A Chance to Cut is a Chance to Cure

Thursday, April 14, 2005

Broken Hearts......
From The Wall Street Journal($$):For Some Transplant Patients,Diseased Hearts Are Lifesavers:

Every year about 500 people on the waiting list for a heart transplant die before an organ is made available. Thousands more die because they are considered too old or sick to get on the list to begin with.

But some heart surgeons are demonstrating that many of these people could be saved if transplant hospitals were less particular about the quality of donor hearts. They're starting programs that provide lower-quality hearts to older and sicker patients -- and sparking debate about how a transplant system that fails to help many people could be improved.

Beyond the 2,058 hearts transplanted last year, an additional 3,058 were offered by families of the newly dead, according to the nonprofit Scientific Registry of Transplant Recipients. But these hearts were rejected, often because they were not top quality. They were either buried or cremated with their original owners.

What a horrible waste of a scarce resource. But some centers are attempting to get some use from the "suboptimal heart":

Hillel Laks, a transplant surgeon at the University of California at Los Angeles, contends that half the rejected hearts are suitable for transplanting. In his "alternate heart" program here, Dr. Laks refurbishes defective donor hearts, sometimes performing bypass surgery on their clogged arteries while the organs are on ice. He and his colleagues give infected donors heavy-duty antibiotics after brain death but before their hearts are removed. Sometimes, as in the case of Fred Austin, Dr. Laks simply puts an old heart in an old person.

When Mr. Austin's failing heart brought him to the brink of death at age 75, he was too old to get one of the prime hearts used in mainstream transplant programs. UCLA offered him the heart of a 62-year-old donor -- one that other hospitals in the region didn't want.

Mr. Austin was delighted to get it. "I wouldn't have lasted another three months," he says. Eleven days after his surgery in December 2002, Mr. Austin called up some buddies for a game of golf. Now, at 77, he hits the links three times a week.

Mr. Austin, one of the oldest people ever to receive a transplant, was lucky. Some 50,000 people die each year of congestive heart failure, a progressive worsening of pumping function. Many of those patients would have liked to get placed on the heart-transplant waiting list but couldn't do so, doctors say.

Here is how it works:

The system for allocating hearts starts with a waiting list that gives priority to those who are sickest and have waited the longest. When a heart becomes available, the hospital treating the deceased person keeps him or her on life support and informs a regional "organ procurement organization." The organization, working through its waiting list, furiously makes calls to place the organ -- looking for a surgeon and patient, preferably nearby, who are ready to receive the heart right away.

With "marginal" hearts, the organization will often call around everywhere and find no takers. That's where UCLA and other hospitals with an "alternate" list come in. After everyone else says no, the organization will call one of these hospitals and look for an alternate patient to accept the marginal heart. Patients on the alternate list must agree that they won't ordinarily be eligible for a heart from the regular list.

Even active infection doesn't get in the way:

The hearts that end up in alternate-list patients have various problems. A recent innovation at UCLA has been to accept hearts from patients who died from bacterial meningitis -- a practice viewed as almost unthinkable a few years ago. Over the past three years, nine such hearts have been transplanted at UCLA. Thanks to heavy antibiotic doses for both the donor and the recipient, none of the recipients have gotten meningitis so far.

And the results are fairly comparable:

Duke, which established its alternate program in 2000, and Columbia, which began its program in 2001, both have found that alternate recipients do somewhat worse than standard ones but still fairly well. Columbia found that 75% to 80% of its alternate patients live a year after the transplant, combined with 90% in its regular program.

Doctors say that those who don't make it usually die from underlying health problems, not problems with the donated heart. "A lot of the hearts that we classified as marginal are working extremely well," says Donna M. Mancini, a cardiologist at Columbia University Medical Center.

Some don't think the "alternate list" is fair:

Rather than setting up alternate lists, some centers believe the best policy is to expand their definition of who is eligible for the regular list. Many surgeons are now willing to put patients as old as 70 on the regular list, giving them the same chance as younger people to get a good-quality heart.

Cedars-Sinai Medical Center in Los Angeles dropped its alternate list several years ago on the theory that it wasn't fair. "If a patient is a candidate for transplantation he should get a good heart, and age should not be a discriminatory factor," says Alfredo Trento, director of cardiothoracic surgery.

UCLA's Dr. Laks sees it differently. Since top-quality hearts are "a scarce resource," Dr. Laks says, "we have an obligation to give the heart to someone who has the best chance of surviving."

So if you were an older patient in need of a heart transplant would you rather die on the waiting list for a heart from an eighteen year-old or take one from a 50 year old that you could get right away? I'll take the old one, thank you very much, since my other medical problems will likely do me in before the heart will give out. Are the oldsters being treated unfairly?
While the risks are many, some are willing to take them:

That conclusion still leaves another ethical dilemma: How far should transplant centers go in using marginal organs? A handful of centers have tried transplanting hearts from patients with hepatitis C, a virus that can lead to fatal liver disease. UCLA suspended such transplants when several recipients were infected, though it may restart. At the Cleveland Clinic, the hepatitis C transplant program has been scaled back after a study found that 14% of recipients contracted severe liver disease.

But some desperate patients would rather live with hepatitis C than face imminent death. One 59-year-old accountant from Long Island, who asked that his name not be used, was assigned to the alternate list at New York-Presbyterian Hospital, the teaching hospital for Columbia University, because of diabetes and kidney trouble. In March 2002, he received a heart from a 45-year-old man infected with hepatitis C.

The recipient is at risk for contracting hepatitis, but he says he is grateful for the chance at life. "Three years ago I was a dead man, and now here I am," he says. "I feel fantastic. I have a job, I have a family, life is good."

But the drive to make one's statistics look good, rather than ethics will limit the "alternate list":

Outside of big urban hospitals few people have access to alternate-heart programs -- in large part because surgeons fear risk-taking could harm their statistics. "Cardiac transplant programs all over the U.S. are carefully scrutinized for outcome. If programs fall below a certain standard, it's a big hassle because you have to justify your program to Medicare and insurance carriers," says James Kirkland, director of cardiothoracic transplants at the University of Alabama at Birmingham.

Partly for this reason, UAB doesn't have an alternate-heart program, but Dr. Kirkland is in the early stages of organizing an international clinical trial in which UAB would likely participate. The trial would compare the success of programs such as UCLA's to the implantation of a left ventricular assist device.

(emphasis mine). So the cherry picking continues....

Labels: Transplantation