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Ann Thorac Surg 1996;62:1578-1579
© 1996 The Society of Thoracic Surgeons
Division of Cardiothoracic Surgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa
Recipient and donor selection criteria were originally developed to minimize the morbidity and mortality of early cardiac transplantation. With the introduction of cyclosporine to immunosuppressive regimens in the early 1980s, the incidences of infection and rejection decreased in the cardiac transplant recipient patient population. The attendant improvement in early and late survival led to utilization of what were previously defined as high-risk cardiac donors, and the extension of heart transplantation to patients who did not comply with traditional selection criteria. In this issue of The Annals of Thoracic Surgery, Blanche and colleagues [1] describe their experience with cardiac transplantation in 6 patients 70 years of age and older. All 6 patients survived the cardiac transplantation and are reported to be clinically well with normal cardiac function at a mean follow-up time of 9 months. When considering offering cardiac transplantation to septuagenarians, two questions must be answered. First, can cardiac transplantation be successfully performed in the elderly; and second, should cardiac transplantation be offered to the elderly?
Originally, cardiac transplantation was offered to patients less than 50 to 55 years of age. According to the United Network for Organ Sharing database, only 1.4% of patients (24 of 1,676) who underwent cardiac transplantation in 1988 were more than 65 years old [2]. In 1994, however, that rate had nearly tripled; 4.1% of the patients (97 of 2,340) who underwent a heart transplant were more than 65 years of age. Increasingly, cardiac transplantation has been offered to older patients as short-term results approach those achieved in younger patients [5–5]. In 1988, Frazier and colleagues [5] described their experience with 28 cardiac transplant recipients more than 60 years of age. The incidences of infection and rejection in the older patients were comparable with those in patients less than 60 years of age, although four of the five deaths that occurred in the older age group were caused by infection. The 1-year actuarial survival for patients more than 60 years of age was 83%, compared with 75% for the remainder of their cardiac transplant recipients. In 1996, Bull and colleagues [6] reported on 101 patients more than 60 years of age at the time of cardiac transplantation. Patients in the older age group had significantly fewer rejection episodes per patient than the patients who were younger than 60 years of age at the time of transplantation. However, the 6-year actuarial survival for patients more than 60 years of age was only 54%, compared with 72% for patients younger than 60 years of age at the time of transplantation (p < 0.05). Furthermore, patients more than 60 years of age at the time of cardiac transplantation were more likely to die of an infectious complication or malignant disease.
The clinical experience summarized above has taught us that patient selection is of paramount importance when considering cardiac transplantation in the elderly. Older patients must be carefully screened for comorbid conditions that may influence the long-term outcome after transplantation, including peripheral vascular disease, osteoporosis, colon cancer, and, in men, prostate cancer. As part of the standard work-up, ankle-brachial indices, carotid duplex scan, abdominal aortic ultrasonography, bone density determination, colonoscopy, digital rectal examination, and a serum prostate-specific antigen test will usually identify potential contraindications to transplantation. After transplantation, osteoporosis prophylaxis should include calcium supplements, calcitonin, and, in recalcitrant cases, testosterone or estrogen. It does not appear that older cardiac transplant recipients are at increased risk of dying of renal or cerebrovascular disease. Older patients are, however, more susceptible to fatal infectious complications and malignant disease. Ongoing, careful surveillance will allow timely identification of infections and new malignancies.
Thus, in answer to the first question, can cardiac transplantation be successfully performed in the elderly, it appears that carefully selected older patients can undergo cardiac transplantation with no increase in operative risk. However, actuarial survival curves for older versus younger patients begin to diverge 1 year after transplantation.
That brings us to the second question: should cardiac transplantation be offered to the elderly? In this era of heightened moral and fiscal accountability, reduced midterm survival in elderly cardiac transplant recipients must force clinicians to question the wisdom of allocating a scarce resource, the donor heart, to a patient population that will derive less than optimal benefit from that resource. Between 1988 and 1994, the size of the cardiac transplant waiting list increased by 185%, from 1,030 to 2,933 registrants [2]. During the same time period, the number of patients who underwent cardiac transplantation increased by only 40% (from 1,676 to 2,340). Waiting times for cardiac transplantation have increased accordingly. The median waiting time in 1988 was 116 days, whereas the longest median waiting time this decade, 256 days, occurred in 1992. In 1988, 35% of registrants were on the waiting list for 6 months or more. Although the median waiting time for cardiac transplantation declined to 184 days in 1994, the number of registrants who were on the waiting list for 6 months or more during that year increased to 66%. As patients with end-stage cardiomyopathy deteriorate hemodynamically over time, it is not surprising to find that the percentage of recipients on life support systems just before transplantation increased from 31% (716 of 2,297 patients) to 54% (1,172 of 2,172 patients) between 1993 and 1994. Relaxation of recipient selection criteria will further increase the gap between donor organ supply and demand.
Most health care workers, and a large segment of the lay public, are well acquainted with the shortage of organ donors. Public service announcements and the recent advertising campaign created by the Ad Council with the slogan "Share your life, share your decision" seek to increase the number of organ donors. Any increase in organ donation due to public education programs may, in part, be offset by vehicular passive restraint systems, seat belt and motorcycle helmet laws, handgun legislation, and more proficient trauma care. Although the latter have a positive impact on society, they will not alleviate and may, in fact, exacerbate the organ donor shortage. Furthermore, hearts are not retrieved from all organ donors. In 1994, 2,527 hearts were retrieved from 5,104 donors, for a utilization rate of 49.5% [2]. Donor hearts may be deemed unsuitable for transplantation for a variety of reasons, including advanced donor age, high-dose inotrope requirement, increased myocardial enzyme levels, wall motion abnormalities on echocardiogram, and the need for prolonged cardiopulmonary resuscitation during the initial donor management. Blanche and colleagues [1] have expressed a willingness to use donor hearts that were deemed unsuitable and would be discarded by other transplant programs. The concept of high-risk donation is not new, as several centers have liberalized the criteria for acceptable cardiac donation with excellent results [7, 8]. Blanche and colleagues also propose that elderly patients be added to a "secondary list" comprising individuals who would only receive hearts rejected by all other transplant centers. Although the administrative details associated with maintaining such a secondary list may ultimately prove prohibitive, such a list may pass public scrutiny by ensuring that the organ distribution system is fair, when including a clinical application that must, at this time, be considered experimental.
Accordingly, the second question, should cardiac transplantation be offered to the elderly, is much more difficult to answer. Should the goal of transplantation be to allow the patient to once again become a contributing member of society by returning the patient to the work force? Or should the goal of transplantation be to allow an individual to enjoy a satisfying retirement with a reasonable quality of life? Health care providers, in general, are loath to limit any individual's access to health care, particularly when limited access is based on age criteria alone. However, when offering any therapeutic modality to a patient, it is imperative that the physician demonstrate a high degree of social responsibility.
Medical management and cardiac transplantation are the only therapeutic modalities currently available to patients with class IV heart failure. Although oral inotropes, cardiomyoplasty, implantable blood pumps, and xenotransplantation hold great promise for the future, these forms of therapy are not available to most clinicians caring for cardiomyopathic patients at this time. The results achieved by Blanche and associates with cardiac transplantation in septuagenarians are commendable. However, the efficacy of cardiac transplantation in the elderly will only be proved when long-term follow-up is available. In the interim, older recipients should be matched with high-risk donors, a practice that provides an acceptable outcome.
Footnotes
Address reprint requests to Dr Richenbacher, Division of Cardiothoracic Surgery, The University of Iowa Hospitals and Clinics, 200 Hawkins Dr, 1613B JCP, Iowa City, IA 52242-1062 (e-mail: wayne-richenbacher{at}uiowa.edu).
References
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