**7. Heart transplantation waiting list priority**

Nearly 100,000 people worldwide have received a new heart since the first HTx 50 years ago, 8000 of them in Spain, which makes it a country with a remarkable experience [52]. Each year priority criteria on the waiting list are reviewed. The 2017 priority criteria in adult population in Spain are summarized in **Table 6**.

The objective of this model is to prioritize those patients in the most critical situation. The ASIS-TC study showed a median waiting time for patients in urgency Grade 0 of 7.6 days allowing HTx in nearly 80% of this population [34]. Other countries like the U.S have a more heterogeneous group of patients listed in emergency situation (Status 1A) (**Table 7**), which makes waiting times more prolonged, between 47 and 413 days, depending on the region

#### **Urgency Grade 0: national (**priority over the rest of grades**)**


**Urgency Grade 1: regional (**priority over elective patients in reference zone**)**


#### **Elective**

**7. Heart transplantation waiting list priority**

**Table 5.** Contraindications for heart transplant (Source Sanchez-Enrique et al. [51]).

in Spain are summarized in **Table 6**.

**Absolute contraindications**

24 Heart Transplantation

• Systemic disease with life expectancy <2 years:

· Severe chronic obstructive pulmonary disease (FEV1 < 1 L)

· Pulmonary vascular resistance >3 Wood units despite treatment

• Age > 70 years (carefully selected patients may be considered)

• Severe peripheral arterial or cerebrovascular disease not suitable for treatment • Other serious comorbidities with poor prognosis, such as neuromuscular diseases

muscle loss, fatigue, slow walking speed, and low levels of physical activity) are present

and establish a time to wait after remission)

• Irreversible pulmonary hypertension · Pulmonary artery systolic pressure > 50 mmHg

· Transpulmonary gradient >12 mmHg

(HbA1c > 7.5%) despite treatment

considered with strict management

• Current tobacco, alcohol or drug abuse

• Elevated panel-reactive antibody test defined as >10%

**Relative contraindications**

• Obesity: BMI > 35 kg/m2 • Cachexia: BMI < 18 kg/m2

• Insufficient social support

FEV1

mass index.

Nearly 100,000 people worldwide have received a new heart since the first HTx 50 years ago, 8000 of them in Spain, which makes it a country with a remarkable experience [52]. Each year priority criteria on the waiting list are reviewed. The 2017 priority criteria in adult population

: forced expiratory volume in 1 s; VAD: ventricular assist device; HIV: human immunodeficiency virus; BMI: body

· Active neoplasm (if preexisting, evaluation with an oncology specialist is necessary to stratify the risk of recurrence

· Systemic disease with multi-organ involvement (systemic lupus erythematosus, amyloidosis, sarcoidosis)

• Diabetes with end-organ damage (except non-proliferative retinopathy) or persistent poor glycemic control

• Active infection, except VAD infection. Patients with HIV, hepatitis, Chagas disease and tuberculosis can be

• Frailty: when three of five possible symptoms (including unintentional weight loss of >5 kg within the past year,

· Renal or hepatic severe dysfunction, if associated renal or liver transplant is not performed

The objective of this model is to prioritize those patients in the most critical situation. The ASIS-TC study showed a median waiting time for patients in urgency Grade 0 of 7.6 days allowing HTx in nearly 80% of this population [34]. Other countries like the U.S have a more heterogeneous group of patients listed in emergency situation (Status 1A) (**Table 7**), which makes waiting times more prolonged, between 47 and 413 days, depending on the region • Patients not included in Grade 0 or Grade 1 categories.

STVAD: short-term ventricular assist device; LTVAD: long-term ventricular assist device.<sup>a</sup> e.g., Levitronix Centrimag. b e.g., Impella CP, Impella 5.0, Tandem Heart.

c Maximum time in urgency Grade 0 will be 7 days, once this time has passed the patient will be in Urgency Grade 1. <sup>d</sup>e.g., BerlinHeart Excor, Hearmate II, Heartmate 3, Heartware HVAD.

e e.g., BerlinHeart Excor.

**Table 6.** Priority criteria for heart transplant donors in Spain (Adapted from barge et al. [53]).

[47]. This shows the importance of defining homogeneous criteria to define each stage of classification for HTx waiting list, especially in the setting of emergency. A new more precise classification for the U.S. is expected to be published in 2018.


**Table 7.** Status codes for heart transplantation in U.S. (Source Kittleson et al. [47]).
