Today, there are 3,390 patients awaiting heart transplantation in the US.
Today, 1,785 heart transplants have taken place in the US in 2012.
In 2011, 2,322 heart transplants were completed.
A new reader recently messaged regarding her father and his need for heart transplantation. She has been attempting to enroll her 73-year old father in a program for persons aged 70 or more at Duke University. Apparently, Duke is now accepting elderly persons needing a heart transplant and offering these individuals hearts that would not otherwise be used. In other words, subpar or aged hearts that do not meet the transplant center’s protocol.
My first question is that if anyone out there knows of other hospitals engaging in this form of transplantation, please contact me.
Interestingly, on December 5, 2012, the European Source of Cardiology announced that donor hearts previously rejected for transplantation are now being declared viable for transplantation using pharmacological stress echo. This finding was presented at the EUROECHO and other Imaging Modalities 2012 event in Athens. The presenter was the highly regarded Dr. Tonino Bombardini of Pisa, Italy.
EUROECHO and other Imaging Modalities is an annual event that also serves as a meeting of the European Association of Cardiovascular Imaging (EACVI), a registered branch of the European Society of Cardiology.
Hearts Being Wasted
Astonishingly, in Europe 4,500 hearts that are approved for transplantation are not being used every year. Br. Bombardini explained this phenomenon, “”Many of these hearts could be used if we could increase confidence that the transplantation would be successful.”
In Europe the use of hearts from donors aged 50 or more amounts to about 21 percent of heart transplantations on the continent. In the US, most hospitals do not accept hearts aged more than 45.
As in the US, demand in Europe is ever increasing and supply is short. Bombardinin explained the net effect of this unfortunate reality, “”But the lengthening of waiting lists for heart transplantation is a significant healthcare emergency and as a consequence, the criteria for acceptance of donor hearts have been expanded to include donors over the age of 55 years.”
That is a wide gap between European and US protocols. Bombardini continued, “Despite the expanded criteria, clinicians are hesitant to use hearts from older donors. The use of stress echocardiography to select hearts ‘too good to die’ may be a possible approach to resolving the mismatch between organ supply and demand.”
Between 2005 and 2012, a project, known as the ADONHERS Project, was launched on the continent. The project took 66 heart transplant donors who would not meet the standards of the day because of age. The average age of the donors was 55. After the donors were legally declared dead, due to brain damage, 47 hearts were removed. After testing, physicians and scientists were surprised that 35 of the hearts were acceptable for heart transplantation. For six of the hearts, matches could not be found. However, when the hearts were subjected to cardiac autopsy, there was a complete absence of coronary disease.
The remaining 29 hearts were successfully transplanted. After one month, the recipients and their new hearts were evaluated. Of the 29 grateful recipients, 26 patients had normal heart function and structure. The function was evaluated based on angiography, intravascular ultrasound, hemodynamic tests and ventriculography. Three patients had minor single vessel disease.
After 27 months, 26 patients were alive. Three had died from “general sepsis, neoplasia and recurrent multiple myeloma.” The conclusion of the program was that the age limit could be moved from the current 55 years of age to 65 years of age, a far cry from where US heart transplant centers are positioned.
Bombardini concluded, “Pharmacological stress echo is inexpensive and allows a simultaneous evaluation of inducible ischemia and contractile reserve of the left ventricle – therefore, it is capable of unmasking prognostically meaningful occult coronary artery disease or cardiomyopathy.”
“Pharmacological stress echo is already an established technique that is used to assess and risk stratify patients with known or suspected coronary artery disease. We have shown that it can also be used to identify hearts suitable for transplantation that would previously have been unused. This requires cardiologists with experience of stress echo and ideally a second opinion from a cardiologist in a core lab (using tele-echocardiography), who can give the green light for donation.”
With 2012 seeming to be a disappointing year for heart transplant wait-listers in the US, well below 2011 and 2010 volume, it is encouraging that Duke is seeking to put every heart to use. Hopefully, other centers will follow.