J Korean Med Sci.  2025 Jan;40(3):e14. 10.3346/jkms.2025.40.e14.

Prognostic Value of Ambulatory Status at Transplant in Older Heart Transplant Recipients: Implications for Organ Allocation Policy

• Hyun J
• Youn JC
• Hong JA
• Kim D
• Kim JJ
• Kim MS
• Oh J
• Kim JJ
• Jung MH
• Kim IC
• Lee SE
• Park JJ
• Kim MS
• Jung SH
• Cho HJ
• Lee HY
• Kang SM
• Choi DJ
• Kobashigawa JA
• Stehlik J
• Choi JO

• KMID: 2564225
• DOI: http://doi.org/10.3346/jkms.2025.40.e14

Abstract

Background
Shortage of organ donors in the Republic of Korea has become a major problem. To address this, it has been questioned whether heart transplant (HTx) allocation should be modified to reduce priority of older patients. We aimed to evaluate post-HTx outcomes according to recipient age and specific pre-HTx conditions using a nationwide prospective cohort.
Methods
We analyzed clinical characteristics of 628 patients from the Korean Organ Transplant Registry who received HTx from January 2015 to December 2020. Enrolled recipients were divided into three groups according to age. We also included comorbidities including ambulatory status. Non-ambulatory status was defined as pre-HTx support with either extracorporeal membrane oxygenation, continuous renal replacement therapy, or mechanical ventilation.
Results
Of the 628 patients, 195 were < 50 years, 322 were 50–64 years and 111 were ≥ 65 years at transplant. Four hundred nine (65.1%) were ambulatory and 219 (34.9%) were nonambulatory. Older recipients tended to have more comorbidities, ischemic cardiomyopathy, and received older donors. Post-HTx survival was significantly lower in older recipients (P = 0.025) and recipients with non-ambulatory status (P < 0.001). However, in contrast to non-ambulatory recipients who showed significant survival differences according to the recipient’s age (P = 0.004), ambulatory recipients showed comparable outcomes (P = 0.465).
Conclusion
Our results do not support use of age alone as an allocation criterion. Transplant candidate age in combination with some comorbidities such as non-ambulatory status may identify patients at a sufficiently elevated risk at which suitability of HTx should be reconsidered.

Keyword

Heart Transplantation; Age; Ambulatory Status; Survival; Outcome

Figure

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  Fig. 1 Non-ambulatory heart transplant recipients classified by supporting therapy.CRRT = continuous renal replacement therapy, ECMO = extracorporeal membrane oxygenation, MV = mechanical ventilation.

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  Fig. 2 Survival curves according to (A) recipient age and (B) pre-transplant ambulatory status.

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  Fig. 3 Survival curve and hazard of mortality according to pre-transplant ambulatory status and age of recipient. Post-transplant survival according to the recipient’s age in (A) pre-transplant ambulatory and (B) non-ambulatory status.

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  Fig. 4 Freedom from rejection, CAV, and infection according to age and ambulatory status. Freedom from (A) moderate-to-severe rejection, (B) CAV, and (C) infection according to recipient age. Freedom from (D) moderate-to-severe rejection, (E) CAV, and (F) infection according to ambulatory status.CAV = cardiac allograft vasculopathy.

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  Fig. 5 Freedom from and hazard of infection according to pre-transplant ambulatory state and age of recipient. Freedom from post-transplant infection according to recipient’s age in (A) pre-transplant ambulatory and (B) pre-transplant non-ambulatory status.

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