1. 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. Are DT / BTT designations still relevant?

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

3. 1. Payer perspective VAD indication important for eligibility determination and for budgeting

4. 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 …’

5. 2. Provider perspective (us)

9. 2008-2011 Wever-Pinzon O, Stehlik J. Circulation 2013 Jan 29;127(4) Waiting list mortality

10. Transplant rate Colvin-Adams M. AJT 2014 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

11. Is this a scientific / clinical care proposition or rather expression of desperation? Are DT / BTT designations still relevant?

12. Proposed revision of US heart allocation Meyer DM, AJT 2014

13. 3. Patient perspective 22-year old patient

14. Expected survival – 22 year old male 99.4% 99.0% National Vital Statistics Reports. 58 (21), 2010

15. Clinical scenario 22-year-old Non-ischemic CM NYHA IV / Stage D, now inotrope dependent

16. Expected survival - medical therapy Clinical trials in NYHA III/IV HF Survival in patients on inotropic support Seattle HF Model

17. Expected survival

18. Expected survival – heart transplant

19. Expected survival – DT VAD Data courtesy of Kirklin JK, Naftel DC

20. Expected survival - BTT VAD Data courtesy of Kirklin JK, Naftel DC

21. Expected survival - BTT VAD Data courtesy of Kirklin JK, Naftel DC

22. 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