Is There a Crisis in Heart Transplantation? Reflection over 10 Years

doi:10.4236/ojots.2012.21001

Paper Menu >>

Journal Menu >>

Open Journal of Organ Transplant Surgery, 2012, 2, 1-4

http://dx.doi.org/10.4236/ojots.2012.21001 Published Online February 2012 (http://www.SciRP.org/journal/ojots) 1

Is There a Crisis in Heart Transplantation?

Reflection over 10 Years

Karin Purshouse1, Stephen Large2*, Henry Darg ie3, John Dunning2, James Neuberger4

1Newcastle University, Newcastle, UK

2Papworth Hospital, Cambridge, UK

3Hon Consultant Cardiologist Western Infirmary, Glasgow, UK

4Associate Medical Director for NHS Blood and Transplant, Queen Elizabeth Hospital, Birmingham, UK

Email: *[email protected]

Received October 14, 2011; revised December 1, 2011; accepted December 20, 2011

ABSTRACT

Heart transplantation is withou t doubt a v ery effective treatment for patients’ whose lives and well- being are threatened

by their failing h eart. W e prev iously categ orized o ur co ncerns into four areas or Ds: Donor av ailability, Diso rganization,

Disillusionment (of clinicians) and Disaffection (of tomorrow’s clinicians). After a decade, this is a timely reflection on

this crisis of cardiac transplantation. It is also appropriate to set this in the context of a fifth D, the Demand for heart

transplantation. In this reflective analysis, we use the 5 Ds to explore the current climate in heart transplantation, with

particular reference to the situatio n in the UK.

Keywords: Heart Transplantation; Heart Failure

1. The 5 Ds

It is almost a decade since we asked the question “Is

there a crisis in cardiac transplantation” [1]. Heart trans-

plantation is without doubt a very effective treatment for

patients with heart failure, and a decade has passed since

we explored a potential crisis in cardiac transplantation.

We categorized our concerns into four areas or Ds: Do-

nor availability, Disorganization, Disillusionment (of clini-

cians) and Disaffection (of tomorrow’s clinicians) [1]. So

how have things changed in the last 10 years in the UK?

MacGowan and colleagues recently discussed the decline

in cardiac transplantation, focusing on the evolution of

surgical techniques [2]. Here, we add a fifth D—Demand

and present a detailed exploration of the “Five Ds” to

build on the findings of previou s commentaries.

There are good data available now, so much so that we

can see clearly a steady decline in the number of cardio-

thoracic donor organs available and transplants under-

taken. UK cardio-thoracic donor organ numbers have

halved from 244 to 115 between 1999 and 2010, with the

number of transplants falling correspondingly in this pe-

riod [3]. In 2002 we described a “life cycle of cardiac

transplantation” similar to that seen in industry [1], with

growth, mature and decline phases and demonstrated that

it was in decline 10 years ago. Data from the Interna-

tional Society for Heart and Lung Transplantation (ISHLT)

indicates continued decline [4].

This is not restricted to the UK as the number of trans-

plants has been declining steadily worldwide (Figure 1).

1.1. Disorganisation

Whilst it would be easy to simply blame the decline in

transplantation on the fall in donors, we have sought to

explore the wider barriers and consequences thereof on

cardiac transplantation. It is our opinion that there are

various levels at which disorganisation might limit a do-

nor organ being used, and it is clear that some of these

have improved [1]. Barriers to transplantation may be

neatly categorised into three groups which will be ev alu-

ated in turn: 1) dono r registration, 2) converting a poten-

tial donor organ into an available organ, and 3) the even-

Figure 1. Number of Heart Transplants reported by year.

With kind permission from ISHLT (2010).

K. PURSHOUSE ET AL.

tual use of the organ.

1) In terms of organ registration: NHS Blood and

Transplant has done much to improve donor registration

organisation, and subsequently just over a quarter of the

UK population are on the organ donor list. The issue of

low donor supply has been tackled by developing inno-

vative donor registration routes, such as through the

Driver and Vehicle Licensing Agency (DVLA), when re-

gistering with a General Practitioner or when applying

for a store card with a national chemist chain. Recently

they launched the first multi-media campaign. Despite

these efforts, registration rates remain low. In addition,

only 38% of heart-beating solid organ donors permit the

donation of cardiothoracic organs [3]. Perhaps there is a

Distaste for heart transplantation in our population which

is proving the limiting factor, and a fear of planning for

the end of life at a young age [5].

2) The undertaking of the recent National Potential Do-

nor Audit (a 24 month study between April 2007 and

March 2009 ) showed 30,693 deaths in UK intensive care

units (ICUs) (15,342 per year) and the process of transla-

tion into solid organ donation. Brain stem death was pre-

sent in some 10% (3065). Organ donation was princi-

pally lost through failure to perform brain-stem death

tests in 23% of this group and fu rthe r 37% where co nsen t

for organ donation was not obtained [6]. Two hundred

and fifty eight heart transplants were performed in this 24

month period representing 8% of all ITU deaths [3]. On-

going priorities include engagement with ICU teams to

encourage donation and clarify ethical and legal matters,

and removal of the financial barriers that exist in UK

hospitals for the high cost of retrieving organs by reim-

bursing hospitals.

3) 97% of hearts retrieved were subsequently trans-

planted [3].

1.2. Donor Availability

Donor availability is part of the problem despite an in-

crease in the nu mber of donor registration s (over 16 mil-

lion out of a UK population of around 60 million) [3]. Mo-

re worrisome is donor usage. Although organ donation

continues to fall, 33% of the 623 solid organ donors do-

nated cardiothoracic organs but only 19% (120) of hearts

were transplanted: a rate of 1 used for every 5 donated,

with no clear medical justification for not using the re-

mainder [3]. Ten years ago this was of the order of 1

used of every 3 offered. The reality remains that in the

UK only 43% of those waiting on transplant lists are

transplanted, with 9% dying whilst awaiting a heart [3]

and so many more removed from the list due to deterio-

ration of their condition making them no longer candi-

dates for heart transplantation. The number of patients on

the waiting list for heart transplantation has probably

never reflected demand and especially so lately with

more than 50% of hear ts tr ansp lan ts in the UK now being

labelled as “urgent”; that is, an acutely ill patient dete-

riorating too fast to get on to the waiting list. These pa-

tients form the tip of a huge iceberg that is made up of

the cardiac deaths in younger people following myocar-

dial infarction at a rate of some 600/100,000. A recent

survey in Scotland has shown that in 2009/10 there were

415 deaths in patients under 65 years of age who died

either in hospital or in the 1st year after admission for

either acute MI or heart failure (personal communication:

Professor Henry Dargie, Hon Consultant Cardiologist

Western Infirmary Glasgow, Former Director of Scottish

Advanced Heart Failure Service).

1.3. Disillusionment

We previously identified a three-and-a-half fold differ-

ence between individual surgeon’s operating activities

(i.e. number of operations) within units. Things have cha-

nged: units are fewer (6 adult for the UK) and clinical

activity more evenly shared amongst colleagues. How-

ever there is a national performance measure to be met,

demanding a reasonable transplant unit surviv al for heart

recipients at 12 months. It may be an unrealistic bar to

scale considering the direction of clinical heart transplant

activity which is aimed at a po pulation whose life expec-

tancy is likely to be 50% at one year and, overall, no

more than 2 years. A number of units have failed to ac-

hieve this outcome at times lead ing to reviews of practice.

It may be that such a demand is leading to disillusion-

ment amongst transplantation surgeons.

1.4. Disaffection

It is important to highlight that activity, describ ed as 115

operations in 2009, amalgamates pediatric and adult

heart transplantation. There are three pediatric centres

and six adult for the UK (two combined units and one

stand alone pediatric centre: a total of seven overall).

Each unit can hope for an annual activity of 22 heart

transplants but reality shows that two centres had an an-

nual activity below 10. Each unit will each have five

surgeons or so wh ich translates into an individual annual

experience of three heart transplants. Is this enough to

maintain the competency of a surgeon? Certainly heart

transplantation is seen as a demanding career by tomor-

row’s clinicians and our concerns that transplant Units’

reliance on senior surgeons indicates a continuing Disaf-

fection towards heart transplantation amongst trainees.

1.5. Demand

So what of the Demand for cardiac transplantation? There

has been a 48% decrease in the number of patients Regis-

tered on the active heart transplant list be tween 2000 and

2009 [3]. This does not necessarily suggest that Demand

K. PURSHOUSE ET AL. 3

is waning. This waiting list redu ction could be due to the

waiting list protocol introduced in 2002. The reality is

that at least half of the patients undergoing transplanta-

tion deteriorate too quickly to get on to a waiting list, un-

dergoing urgent heart transp lantation. Waiting lists aside,

what is the Demand likely to be if all patients had ready

access to heart transplantation? If we use the number of

deaths from acute myocardial infarction in those aged

less than 70 years as a crude measure of potentially sal-

vageable lives we find that over 6500 lives could be

saved based on deaths registered in 2008 [7]. This

loosely defined group represents 22.6% of all deaths

from acute myocardial infarction, indicating a massive

Demand. The National Heart Failure Audit further notes

47.5% of all patients admitted with acute heart failure

have either died or been readmitted at one year [8]. We

are not alone in highlighting the significant demand. It is

sobering to recall that the National Service Framework

2000 set a standard for patients in heart failure, stating

that “treatments most likely to both relieve their symp-

toms and reduce their risk of death should be offered”

[9].

2. A Future for Heart Transplantation?

What does the future hold for heart transplantation? It’s

tempting to say “not much” unless we address the fol-

lowing 5 points:

1) The possibility of obtaining hearts from new

sources. Animals as heart donors (xenografts) continue to

be explor ed and op timism remains h igh th at research will

translate into clinical trials [10]. Non heart-beating or

Donation after Cardiac Death (DCD) heart donation re-

mains at an experimental stage but shows promise. Ali et

al. have identified that DCD donation may be appropriate

for cardiac transplantation and requires continued inves-

tigation [11]. Renal DCD grafts seem to be as successful

as grafts from brain dead donors (DBD) [12]. These

measures may lead to an increase in donor hearts.

2) Review the expectation of high survival at one year

after heart transplantation. Hypothetically, sixty adult

heart transplants (the number of operations this year)

with, say, 90% survival promises 54 patients will survive

to one year. However 250 patients receiving heart trans-

plants with a lower (70%) expected survival at one year

gives 187 the chance of surviving beyond one year. This

apparent relaxing of standards appears to be unattractive

by significantly raising the patient’s risk of death fol-

lowing heart transplantation as seen at 1 year. Of course,

it does mean that more patients hoping for heart trans-

plantation will receive this life saving treatment.

3) In terms of volume of providers it would be wise to

reduce the number of centres offering heart transplanta-

tion if only to ensure individual centres and their clini-

cians’ competence as activity continues to fall.

4) Used as a bridge to transplantation, mechanical sup-

port in the form of implantable heart assist devices al-

lows patients to live inde pendently with improved quality

of life whilst waiting for a transplant. They are also rec-

ommended as destination therapy in heart failure and

used as such in 10% of patients, despite inferior long

term outcomes compared with transplantation [13,14].

5) In the future, biological repowering of the failing

heart, perhaps with progenitor cell technology, may buy

time for patients waiting for a transplan t [15].

Without these steps the crisis of heart transplantation

will be resolved b y Disappearance of this extraord inarily

effective therapy.

REFERENCES

[1] S. Large, “Is There a Crisis in Cardiac Transplantation,”

The Lancet, Vol. 359, No. 9308, 2002, pp. 803-804.

doi:10.1016/S0140-6736(02)07870-4

[2] G. A. Macgowan, G. Parry, S. Schueler and A. Hasan,

“The Decline in Heart Transplantation in the UK,” British

Medical Journal, Vol. 342, 2011, p. d2483.

[3] “NHS Blood and Transplant Annual Report 2009/10.

Transplant activity in the UK,” 2011.

http://www.organdonation.nhs.uk/ukt/statistics/transplant

_activity_report/current_activity_reports/ukt/activity_rep

ort_2009_10.pdf

[4] C. Murphy and C. Counter, “National Potential Donor

Audit Summary Report for the Period 1st April 2007 -

31st March 2009,” NHS Blood and Transplant, 2009.

[5] C. Conesa, A. R. Zambudio, P. Ramírez, M. Canteras, M.

del Rodríguez and P. Parrilla, “Socio-Personal Profile of

Teenagers Opposed to Organ Donation,” Nephrology Di-

alysis Transplantation, Vol. 19, No. 5, 2004, pp. 1269-

1275. doi:10.1093/ndt/gfh075

[6] J. Stehlik, L. B. Edwards, A. Y. Kucheryavaya, P. Aurora,

J. D. Christie, R. Kirk, F. Dobbels, A. O. Rahmel and M.

I. Hertz, “The Registry of the International Society for

Heart and Lung Transplantation: Twenty-Seventh Official

Adult Heart Transplant Report—2010,” The Journal of

Heart and Lung Transplantation, Vol. 29, No. 10, 2010,

pp. 1089-1103. doi:10.1016/j.healun.2010.08.007

[7] Office of National Statistics, Deaths Registered in 2008,

August 2009.

[8] National Heart Failure Audit 2008/2009, NHS Informa-

tion Centre, 2009.

[9] NHS—Our Healthier Nation, National Service Frame-

work—Coronary Heart Disease. 2000.

[10] R. N. Pierson III, A. Dorling, D. Ayares, M. A. Rees, J. D.

Seebach, J. A. Fishman, B. J. Hering and D. K. Cooper,

“Current Status of Xenotransplantation and Prospects for

Clinical Application,” Xenotransplantation, Vol. 16, No.

5, 2009, pp. 263-280.

doi:10.1111/j.1399-3089.2009.00534.x

[11] A. Ali, P. White, K. Dhital, M. Ryan, S. Tsui and S.

K. PURSHOUSE ET AL.

Large, “Cardiac Recovery in a Human Non-Heart-Beat-

ing Donor after Extracorporeal Perfusion: Source for

Human Heart Donation?” Journal of Heart & Lung

Transplantation, Vol. 29, No. 3, 2009, pp. 290-293.

[12] A. D. Barlow, M. S. Metcalfe, Y. Johari, R. Elwell, P. S.

Veitch and M. L. Nicholson, “Case-Matched Comparison

of Long-Term Results of Non-Heart Beating and Heart-

Beating Donor Renal Transplants,” British Journal of

Surgery, Vol. 96, No. 6, 2009, pp. 685-691.

doi:10.1002/bjs.6607

[13] J. K. Kirklin, D. C. Naftel, R. L. Kormos, L. W. Steven-

son, F. D. Pagani, M. A. Miller, K. L. Ulisney, J. T. Bald-

win and J. B. Young, “Second INTERMACS Annual Re-

port: More Than 1,000 Primary Left Ventricular Assist

Device Implants,” The Journal of Heart and Lung Trans-

plantation, Vol. 29, No. 1, 2010, pp. 1-10.

doi:10.1016/j.healun.2009.10.009

[14] K. Dickstein, P. E. Vardas, A. Auricchio, J. C. Daubert, C.

Linde, J. McMurray, P. Ponikowski, S. G. Priori, R. Sut-

ton and D. J. van Veldhuisen, ESC Committee for Prac-

tice Guidelines (CPG), A. Vahanian, A. Auricchio, J. Bax,

C. Ceconi, V. Dean, G. Filippatos, C. Funck-Brentano, R.

Hobbs, P. Kearney, T. McDonagh, B. A. Popescu, Z.

Reiner, U. Sechtem, P. A. Sirnes, M. Tendera, P. Vardas,

P. Widimsky, Document Reviewers, M. Tendera, S. D.

Anker, J. J. Blanc, M. Gasparini, A. W. Hoes, C. W. Is-

rael, Z. Kalarus, B. Merkely, K. Swedberg, A. J. Camm,

“2010 Focused Update of ESC Guidelines on Device

Therapy in Heart Failure: An Update of the 2008 ESC

Guidelines for the Diagnosis and Treatment of Acute and

Chronic Heart Failure and the 2007 ESC Guidelines for

Cardiac and Resynchronization Therapy. Developed with

the Special Contribution of the Heart Failure Association

and the European Heart Rhythm Association,” European

Heart Journal, Vol. 31, No. 21, 2010, pp. 2677-2687.

[15] V. Schächinger, Intracoronary Bone Marrow-Derived Pro-

genitor Cells in Acute Myocardial Infarction,” The New

England Journal of Medicine, Vol. 355, No. 12, 2006, pp.

1210-1221. doi:10.1056/NEJMoa060186