH) before transplant has tripled over the past 5 years, from 18 TAHs in 2008 to 54 in 2013, while ventilator support has decreased by nearly two-thirds (Figure HR 3.3). Recipient Characteristics
The mean age of heart transplant recipients increased from 51.3 years in 2003 to 53.2 years in 2013. The proportion of recipients aged 65 years or older doubled to 20.9% during that same period. Most recipients were white men; however, 21.7% were black, which is a notable increase since 2003. Women comprised 27.4% of recipients. The typical recipient had blood type A or O. The proportion of private payers declined by 10.6% to 48.5% in 2013, mirrored by an increase in Medicare as the primary payer to 35.1% of recipients. Although a waiting time to transplant of less than 31 days was most common, occurring for 23.8% of candidates in 2013, waiting times between 3 months and 2 years became more frequent. Simultaneous heart-kidney and heart-liver transplants increased in frequency, while heart-lung transplants became even rarer; in 2013, only 16 heart-lung transplants were performed (Figure HR 3.4). Since 2003, status 1A and 1B listings (Figure HR 1.3) have increased markedly. This increase
data behind the figures can be downloaded from our website, at srtr.transplant.hrsa.gov
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OPTN/SRTR 2013 Annual Data Report
in higher urgency listings corresponded to an almost 2-fold increase in the proportion of status 1A recipients, to 65.1%. In contrast, status 1B transplants were less common in 2013, occurring in 31.4% of recipients, and status 2 transplants declined from 26.4% in 2003 to 3.5% of transplants in 2013 (Figure HR 3.4). Survival after Heart Transplant
One-year survival in patients who underwent heart transplant from 2006 through 2008 was 88.1%; 3-year survival was 81.3% and 5-year survival 75.3%. Survival was slightly lower for women, particularly after year 3 posttransplant. Among the age groups, survival during year 1 was lowest for recipients aged 65 years or older; however, after year 1, survival was worst for recipients aged 18 to 34 years. At 5 years, survival was only 67.4% for recipients aged 18 to 34 years, compared with 76.7%, 77.0%, and 73.5% for ages 35 to 49 years, 50 to 64 years, and 65 years or older, respectively (Figure HR 5.1). Although the reason is difficult to determine, this difference may be a result of the etiology of heart failure, possibly immunologic complications (rejection), or psychosocial challenges that may be unique in the younger population. Early survival was similar in all race groups; however, curves diverged at 11 months, at which point survival for black recipients became lower. By year 3, survival was only 75.8% for blacks, compared with 82.7% for whites and 81.6% for other race groups. By year 5, survival was 68.8% for blacks, compared with 77.0% for whites. Survival was slightly lower for recipients with prior VADs than for those without VADs. Survival did not differ meaningfully between the medical urgency categories at any time point (Figure HR 5.1). The number of heart transplant survivors continued to increase. On June 30, 2013, 27,120 heart transplant recipients were alive with a functioning graft, most aged 50 years or older (Figure HR 5.2). Posttransplant morbidity
Rejection remains an important cause of morbidity after heart transplant; the cumulative incidence of rejection at 1 year was 23.6%. Rejection was most prevalent in recipients aged 18 to 34 years. As might be expected, the lowest occurrence of rejection was among the oldest age group, particularly those aged 65 years or older (Figure HR 5.3). Viral serologies were important risk factors for morbidity after transplant. Epstein-Barr virus (EBV) infection is associated with lymphoma and posttransplant lymphoproliferative disorder (PTLD), and cytomegalovirus (CMV) infection is strongly linked to cardiac allograft vasculopathy. Recipients who are EBV negative are more likely to have a positive (11.9% of all matches 2009-2013) than a negative donor (0.7%), due to the frequency of EBV in the general popula-
tion (Figure HR 4.2). The risk of PTLD in EBV-negative recipients was more than twice that in EBV-positive recipients at 5 years, 1.8% vs. 0.7%, respectively (Figure HR 5.4). Overall, the incidence of PTLD was low in this population, only 0.9% at 5 years (Figure HR 5.4). The leading causes of death during year 1 posttransplant were infection, cardiovascular/cerebrovascular disease, and graft failure. After year 1, however, cardiovascular/cerebrovascular disease became a more common cause of death, followed by infection and graft failure (Figure HR 5.7). Summary
Current trends reflect the increasing use of mechanical circulatory support as a bridge to transplant. Listing as status 2 is becoming less common, as most patients are listed in a higher medical urgency category. VADs have had a great impact on the upward trend toward listing patients at higher urgency categories.
Pediatric Heart Transplant Pediatric Waitlist Trends
In 2013, the number of new pediatric candidates added to the heart transplant waiting list increased to 589, with very few added as inactive status. At year-end 2013, almost 350 candidates were awaiting heart transplant, with 64.5% listed as active (Figure HR 6.1). The largest age group of children on the waiting list was 11 to 17 years (33.3%), followed by younger than 1 year (28.1%), 1 to 5 years (24.1%), and 6 to 10 years (14.6%). Almost 55% of heart transplant candidates were white, 20.0% were black, 19.9% were Hispanic, and less than 5% were Asian (Figure HR 6.2). The proportion of waitlist candidates aged younger than 1 year increased from 4.7% in 2003 to 17.4% in 2013 (Figure HR 6.3). Sex and race distribution remained relatively similar in 2003 and 2013. For candidates waiting on December 31, 2013, congenital defect was the leading cause of heart disease (45.6%). Just over half of candidates (57.5%) waiting for a heart transplant on December 31, 2013, had been waiting for less than 1 year, compared with 38.2% in 2003. Almost 30% of candidates were listed as status 1A in 2013, compared with 8.8% in 2003. Another notable change is the increase in the number candidates using VADs at the time of listing, from 0.9% in 2003 to 5.1% in 2013 (Figure HR 6.3). Among candidates removed from the waiting list in 2013, 73.6% underwent transplant, 9.3% died, 8.6% were removed from the list because their condition improved, and 5.3% were considered too sick to undergo transplant (Figure HR 6.4). Almost 75% of patients newly listed in 2010 underwent transplant within 3 years, 9.8% died, 10.8% were removed from the list, and 5.1% were still waiting (Figure HR 6.5).
5 heart
The rate of heart transplants among active pediatric waitlist candidates decreased from a peak of almost 300 per 100 waitlist years in 2006 to 196 per 100 waitlist years in 2013, likely attributable to a growing waiting list. Transplant rates varied by age, with the highest rates for candidates aged less than 1 year, at 317 transplants per 100 waitlist years, followed by candidates aged 11 to 17 years, at 212 transplants per 100 waitlist years. Transplant rates for candidates aged 1 to 5 and 6 to 10 years were similar, at approximately 145 transplants per 100 waitlist years (Figure HR 6.6). Waitlist mortality continues to decrease; rates were almost half the rates observed a decade earlier. The waitlist mortality rate was highest for candidates aged younger than 1 year, at 42 deaths per 100 waitlist years in 2012-2013, almost 2.5 times higher than the rate for candidates aged 1 to 5 years (Figure HR 6.7). Waitlist mortality among candidates with a VAD at the time of listing has declined over time and now almost equals that of candidates without a VAD. Looking at cause of disease, waitlist mortality was highest in candidates with congenital defects or dilated myopathy/myocarditis (Figure HR 6.7). Pediatric Transplant
The number of pediatric heart transplants performed each year increased from 294 in 2002 to 411 in 2013, with the largest increase in candidates aged 11 to 17 years (Figure HR 6.8). Over the past decade, the age, sex, and race of pediatric heart transplant recipients changed little. Congenital defects remain the most common primary cause of disease, affecting 43.4% of recipients in 2011-2013. The proportion of recipients undergoing retransplant has remained stable over the decade at 6% to 7%. The percentage of ABO-incompatible transplants in 2011-2013 was 3.6%, increased from 1.3% a decade earlier. The proportion of recipients with private insurance decreased and Medicaid coverage increased. The proportion of patients who underwent transplant as status 1A increased from 67.9% in 2001-2003 to 89.6% in 2011-2013. VAD use increased from only 8.4% of transplant recipients in 2001-2003 to 23.0% in 2011-2013 (Figure HR 6.9). Among pediatric heart transplant recipients from 2009 to 2013, 56.6% were CMV negative and 41.9% were EBV negative (Figure HR 6.10). The combination of a CMV-positive donor and CMV-negative recipient occurred in 28.8% of
transplants; for EBV, this occurred in 31.1% of transplants (Figure HR 6.10). The incidence of PTLD among EBV-negative recipients was 5.9% at 5 years after transplant, compared with 2.3% among EBV-positive recipients (Figure HR 6.11). Pediatric Immunosuppression and Outcomes
Substantial changes in immunosuppression have occurred in heart transplantation. In 2013, the most common induction therapy was T-cell depleting agents, used in almost half of heart transplant recipients, followed by interleukin-2 receptor antagonists in 20.2%. No induction therapy was reported in 35.0% of recipients. The initial immunosuppression agents used most commonly in 2013 were tacrolimus (86.5%), mycophenolate mofetil (92.1%), and steroids (67.7%). Mammalian target of rapamycin inhibitors were used in only 1.0% of recipients at the time of transplant but use increased to 8.6% at 1 year after transplant. Steroid use at 1 year after transplant was reported in 63.0% of recipients (Figure HR 6.12). Patient survival was 96.9% at 30 days for transplants performed in 2013, 92.7% at 1 year for transplants performed in 2012, 87.1% at 3 years for transplants performed in 2010, 76.5% at 5 years for transplants performed in 2008, and 60.4% at 10 years for transplants performed in 2003 (Figure HR 6.13). Among patients undergoing transplant in 2001-2008, 1-, 3-, and 5-year patient survival was 87.3%, 79.9%, and 74.1%, respectively (Figure HR 6.16). Patient survival was poorest for heart transplant recipients aged younger than 1 year. The leading identified causes of death were graft failure and cardio/cerebrovascular disease, with almost identical rates at 1 year and 5 years after transplant (Figure HR 6.17). The rate of late graft failure is traditionally measured by the graft half-life conditional on 1-year survival, defined as the time to when half of grafts surviving at least 1 year are still functioning. For heart transplants performed in 2011, the 1-year conditional graft half-life was 15.2 years (Figure HR 6.14). The incidence of first acute rejection increases over time after transplant. Interestingly, the age cohort with the highest incidence of acute rejection at all time points was aged 6 to 11 years, with almost half experiencing rejection by 2 years after transplant (Figure HR 6.15).
data behind the figures can be downloaded from our website, at srtr.transplant.hrsa.gov
OPTN/SRTR 2013 Annual Data Report
waiting list
4000
New patients
4000
Patients
3000
Patients on list on Dec 31 each year Active Inactive All
3000 Patients
6
2000 Active Inactive All
1000
2000 1000
0
0 03
05
07 Year
09
11
13
03
05
07 Year
09
11
13
HR 1.1 Adults waiting for heart transplant A new patient is one who first joined the list during the given year, without having been listed in a previous year. Previously listed candidates who underwent transplant and subsequently relisted are considered new. Candidates concurrently listed at multiple centers are counted once. Concurrently listed candidates who are active at any program are considered active; those who are inactive at all programs are considered inactive.
HR 1.2 Distribution of adults waiting for heart transplant Candidates waiting for transplant any time in the given year. Candidates listed concurrently at multiple centers are counted once. Age is determined at the later of listing date or January 1 of the given year. Time on the waiting list is determined at the earlier of December 31 or removal from the waiting list. Medical urgency status is the most severe during the year. Active and inactive patients are included. VAD, ventricular assist device.
7 heart
waiting list Age
Sex Race
Citizenship
Primary diagnosis
Heart tx history Blood type
Waiting time
Medical urgency
VAD at listing Multi-organ
All candidates
18-34 35-49 50-64 65+ Female Male White Black Hispanic Asian Other/unknown US citizen Non-citizen resident Non-citizen non-resident Other/unknown Coronary artery disease Cardiomyopathy Congenital disease Valvular disease Other/unknown First transplant Retransplant A B AB O < 1 year 1-< 2 years 2-< 3 years 3-< 4 years 4-< 5 years 5+ years 1A 1B 2 Inactive Heart only Heart-kidney Heart-lung Other
2003 N % 324 9.9 791 24.2 1,723 52.8 426 13.1 772 23.7 2,492 76.3 2,480 76.0 460 14.1 238 7.3 72 2.2 14 0.4 3,221 98.7 33 1.0 7 0.2 3 0.1 1,390 42.6 1,444 44.2 107 3.3 85 2.6 238 7.3 3,172 97.2 92 2.8 1,036 31.7 321 9.8 49 1.5 1,858 56.9 1,121 34.3 539 16.5 360 11.0 331 10.1 232 7.1 681 20.9 62 1.9 342 10.5 1,365 41.8 1,495 45.8 126 3.9 3,055 93.6 58 1.8 145 4.4 6 0.2 3,264 100.0
2013 N % 341 10.2 716 21.4 1,667 49.9 617 18.5 784 23.5 2,557 76.5 2,212 66.2 782 23.4 242 7.2 82 2.5 23 0.7 3,261 97.6 15 0.4 7 0.2 58 1.7 1,184 35.4 1,791 53.6 143 4.3 48 1.4 175 5.2 3,223 96.5 118 3.5 1,064 31.8 388 11.6 79 2.4 1,810 54.2 1,768 52.9 667 20.0 342 10.2 197 5.9 132 4.0 235 7.0 326 9.8 1,312 39.3 895 26.8 808 24.2 886 26.5 3,125 93.5 142 4.3 42 1.3 32 1.0 3,341 100.0
HR 1.3 Characteristics of adults on the heart transplant waiting list on December 31, 2003, and December 31, 2013 Patients waiting for transplant on December 31, 2003, and December 31, 2013, regardless of first listing date; active/inactive status is on this date, and multiple listings are not counted.
data behind the figures can be downloaded from our website, at srtr.transplant.hrsa.gov
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OPTN/SRTR 2013 Annual Data Report
waiting list Age
1000 Transplants per 100 wait-list years
Transplants per 100 wait-list years
1000 800
18-34 35-49 50-64 65+
600 400 200 0 05
07 Year
09
11
600 400 200
13
03
Medical urgency
800
1000 Transplants per 100 wait-list years
Transplants per 100 wait-list years
A B AB O
800
0 03
1000
Blood type
Status 1A Status 1B Status 2 All
600 400 200 0
05
07 Year
09
11
13
11
13
VAD at listing
800 Yes No
600 400 200 0
03
05
07 Year
09
11
13
03
05
07 Year
09
HR 1.4 Heart transplant rates among active adult waitlist candidates Transplant rates are computed as the number of deceased donor transplants per 100 patient-years of active waiting in a given year. VAD, ventricular assist device.
No data
47.3 54.6
84.0
124.2
224.5 148.9
No data
34.3 40.9
48.4
57.4
74.0 64.9
HR 1.5 Deceased donor heart transplant rates per 100 waitlist years among active adult candidates, by DSA, 20122013
HR 1.6 Percentage of adult waitlisted candidates who underwent deceased donor heart transplant within 1 year, by DSA, 2012
Transplant rates by DSA of the listing center, limited to candidates with active time on the waiting list in 2012 and 2013; deceased donor transplants only. Maximum time per listing is 2 years. Candidates listed concurrently in a single DSA are counted separately.
Candidates listed concurrently in a single DSA are counted once in that DSA; candidates listed in multiple DSAs are counted separately per DSA.
9 heart
waiting list Patients at start of year Patients added during year Patients removed during year Patients at end of year
2011 2,898 2,811 2,862 2,847
2012 2,843 3,025 2,805 3,063
2013 3,058 3,293 3,019 3,332
Removal reason Deceased donor transplant Patient died Patient refused transplant Improved, tx not needed Too sick for transplant Other
1,948 332 16 165 191 210
2,005 306 21 145 190 138
2,116 338 14 146 223 182
HR 1.7 Heart transplant waitlist activity among adults
HR 1.8 Three-year outcomes for adults waiting for heart transplant, new listings in 2010
Candidates concurrently listed at more than one center are counted once, from the time of earliest listing to the time of latest removal. Candidates who are listed, undergo transplant, and are relisted are counted more than once. Candidates are not considered to be on the list on the day they are removed; counts on January 1 may differ from counts on December 31 of the prior year. Candidates listed for multi-organ transplants are included.
Medical urgency at listing
20 Median months to transplant
Median months to transplant
20
Adults waiting for heart transplant and first listed in 2010. Candidates concurrently listed at more than one center are counted once, from the time of earliest listing to the time of latest removal. DD, deceased donor.
15 Status 1A Status 1B Status 2
10 5 0 02-03
VAD at listing No VAD VAD All
15 10 5 0
04-05
06-07 08-09 Year of listing
10-11
12-13
02-03
04-05
06-07 08-09 Year of listing
10-11
12-13
HR 1.9 Median months to heart transplant for waitlisted adults, by medical urgency and VAD status at listing Observations censored at earliest of December 31, 2013, transfer to another center, or removal from waiting list due to improved condition; otherwise, candidates contribute waiting time until deceased donor transplant. Kaplan-Meier competing risks methods used to estimate time to transplant. Analysis performed per candidate not per listing. Only the first transplant is counted. VAD, ventricular assist device.
data behind the figures can be downloaded from our website, at srtr.transplant.hrsa.gov
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OPTN/SRTR 2013 Annual Data Report
waiting list 20 15 18-34 35-49 50-64 65+ All
5 0
120
04-05
10-11
12-13
20 15 10
White Black Hispanic Asian
5
No Yes
60 40 20 0
04-05
06-07 08-09 Year
10-11
12-13
06-07 08-09 Year
10-11
12-13
20 15 10
Coronary artery dis. Cardiomyopathy Congential dis. Valvular dis.
5
02-03
Blood type
120
100 A B AB O
80 60 40 20 0
04-05
Primary diagnosis
0
02-03
120
100
02-03
25
0
06-07 08-09 Year
VAD at listing
80
Race
Deaths per 100 wait-list years
10
02-03
Deaths per 100 wait-list years
Deaths per 100 wait-list years
25
Deaths per 100 wait-list years
Age
Deaths per 100 wait-list years
Deaths per 100 wait-list years
25
02-03
04-05
06-07 08-09 Year
10-11
12-13
Medical urgency
100
Status 1A Status 1B Status 2 Inactive
80 60 40 20 0
04-05
06-07 08-09 Year
10-11
12-13
02-03
04-05
06-07 08-09 Year
10-11
12-13
HR 1.10 Pretransplant mortality rates among adults waitlisted for heart transplant Mortality rates are computed as the number of deaths per 100 patient-years of waiting in the given year range. Candidates concurrently listed at multiple centers are counted once. Deaths after removal from the waiting list are not counted. Rates by status are calculated as the number of transplants for a given status divided by total waiting time in the year at that status. Age is determined at the later of listing date or January 1 of the given year. VAD, ventricular assist device.
11 heart
deceased donation Age
