Ann Thorac Surg 1996;62:1447
© 1996 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Michel Carrier, MD
Department of Cardiac Surgery Montreal Heart Institute 5000 Belanger St East Montreal, PQ H1T 1C8, Canada
See also page 1442.
Patient selection for heart transplantation has evolved from the use of strictly defined and rigidly enforced criteria two decades ago, to a process of decision-making in which the risks and benefits from the procedures are assessed for each candidate. Although these changes in the selection process are most often based on trial and error, several traditional barriers have been waived, and age itself, for instance, is no longer an issue for heart transplantation. In their article, Blanche and colleagues report on 40 patients 65 years and older who underwent cardiac transplantation, with results comparable with those seen in a younger population of patients. The older patient group averaged 68 years of age, with a range of 65 to 77 years. Aside from the shorter follow-up in this group, allograft ischemic time, operative mortality, hospital stay, cost, and rejection rates were similar in both groups. Actuarial survival at 36 months after transplantation was lower in older patients, averaging 72%, compared with 81% in the younger population, a nonstatistically significant difference. The crude death rate was also slightly better in the younger group, since 18% (25/138) of younger and 20% (8/40) of older patients died during follow-up.
Blanche and colleagues have shown that successful results can be obtained in an older population who undergo cardiac transplantation, which now represents 22% of their patients. Although they recognize the increasing demand on the limited resource of donor hearts, they fail to analyze its impact on the nationwide organ distribution. The United Network for Organ Sharing and Organ Procurement and Transplantation Network 1995 Annual Report indicates that although the number of people on the waiting list for heart transplantation increased by 90%, the number of heart transplantations increased by only 13%, and the number of patients on the waiting list who died increased by 25% between 1990 and 1995 in the United States. In 1994, 1.6% of patients waiting for heart transplants were older than 65 years and 4% of patients who underwent heart transplantation were in the older age group. Moreover, the older patients have the lowest rate of survival and a shorter waiting time on the transplantation list. Similar results are observed in Canada.
Blanche and colleagues rightly suggest that donor criteria can safely be expanded, although they fail to explain why and how a donor heart is deemed appropriate for an older patient but unsuitable for a younger one. They also raise the possibility that the complex medical and ethical issues surrounding recipient selection for heart transplantation should be addressed by professional and governmental organizations rather than by transplant physicians. In recent years, government and bureaucratic measures have frequently failed to solve such issues. In our program, older patients are evaluated only if they have single-organ damage, that is, a failing heart. Patients with associated medical conditions, as most older patients have, are treated with aggressive medical treatment and are not considered for heart transplantation.
Patient selection for heart transplantation will remain a difficult issue, given the current shortage of organ donors. That every potential recipient must be evaluated individually in terms of risks and benefits is generally accepted. However, transplant physicians must remember that patient survival is lower in the older age group and that they have the moral obligation to make the best use of a scarce resource, that is, the cardiac allograft. The long-term success of cardiac transplantation in this group of patients will have to be compared with that of the newer and upcoming medical treatments to determine the proper place for heart transplantation in older patients.
Related Article
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Heart Transplantation in Patients 65 Years of Age and Older: A Comparative Analysis of 40 Patients
- Carlos Blanche, Johanna J. M. Takkenberg, Sharon Nessim, Mabelle Cohen, Lawrence S. C. Czer, Jack M. Matloff, and Alfredo Trento
Ann. Thorac. Surg. 1996 62: 1442-1446.
[Abstract]
[Full Text]
