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Ann Thorac Surg 1997;64:1866-1867
© 1997 The Society of Thoracic Surgeons

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Update

Cardiac Transplantation in Patients over 60 Years of Age

As Originally Published in 1988:

Updated in 1997 by O. H. Frazier, MD, Branislav Radovancevic, MD, Nancy Abou-Awdi, RN, Pinar Ates, MD, and Denton A. Cooley, MD

Section of Cardiac Transplantation, Division of Cardiovascular Surgery, Texas Heart Institute at St. Luke's Hospital, Houston, Texas

Relatively few patients beyond the age of 60 years undergo cardiac transplantation. This phenomenon results in part from data indicating that older patients have poor survival rates [1] and that donor hearts should therefore go to younger patients, whose survival rates are better. Our 5-year survival data, however, do not support this premise, and in fact, our continuing experience [2] has convinced us more firmly than ever that the benefits of cardiac transplantation should not be denied to older patients.

Our series now includes 95 patients (88 men and 7 women) aged 60 years or older (range, 60 to 69 years; mean, 63.3 years). Twenty-three of the patients (24.2%) were more than 65 years old. The most common indication for transplantation was ischemic cardiomyopathy (59 cases; 62.1%). While awaiting transplantation, 23 patients (24.2%) required mechanical circulatory support, usually an intraaortic balloon pump. Eighty-eight underwent an orthotopic cardiac transplantation, and 7 had a heterotopic procedure.

Selective induction immunosuppression consisted of a 5-day course of monoclonal antibody (OKT3) in 25 patients (26.3%) and ATGAM (The Upjohn Company; Kalamazoo, MI) in 4 patients (4.2%). Maintenance immunosuppression typically consisted of standard triple therapy with cyclosporine, azathioprine, and steroids.

During a maximal follow-up period of 9 years (mean, 3.18 ± 2.87 years), the incidence of rejection was 0.8 episodes per patient per surgical year. Sixty-one patients (64.2%) had 116 postoperative infections that required therapy. The infections were bacterial in 60 cases (51.7%), viral in 27 cases (23.3%), fungal in 20 cases (17.2%), and protozoal in 9 cases (7.8%). Fifteen of the 61 infected patients succumbed to this complication. Figure 1 shows the causes of death. When compared with other age groups, the elderly patients did not have a statistically significant difference in survival rates (Fig 2).

View larger version (16K): [in this window] [in a new window]   Fig 1. . Primary cause of death. (CAD = coronary artery disease; *p = 0.047.)

View larger version (13K): [in this window] [in a new window]   Fig 2. . Postoperative survival statistics, comparing various age groups. (NS = not significant.)

On the basis of these findings, we still maintain that patients should not be barred from cardiac transplantation because of advanced age alone. Of course, the optimal candidate is one whose physiologic age is relatively young and who has heart failure alone, without other organ failure.

Currently, only 50% of kidney donors are also heart donors. Better, more aggressive management of elderly potential cardiac donors—with high doses of inotropic drugs, echocardiography, and coronary angiography—might make the harvesting of older donor hearts for older recipients a more widely accepted practice.

Footnotes

Address reprint requests to Dr Frazier, Texas Heart Institute, MC 3-258, PO Box 20345, Houston, TX 77225-0345.

References

1. Miller LW, Kubo SH, Young JB, Stevenson LW, Loh E, Costanzo MR. Medical management of heart and lung failure and candidate selection: report on the consensus conference on candidate selection for heart transplantation—1993. J Heart Lung Transplant 1995;14:562–71.[Medline]
2. Frazier OH, Macris MP, Duncan JM, Van Buren CT, Cooley DA. Cardiac transplantation in patients over 60 years of age. Ann Thorac Surg 1988;45:129–32.[Abstract/Free Full Text]
3. Ferras C, Powers M. Quality of life index: development and psychometric properties. Adv Nurs Sci 1985;10:15–24.[Medline]

This article has been cited by other articles:

				B. T. Bethea, D. D. Yuh, J. V. Conte, and W. A. Baumgartner Heart Transplantation Card. Surg. Adult, January 1, 2003; 2(2003): 1427 - 1460. [Full Text]

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michael P. Macris J. Michael Duncan Denton A. Cooley Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Frazier, O. H. Articles by Cooley, D. A. Search for Related Content PubMed PubMed Citation Articles by Frazier, O. H. Articles by Cooley, D. A.