| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1997;64:289-290
© 1997 The Society of Thoracic Surgeons
Department of Thoracic & Cardiovascular Surgery, The Sanger Clinic, PA, 1001 Blythe Blvd, Suite 300, Charlotte, Nc 28203.
To the Editor:
What did the future generation ever do for me? George Bernard Shaw
I read with great interest the article "Heart Transplantation in Patients 70 Years of Age and Older: Initial Experience" by Blanche and associates [1], in which they presented the feasibility of heart transplantation in a selected group of otherwise healthy septuagenarians with excellent clinical results. Besides demonstrating the above, they also noted an age-associated decreased incidence of rejection, a phenomenon probably analogous with the excellent acceptance of homologous and heterologous valve grafts by older patients. Blanche and associates seem somewhat ill-at-ease to handle the question: Is it appropriate to spend additional money and to deplete the scarce pool of donor hearts for the elderly population, which "has the potential to become a burden to society and [may] exhaust the precious resources available"? (Nota bene: One may rightfully remark though that it was the now elderly who built today's society and accumulated the available resources.)
The answer may be easier than it seems at first glance. Our society has already decided that the health of all of our citizens is equally precious and unless it is their "time to go" the health needs of the elderly should be taken care of. As a matter of fact, since the establishment of Medicare they often fare better than the rest of the population. Also a heart transplant is not much more expensive than a quadruple coronary bypass with an aortic valve replacement.
As far as making donor hearts available for the elderly population, Blanche and associates raise the question: Who should get the heart? The young, whose life expectancy is naturally better, or the old, who may live a shorter but nevertheless enjoyable and well-deserved life span?
They choose what in my opinion is a somewhat of a cop-out (also embraced by the Editorial commentator) to transplant into the elderly hearts from "high-risk" donors, ie, organs that appeared to be still viable but because of various reasons, such as repeated defibrillation, ventricular hypertrophy, or too small donor were not suitable for younger recipients.
Although by the grace of God all these "high-risk" organs functioned well, this solution (and I am sure I have the support of the senior members of The Society of Thoracic Surgeons) leaves a sour taste in my mouth. We do not want bad hearts, we want good hearts, but not necessarily young hearts!
Why would it be wrong to transplant a 65-year-old healthy heart no teenager would accept into a 70-year-old patient? The shortcoming of this approach would naturally be that 65-year-old hearts often have unknown coronary heart disease, which could make transplantation futile.
Five years ago my colleagues and I presented a method called "bench coronary arteriography," that is, ex vivo contrast examination that allows easy and fast detection of pathologic changes in the coronary arterial system of the explanted donor heart before it is accepted for transplantation. We postulated that the method, which could be done in a few minutes and would in no way affect the function of the donor organ, "would allow a substantial extension of the age limits of donor hearts for transplantation."
Why not?
References
Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Rm 6215, Los Angeles Ca 90048.
To the Editor:
A long journey begins with a small step. (Chinese proverb)
I certainly agree with Dr Robicsek's assertion that the health of all our citizens is equally precious, and the health needs of the elderly should not be overlooked. In fact, our approach of offering heart transplantation to septuagenarians implies that age per se is not a limiting factor in deciding who receives a transplant. Rather, it is the associated medical conditions that determine if heart transplantation is a viable option [1].
Traditionally, the transplant community has placed an age limit on heart transplantation, which was based on data that young patients will receive more benefit than older patients [2]. Our experience in heart transplantation in patients 65 years of age and older challenges that concept as we demonstrated no difference in outcome when compared with younger patients [3].
However, as we raise the recipients' age and cross the line into the eighth decade, there are a number of questions that are posed and require answers. Can septuagenarians tolerate immunosuppression and its related complications? How do they fare in the long run? Will immunosuppression trigger malignancies at this age? Most importantly, are there data to decide how old is too old for heart transplantation, and, in these changing times, where should we draw the line?
As we embarked into unknown territory with this cohort of patients, we had to proceed with caution as well as sound ethics. We were aware that this issue was highly controversial, was open to criticism, and, as we expected, would leave a very sour taste in many mouths. On the one hand, heart transplantation was historically developed for "younger" individuals with a potentially long life ahead of them. On the other hand, in this society and others, "older" individuals have been revered and should therefore have as much right as everyone else to equal consideration, including access to the scarce resources of donor organs. That is the case of septuagenarians undergoing liver or kidney transplantation using healthy allografts. In our society, everyone, irrespective of age, theoretically has the same right to all health resources available. Our approach regarding age in heart transplantation represents a step in that direction.
When we look back at the history of heart transplantation, the same concern was present in the early days when potential candidates older than 50 years of age were considered for transplantation. Today, that is no longer an issue. We know for a fact that "high-risk" donors' organs, as used in these septuagenarians, can function properly more often than not, and although they may look like less than ideal hearts, they are indeed good hearts. A good heart is a good heart, irrespective of age.
If our rationale is correct, then it would not be wrong to transplant a 65-year-old healthy heart into a septuagenarian. In fact, it would not be wrong, given appropriate circumstances, to transplant it into a teenager either. We tend to think (perhaps incorrectly) that older, but healthy hearts will function less efficiently and for a shorter period of time than younger hearts, as age may take its toll. It is perhaps more for philosophical than medical reasons that we try to match, when feasible, the recipient's and donor's ages.
As we do not reject a potential candidate for transplantation purely on age criteria, we do not reject a donor heart solely because of age. We currently request coronary angiography to detect silent coronary artery disease in all potential donors older than 40 years of age. This is usually done at the donor hospital, and most of the time, it can be accomplished. I am aware of Dr Robicsek and associates' important contribution regarding "bench coronary angiography," but given the widespread availability of cardiac catheterization and coronary angiography facilities, even in small community hospitals, the application of such technique in the operating room is probably even more limited to exceptional circumstances. We have not rejected an apparent healthy donor heart, even older hearts, because a coronary angiogram could not be performed.
Only long-term follow-up will determine if heart transplantation in septuagenarians is a correct approach. Perhaps, if such therapy turns out to be as successful in the elderly as in younger patients, there will not be a need for an "alternative waiting list" as proposed [1]. Instead, the allocation of donor organs will be done irrespective of age. Time will tell if we are right, but for now we need a first step in that direction.
I thank Dr Robicsek for the opportunity to expand our discussion of these issues without the constraints of a scientific manuscript. I encourage that further debate regarding how all scarce health care resources might be used to improve survival and quality of life in the elderly, not just those of transplant therapy. Doctor Robicsek's epigram by G. B. Shaw is relevant to the questions raised in our article. However, Shaw also said, "Old men are dangerous; it doesn't matter to them what is going to happen to the world." In this case, though, I disagree with Shaw.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
