6
Heart Transplantation

The current listing for heart transplantation does not need to be revised, but the Social Security Administration should reevaluate heart transplant recipients 9 months after surgery to avoid a potential gap in benefits should the claimant continue to be disabled due to residual impairment or due to noncardiac causes.

DESCRIPTION

A heart transplant may be an option for some individuals if standard medical and pacing device therapy cannot successfully treat the symptoms associated with heart failure. Patients who have undergone heart transplantation may experience some physical limitations regarding activities of daily living. Return to work is possible with increased functional status, but may not be the case with every individual who has undergone heart transplantation. Treatment adherence and psychological support after transplant are important indicators for successful functional recovery. In current clinical practice, patients who have undergone cardiac transplantation often take a 6-month period to adequately recover. Cardiac rehabilitation for transplant recipients includes exercise retraining. Medical therapy initially includes high doses of immunosuppression to decrease the chance of rejection. This increases the risk of infection, which diminishes as immunosuppression doses are decreased during the first 6 months after transplantation. The risks of both infection and rejection decrease to a relatively low level by the end of the first year.



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6 Heart Transplantation the current listing for heart transplantation does not need to be revised, but the Social Security administration should reevaluate heart transplant recipients  months after surgery to avoid a poten- tial gap in benefits should the claimant continue to be disabled due to residual impairment or due to noncardiac causes. DESCRIPTION A heart transplant may be an option for some individuals if standard medical and pacing device therapy cannot successfully treat the symptoms associated with heart failure. Patients who have undergone heart transplan- tation may experience some physical limitations regarding activities of daily living. Return to work is possible with increased functional status, but may not be the case with every individual who has undergone heart transplanta- tion. Treatment adherence and psychological support after transplant are important indicators for successful functional recovery. In current clinical practice, patients who have undergone cardiac transplantation often take a 6-month period to adequately recover. Cardiac rehabilitation for transplant recipients includes exercise retraining. Medical therapy initially includes high doses of immunosuppression to decrease the chance of rejection. This increases the risk of infection, which diminishes as immunosuppression doses are decreased during the first 6 months after transplantation. The risks of both infection and rejection decrease to a relatively low level by the end of the first year. 

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  CaRdIoVaSCUlaR dISabIlIty EPIDEMIOLOGY In 2008, 2,163 cardiac transplants were performed in the United States (Lloyd-Jones et al., 2010). Because heart failure affects nearly 6 million Americans, many more heart transplants could be possible if more donor hearts were available for transplantation. In the United States, more than 72 percent of heart transplant recipients are male; 65.5 percent are white; 19.4 percent are between ages 35 and 49, and 54.2 percent are age 50 or older (Lloyd-Jones et al., 2010). Individuals who undergo heart transplan- tation have a high survival rate (see Table 6-1). The Social Security Administration currently grants disability to indi- viduals who have undergone a heart transplant for 1 year after transplan- tation (see Box 6-1) with instruction to evaluate individuals with residual impairment after 1 year under the appropriate cardiac listing. As indicated above, cardiac transplants are shown to be highly successful in improving the functional capacity of recipients past an approximate 6-month recovery period. CONCLUSIONS AND RECOMMENDATIONS The committee concludes the current listing evaluation criterion for heart transplant recipients is appropriate. During the first year after the procedure, patients who receive a cardiac transplant should meet the list- ing and receive disability. If heart transplant recipients continue to experi- TABLE 6-1 Survival Rates After Heart Transplantation, by Sex Survival Rates Men Women 1-year 88.0% 77.2% 3-year 79.3% 77.2% 5-year 73.1% 67.4% SOURCE: Lloyd-Jones et al., 2010. BOX 6-1 Current Listing for Heart Transplant 4.09 Heart Transplant. Consider under a disability for 1 year following surgery;  thereafter, evaluate residual impairment under the appropriate listing. SOURCE: SSA, 2008.

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 hEaRt tRanSPlantatIon ence functional impairment after rehabilitation, residual impairment will likely manifest as a specific cardiac condition that may then be evaluated under another, appropriate listing, such as heart failure or ischemic heart disease. RECOMMENDATION 6-1. Maintain the current listing criterion for heart transplant recipients, meaning the claimant meets the listing (4.09) for 1 year after transplantation surgery. The committee recommends individuals allowed under the heart trans- plant listing who continue to experience impairment should begin the evaluation process at 9 months after being granted disability due to their heart transplants. Beginning the evaluation process 3 months prior to the end of the benefit period will allow those who may qualify under another appropriate listing to avoid a gap in benefits. RECOMMENDATION 6-2. Reevaluate heart transplant recipients for disability 9 months after surgery to avoid a potential gap in benefits should the claimant continue to be disabled because of residual impair- ment from transplantation or other cardiac or noncardiac causes. Physical functional limitations are generally low in the heart transplant population. However, individuals require a period of time to prevent the likelihood of infection, rejection of the donor heart, or other possible com- plications that may occur due to the transplant in the period directly follow- ing transplantation. Although most patients may be fully functional after a 6-month rehabilitation period, the committee concludes that extending the period of disability benefits to 1 year is reasonable, allowing individuals enough time to adequately recover and potentially resume employment or other useful activities. REFERENCES Lloyd-Jones, D., R. J. Adams, T. M. Brown, M. Carnethon, S. Dai, G. De Simone, T. B. Ferguson, E. Ford, K. Furie, C. Gillespie, A. Go, K. Greenlund, N. Haase, S. Hailpern, P. M. Ho, V. Howard, B. Kissela, S. Kittner, D. Lackland, L. Lisabeth, A. Marelli, M. M. McDermott, J. Meigs, D. Mozaffarian, M. Mussolino, G. Nichol, V. L. Roger, W. Rosamond, R. Sacco, P. Sorlie, R. Stafford, T. Thom, S. Wasserthiel-Smoller, N. D. Wong, and J. Wylie-Rosett, on behalf of the American Heart Association Statistics Committee Stroke Statistics Subcommittee. 2010. Heart disease and stroke statistics—2010 update: A report from the American Heart Association. Circulation 121(7):e46–e215. SSA (Social Security Administration). 2008. listing of impairments—adult listings (Part a). disability evaluation under Social Security (blue book). http://www.ssa.gov/disability/ professionals.bluebook/AdultListings.htm (accessed May 3, 2010).

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