On Saturday, March 24th, former Vice President and political insider, Dick Cheney received a heart transplant at the Inova Fairfax Hospital. According to media reports, the Vice President is recovering from the surgery.
Doubtless, this high-profile transplant will raise questions about the award system used by the United Network of Organ Sharing (UNOS) and the Organ Procurement and Transplant Network (OPTN). As mentioned in earlier posts, there is a definite pecking order used by UNOS to determine who receives a donor’s heart.
The Vice President certainly appears well qualified to receive the gift of life. The former VP is 71-years old. He has a long history of heart disease, heart attacks and cardiovascular surgery. The Cheney case is precisely why the public-private entities, UNOS and OPTN were founded. These agencies coordinate the retrieval of donated organs and then select the best candidate to receive the procured organs.
In earlier times, heart transplants were reserved for high profile persons of means. To make the donor award more balanced and more transparent the Congress passed legislation that created UNOS and OPTN. UNOS maintains a file for each waiting transplant patient for all organs.
The file is updated by the hour. In many cases, UNOS knows more about the patient’s likelihood for transplantation than the patient or the patient’s cardiologist. UNOS knows the status, 1A, 1B, 2 or 7 for every wait-listed candidate. UNOS also is aware of which patients are in the hospital and which are not. They have a record describing the blood type of each anxious patient.
In theory, Inova Fairfax Hospital received a heart from a donor, who died as a result of a fatal accident. UNOS received immediate notice that a donor fatality occurred and that a heart is available. UNOS coordinates the retrieval of the donated organs. The agency then identifies the geographical location of the organ. Nest, UNOS reviews their wait list file and matches the blood type of waiting patient to the blood type of the donor.
Once the proper geographical and blood type candidates are identified, UNOS begins to fine-tune their data. All waiting heart transplant recipients of the same blood type are filtered according to status.
Status 1A patients are very sick. For the most part, all status 1A patients are hospitalized. At status 1A, many transplant candidates are too sick to receive the organ.
Status 1B patients are usually on an intravenous feed with a drug called Primacor or are staying alive with a portable Left Ventricle Assist Device (LVAD). Primacor is a drug used to increase the output from the heart. The need for this intravenous feed is determined by a catheterization procedure. The catheterization involves the insertion of a delicate wire to the heart to quantify the heart’s output. The point of entry is either the neck or the groin.
In my case, almost every catheterization was followed by a hospital stay. I received intravenous Primacor for a few days and the heart function would improve. When the numbers improved, I was released. The catheterization is usually an outpatient procedure. While I was in the hospital, I was a status 1B. When I left without the intravenous feed, I became a status 2.
Status 2 wait listers rarely reciev a heart transplant. They meet all the criteria but are not as sick as others. Eventually, status 2 patients become more infirmed and their status changes accordingly.
Because the Primacor can be transported, many of the recipients are on the feed but at their residence and not in the hospital. Those patients are all status 1B.
After experiencing his fifth heart attack over an extended time, Mr. Cheney had an LVAD installed in 2010. The LVAD is a portable device that is an electronic pump connected to the heart. LVAD surgery is major surgery quite similar to open heart surgery. The recovery is strenuous, but the most dangerous side effect of the LVAD is infection.
Infections are bad news for all transplant hopefuls. The common cold is the transplant hopeful’s nightmare. At most centers even a mild infection, like the cold, can result in temporary removal from the active wait list. These patients are classified as status 7 or “not eligible for transplantation.” Some patients voluntarily remove themselves from the active list for personal reasons. Status 7 patients do continue to accrue valuable time on the wait list.
My guess is that Cheney was a status 1B patient because despite the LVAD, he was not hospitalized at the time of the transplant. According to published reports, the VP had been on the wait list for 20 months. During the recovery from LVAD surgery he may or may not have been on the active list but in any case he was accruing time.
Time on the wait list is an important consideration used by UNOS to further filter through the wait list. Hypothetically, in considering two wait list patients with the correct blood type and matching statuses, UNOS would favor the patient who has been on the wait list longer. With almost two years of waiting, Cheney was an excellent candidate.
Some media experts have questioned Cheney’s age. For wait listed transplant patients, age is not supposed to be an issue. What is an issue is the patient’s age when the patient applied for heart transplantation. Some transplant centers, like Columbia Presbyterian, clearly state that candidate must be enrolled in the program prior to age 65. Other centers, like Tampa General, stipulate that the candidate must be enrolled prior to age 70.
Inasmuch as Cheney’s LVAD was installed in 2010, he was under age 70 at the time. He was most likely a staus 1B.
One of the reasons UNOS and OPTN were formed was to ensure a transparent award process. These agencies exist to eliminate favoritism.
From this perspective, one can only conclude the VP Cheney was a good candidate for transplantation and in the eyes of Inova Fairfax Hospital was well enough to undergo what will most likely be an extended recovery.
My search of Inova Fairfax Hospital revealed one oddity. The Hospital performed 19 heart transplants last year, but this is their first this year.
Just about every article and broadcast about the Vice President’s transplant cites figures about how many people are waiting and how many persons are in end stage heart disease and some statistical data about survival rates. Survival figures are generally uniform. The most important rate is survival off the table and the one-year survival rate. At Columbia Presbyterian, the off-table survival rate was 86 percent. At TGH, the off-table rate was about 84 percent. Those figures may have changed since my transplant.
The one-year rate is important, as are the three-year rates and the five-year rates. It is my understanding that these numbers serve as one evaluation tool used by UNOS.
I certainly wish the Vice President a good recovery. Hopefully, he will set his major goal as putting his new heart to work for a good cause. The greatest arena for high-profile transplant recipients to further transplantation is to use their voices to recruit more donors. If Vice President Cheney took this message to the public, he could really “pay it forward.”