CARDIOVASCULAR DEATHS IN HEART TRANSPLANTATION: DOES THE REJECTION PATTERN MATTER ?

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Are DT / BTT designations still relevant?
Josef Stehlik, MD, MPH Associate Professor of
Medicine Medical Director, Heart Transplant
Program University of Utah School of
Medicine Director, ISHLT Transplant Registry No
financial relationships to disclose.
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Are DT / BTT designations still relevant?

• The answer may depend on who is asking
• 1. Payer (health insurance)
• 2. Provider (advanced heart failure team)
• 3. Patient

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1. Payer perspective

• VAD indication important for eligibility
  determination and for budgeting

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Payer view

• (Increasing number of) private insurers
• - declare indication as BTT vs DT
• - BTT patients must be listed for transplant
  
• before VAD implant
• (Some) state Medicaid programs
• - no BTT durable MCS
• VHA - federal insurer
• - heart failure treatment utilizing a
• VAD or total artificial heart

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2. Provider perspective (us)
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Waiting list mortality
Wever-Pinzon O, Stehlik J. Circulation 2013 Jan
29127(4)
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Transplant rate
UNOS Status Transplanted in status Median waiting time
1A 1B 2 64 31 5 78 days 224 days 618 days
Stehlik J, Stevenson LW, Mehra MR. JHLT Oct 2014
Colvin-Adams M. AJT 2014
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Are DT / BTT designations still relevant?

• Is this a scientific / clinical care proposition
  or rather expression of desperation?

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Proposed revision of US heart allocation
Meyer DM, AJT 2014
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3. Patient perspective

• 22-year old patient

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Expected survival 22 year old male
99.4
99.0
National Vital Statistics Reports. 58 (21), 2010
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Clinical scenario

• 22-year-old
• Non-ischemic CM
• NYHA IV / Stage D, now inotrope dependent

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Expected survival - medical therapy
Clinical trials in NYHA III/IV HF Survival in
patients on inotropic support Seattle HF Model
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Expected survival
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Expected survival heart transplant
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Expected survival DT VAD
Data courtesy of Kirklin JK, Naftel DC
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Expected survival - BTT VAD
Data courtesy of Kirklin JK, Naftel DC
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Expected survival - BTT VAD
Data courtesy of Kirklin JK, Naftel DC
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Are DT / BTT designations still relevant?

• Payer
• - relevant for budgeting (eligibility
  determination,
• reimbursement)
• Provider
• - prefer the flexibility of adjusting strategy
• based on circumstances
• Patient
• - does not care about our terminology
• - wants to know the options and likely
  outcomes
• to make informed decisions