Listing criteria for cardiac transplantation: results of an American Society of Transplant Physicians-National Institutes of Health conference

One-year survival in recipients older than 50 bridged to heart transplant with Impella 5.5 via axillary approach

BACKGROUND

Optimizing patients with advanced heart failure before orthotopic heart transplantation (OHT), especially in patients greater than 50 years old, is imperative to achieving successful post-transplant outcomes. Complications are well-described for patients bridged to transplant (BTT) with durable left ventricular assist device (LVAD) support. Given the lack of data available in older recipients after the recent increase in mechanical support use, we felt it crucial to report our center's one-year outcomes in older recipients after heart transplantation with percutaneously placed Impella 5.5 as a BTT.

METHODS

Forty-nine OHT patients were supported with the Impella 5.5 intended as a bridge between December 2019 and October 2022 at Mayo Clinic in Florida. Data were extracted from the electronic health record at baseline and during their transplant episode of care after Institutional Review Boards approval as exempt for retrospective data collection.

RESULTS

Thirty-eight patients aged 50 or older were supported with Impella 5.5 as BTT. Ten patients underwent heart and kidney transplantation within this cohort. The median age at OHT was 63 (58-68) years, with 32 male (84%) and six female patients (16%). Etiology was divided into ischemic (63%) and non-ischemic cardiomyopathy (37%). The baseline median ejection fraction was 19% (15-24). Most patients were in blood group O (60%), and 50% were diabetic. The average duration of support was 27 days (range 6-94). The median duration of follow-up is 488 days (185-693). For patients that have reached the 1-year follow-up timeframe (22 of 38, 58%), the 1-year post-transplant survival is 95%.

CONCLUSION

Our single-center data provides awareness for using the Impella 5.5 percutaneously placed axillary support device in older heart failure patients in cardiogenic shock as a bridge to transplantation. One-year survival outcomes after heart transplantation are excellent despite the older recipient's age and prolonged pre-transplant support.

Current considerations for heart-kidney transplantation

Cardiorenal syndrome is a complex syndrome characterized by dysfunction of the heart and kidneys in an interdependent fashion and is further divided into different subtypes based on primary organ dysfunction. Simultaneous Heart-Kidney transplantation is the treatment of choice for end-stage irreversible dysfunction of both organs, however it may be avoided with determination of cardiorenal subtype and management of primary organ dysfunction. This article discusses types of cardiorenal syndrome, indications and concerns regarding the use of simultaneous heart-kidney transplantation, and outlines algorithms for determination of need for dual vs. single organ transplantation.

Combined Heart-Kidney Transplantation: Indications, Outcomes, and Controversies

Renal dysfunction, a prevalent comorbidity in advanced heart failure, is associated with significant morbidity and mortality after heart transplantation. In the recent era, the field of combined heart-kidney transplantation has experienced great success in the treatment of both renal and cardiac dysfunction in end-stage disease states, and the number of transplants has increased dramatically. In this review, we discuss appropriate indications and selection criteria, overall and organ-specific outcomes, and future perspectives in the field of combined heart-kidney transplantation.

Heart Failure in Older Adults: Medical Management and Advanced Therapies

As the population ages and the prevalence of heart failure increases, cardiologists and geriatricians can expect to see more elderly patients with heart failure in their everyday practice. With the advancement of medical care and technology, the options for heart failure management have expanded, though current guidelines are based on studies of younger populations, and the evidence in older populations is not as robust. Pharmacologic therapy remains the cornerstone of heart failure management and has improved long-term mortality. Prevention of sudden cardiac death with implantable devices is being more readily utilized in older patients. Advanced therapies have provided more options for end-stage heart failure, though its use is still limited in older patients. In this review, we discuss the current guidelines for medical management of heart failure in older adults, as well as the expanding literature on advanced therapies, such as heart transplantation in older patients with end-stage heart failure. We also discuss the importance of a multidisciplinary care approach including consideration of non-medical co-morbidities such as frailty and cognitive decline.

Nonresponse to Acute Vasodilator Challenge and Prognosis in Heart Failure With Pulmonary Hypertension

BACKGROUND

An acute vasodilator challenge is recommended in patients with heart failure and pulmonary hypertension during heart transplant evaluation. The aim of the study was to assess which hemodynamic parameters are associated with nonresponsiveness to the challenge.

METHODS AND RESULTS

This study is a retrospective analysis of 402 patients with heart failure with pulmonary hypertension who underwent right heart catheterization and a pulmonary vasodilator challenge. Among the 140 who fulfilled the transplant guidelines eligibility criteria for the vasodilator challenge, 38 were responders and 102 nonresponders. At multivariable analysis, a diastolic blood pressure of <70 mm Hg, pulmonary vascular resistance of >5 Woods units, and pulmonary artery compliance of <1.2 mL/mm Hg were independently associated with poor response to vasodilator challenge (all P < .001). The presence of any 2 of these 3 conditions was associated with a 90% probability of being a nonresponder. The covariate-adjusted hemodynamic predictors of death in the entire population were a low baseline systolic blood pressure (P = .0017) and a low baseline right ventricular stroke work index (P = .0395).

CONCLUSIONS

In patients with heart failure and pulmonary hypertension, low pulmonary arterial compliance, high pulmonary vascular resistance, and low diastolic blood pressure predict the nonresponsiveness to acute vasodilator challenge whilst a poor right ventricular function predicts a dismal prognosis.

Pulmonary vascular resistance index: Getting the units right and why it matters

Pulmonary vascular resistance (PVR) and PVR index (PVRI) are key variables in a broad range of contexts, including prediction of outcomes in heart and liver transplantation, determining candidacy for closure of atrial or ventricular septal defects, and guiding treatment of pulmonary hypertension. Significant variability exists among the units used to report PVRI in current literature, making the interpretation of data and translation into clinical practice difficult. Here, we will review the measurement and derivation of PVR and PVRI and demonstrate the extent of confusion in the literature. We conducted a literature search of all published articles in PubMed using the term “PVRI.” This yielded 218 sources with defined units for PVRI, including 33 unique variants. Among all reviewed literature, 45.4% of sources reported PVRI with units ending in m² (meters squared), which we defined as correct, whereas 54.6% reported PVRI with units not ending in m², which we defined as incorrect. This lack of uniformity has led to considerable confusion among researchers and clinicians, with potentially life‐altering consequences.

Approaching a Consensus: Psychosocial Support Services for Solid Organ Transplantation Programs

Background—

Solid organ transplantation has become an accepted treatment for individuals with end-stage organ dysfunction. Criteria are being developed in the United States to determine medical eligibility for transplant candidates and competencies for transplant centers and physicians. To date, similar criteria for psychosocial services have not been developed.

Design and Setting—

We queried participants in a specialty psychosocial transplant meeting to determine their views of which psychosocial services are essential to the comprehensive care of transplant patients in the United States.

Results—

There was broad based multidisciplinary support for proactive pretransplant screening to discern individual psychosocial needs; focused pretransplant interventions to improve candidacy and future compliance; and posttransplant programs that address psychosocial, rehabilitation, and financial issues.

Conclusion—

Among psychosocial providers of solid organ transplantation services, there is support for expanding routine screening and support services to individuals who are candidates for and undergo solid organ transplantation.

Psychosocial Assessments and Outcomes in Organ Transplantation

A qualitative review was conducted to define the term psychosocial as applied to transplant patients and to summarize evidence regarding the role and impact of psychosocial assessments and outcomes across the transplant process. English-language case series and empirical studies from January 1970 through April 1990 that were abstracted in Medline and Psychological Abstracts or listed in publications' bibliographies were used as data sources. A qualitative analysis was performed to determine the depth of the case reports and whether the empirical reports obtained statistically reliable, clinically significant findings. The authors conclude that psychosocial assessments differ in content and application to candidate selection depending on the transplant program. Psychosocial status before transplant does not consistently affect medical outcomes after transplant. Psychosocial status generally improves with transplant, although difficulties are prevalent in psychological adjustment and in compliance with medical regimens. Psychiatric history can predict psychological outcomes after transplant but does not consistently predict compliance. Social supports and coping strategies strengthen psychosocial outcomes. Posttransplant psychosocial outcomes may predict physical morbidity and mortality.

Multiorgan transplantation

Kidney transplantation has proven to be the gold standard therapy for severe chronic kidney disease (CKD) due to multiple etiologies in individuals deemed eligible from a surgical standpoint. While kidney transplantation is traditionally considered in conditions of native kidney disease such as diabetes and immunological or inherited causes of kidney disease, an increasing indication for kidney transplantation is kidney dysfunction in the setting of other severe organ dysfunction that requires transplant, such as severe liver or heart disease. In these settings, multiorgan transplantation is now commonly performed, with controversy regarding the appropriate utilization of kidneys transplanted both from a physiological perspective (distinguishing those who require a kidney transplant) and also from an ethical perspective (allocation of a scarce resource to a more morbid population). These issues persist in the setting of simultaneous pancreas-kidney transplant (SPK), in which utilization for patients with type 1 diabetes has been historically accepted. Questions of physiological benefit persist, and utilization is waning despite broader allocation policies that encourage SPK, including consideration for patients with type 2 diabetes. The purpose of this review will be to summarize the physiological data regarding multiorgan transplantation and place these into context while reviewing current allocation policy in the United States.

Preoperative Predictors for Postoperative Problems in Heart Transplantation: Psychiatric and Psychosocial Considerations

The psychiatric and psychosocial evaluation of the heart transplant candidate can identify particular predictors for postoperative problems. These factors, as identified during the comprehensive evaluation phase, provide an assessment of the candidate in context of the proposed transplantation protocol. Previous issues with compliance, substance abuse, and psychosis are clear indictors of postoperative problems. The prolonged waiting list time provides an additional period to evaluate and provide support to patients having a terminal disease who need a heart transplant, and are undergoing prolonged hospitalization. Following transplantation, the patient is faced with additional challenges of a new self-image, multiple concerns, anxiety, and depression. Ultimately, the success of the heart transplantation remains dependent upon the recipient's ability to cope psychologically and comply with the medication regimen. The limited resource of donor hearts and the high emotional and financial cost of heart transplantation lead to an exhaustive effort to select those patients who will benefit from the improved physical health the heart transplant confers.

Cardiac transplantation for older patients: Characteristics and outcomes in the septuagenarian population

BACKGROUND

With increasing age of patients with heart failure, it is important to understand the potential role for orthotopic heart transplant (OHT) in elderly patients. We examined recipient and donor characteristics and long-term outcomes of older recipients of OHT in the United States.

METHODS

Using the United Network for Organ Sharing database, we identified OHT recipients from the years 1987-2014 and stratified them by age 18-59 years old, 60-69 years old, and ≥70 years old. We compared baseline characteristics of recipients and donors and assessed outcomes across groups.

RESULTS

During this period, 50,432 patients underwent OHT; 71.8% (n = 36,190) were 18-59 years old, 26.8% (n = 13,527) were 60-69 years old, and 1.4% (n = 715) were ≥70 years old. Comparing the ≥70 years old group and 60-69 years old group, older patients had higher rates of ischemic etiology (53.6% vs 44.9%) and baseline renal dysfunction (61.4% vs 56.4%) and at the time of OHT were less likely to be currently hospitalized (45.0% vs 50.9%) or supported with left ventricular assist device therapy (21.0% vs 28.3%). Older recipients received organs from older donors (median age 36 years old vs 30 years old) who were more likely to have diabetes and substance use. After OHT, the median length of stay was similar between groups. At 1 year, of patients alive, patients ≥70 years old had fewer rejection episodes (17.8%) compared with patients 60-69 years old (29.5%). The 5-year mortality was 26.9% for recipients 18-59 years old, 29.3% for recipients 60-69 years old, and 30.8% for recipients ≥70 years old.

CONCLUSIONS

Despite advanced age and less ideal donors, OHT recipients in their 70s had similar outcomes to recipients in their 60s. Selected older patients should not routinely be excluded from consideration for OHT.

Advanced therapies for end-stage heart failure

Management of the advanced heart failure patient can be complex. Therapies include cardiac transplantation and mechanical circulatory support, as well inotropic agents for the short-term. Despite a growing armamentarium of resources, the clinician must carefully weigh the risks and benefits of each therapy to develop an optimal treatment strategy. While cardiac transplantation remains the only true “cure” for end-stage disease, this resource is limited and the demand continues to far outpace the supply. For patients who are transplant-ineligible or likely to succumb to their illness prior to transplant, ventricular assist device therapy has now become a viable option for improving morbidity and mortality. Particularly for the non-operative pa-tient, intravenous inotropes can be utilized for symptom control. Regardless of the treatments considered, care of the heart failure patient requires thoughtful dialogue, multidisciplinary collaboration, and individualized care. While survival is important, most patients covet quality of life above all outcomes. An often overlooked component is the patient’s control over the dying process. It is vital that clinicians make goals-of-care discussions a priority when seeing patients with advanced heart failure. The use of palliative care consultation is well-validated and facilitates these difficult conversations to ensure that all patient needs are ultimately met.

Who is the high-risk recipient? Predicting mortality after heart transplant using pretransplant donor and recipient risk factors

BACKGROUND

In this study we sought the following: (1) To objectively assess the risk related to various pretransplant recipient and donor characteristics; (2) to devise a preoperative risk stratification score (RSS) based on pretransplant recipient and donor characteristics predicting graft loss at 1 year; and (3) to define different risk strata based on RSS.

METHODS

The United Network for Organ Sharing provided de-identified patient-level data. Analysis included 11,703 orthotopic heart transplant recipients aged 18 years or greater and transplanted between January 1, 2001 and December 31, 2007. The primary outcome was 1-year graft failure. Multivariable logistic regression analysis (backward p value<0.20) was used to determine the relationship between pretransplant characteristics and 1-year graft failure. Using the odds ratio for each identified variable, an RSS was devised. The RSS strata were defined by calculating receiver operating characteristic curves and stratum specific likelihood ratios.

RESULTS

The strongest negative predictors of 1-year graft failure included the following: right ventricular assist device only, extracorporeal membrane oxygenation, renal failure, extracorporeal left ventricular assist device, total artificial heart, and advanced age. Threshold analysis identified 5 discrete RSS strata: low risk (LR, RSS: <2.55; n=3242, 27.7%), intermediate risk (IR, RSS: 2.55-5.72; n=6,347, 54.2%), moderate risk (MR, RSS: 5.73-8.13; n=1,543, 13.2%), elevated risk (ER, RSS: 8.14-9.48; n=310, 2.6%), and high risk (HR, RSS: >9.48; n=261, 2.2%). The 1-year actuarial survival (%) in the LR, IR, MR, ER, and HR groups were 93.8, 89.2, 81.3, 67.0, and 47.0, respectively.

CONCLUSIONS

Pretransplant recipient variables significantly influence early and late graft failure after heart transplantation. The RSS may improve organ allocation strategies by reducing the potential negative impact of transplanting candidates who are at a high risk for poor postoperative outcomes.

Heart transplantation for heart failure in children

Heart transplantation has become standard therapy for end-stage heart failure in children with cardiomyopathy as well as complex congenital heart disease, and has a significant effect on survival and quality of life. The indications for listing and referral for transplantation are outlined. Evaluation for heart transplantation is discussed, including full pretransplant assessment. ABO incompatible listing and HLA sensitization are discussed, and listing algorithms are outlined for different countries.

The role of kidney biopsy in heart transplant candidates with kidney disease

BACKGROUND

Kidney disease is common in patients with advanced heart failure and can result from intrinsic parenchymal disease or to reversible hemodynamic factors. Distinguishing the two is difficult but is important when selecting patients who will benefit from combined heart and kidney transplantation (HKT) versus heart transplantation (OHT) alone. The goal of this study was to characterize kidney biopsy findings in this population and follow the outcome of patients based on the biopsy results.

METHODS

Thirty heart transplant candidates with an estimated glomerular filtration rate less than 40 mL/min or proteinuria greater than 500 mg/day or a history of amyloidosis underwent kidney biopsies between June 2001 and March 2009. The renal pathologic diagnosis as well as the percent tubular atrophy and interstitial fibrosis on renal biopsy were assessed.

RESULTS

Proteinuria and glomerular filtration rate at the time of evaluation for heart transplant did not correlate with the degree of fibrosis on biopsy. On the basis of the biopsy results, nine patients were listed for OHT and eight patients were listed for HKT. One patient originally triaged to receive OHT and was listed for HKT due to subsequent worsening of renal function. Eight patients received OHT, none required dialysis during a median follow-up period of 18 months.

CONCLUSIONS

Renal biopsy provides useful diagnostic information to differentiate intrinsic renal disease from renal hypoperfusion and helps guide the decision for OHT alone versus combined HKT.

Psychological predictors of mortality in heart transplanted patients: a prospective, 6-year follow-up study

BACKGROUND

Some reports suggest a link between poor psychological adjustment to heart transplantation and an increased risk of subsequent adverse clinical outcome. Despite its prognostic and therapeutic implications, this issue is still lacking adequate empirical studies. We prospectively tested the predictive value of a complete set of psychiatric and psychological variables, collected with both self-rating and observer-based instruments at midterm after heart transplantation, on the subsequent 6-year survival status.

METHODS

Ninety-five heart transplanted patients underwent the structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders-4th Edition and the structured interview for Diagnostic Criteria for Psychosomatic Research and filled three questionnaires assessing the dimensions of psychological distress, quality of life, and psychological well-being. Demographic characteristics and several clinical parameters were also collected. A 6-year follow-up survival was performed.

RESULTS

Analyses of survival showed that hostility, depression, purpose in life, the occurrence of at least one cardiac event, chronic renal insufficiency, diabetes, number of drug prescriptions, a New York Heart Association (NYHA) class more than or equal to II, and ischemic origin of the cardiopathy significantly predicted subsequent survival duration. When multivariate analyses were performed, high levels of hostility and the presence of diabetes resulted the independent predictors of survival status.

CONCLUSIONS

These findings point out the predictive role of specific components of psychological adjustment to heart transplantation and pose the basis for the evaluation of whether the provision of pharmacologic and psychotherapeutic interventions, aimed at reducing the empirically identified psychological risk factors, may result in a better long-term outcome.

Heart failure management: the present and the future

Clinical heart failure has been defined for a long time as a clinical syndrome with symptoms and signs including shortness of breath, cyanosis, ascites, and edema. However, in recent years, with the thought of promoting early diagnosis and heart-failure prevention, the concept of heart failure has often been defined simply as a subject with severe LV dysfunction and a dilated left ventricle, or by some, defined by evidence of increased circulating levels of molecular markers of cardiac dysfunction, such as ANP and BNP. Heart failure has been considered an irreversible clinical end point. Current medical management for heart failure only relieves symptoms, slows deterioration, and prolongs life modestly. However, in the recent years, rejuvenation of the failing myocardium began to seem possible as the accumulating preclinical studies demonstrated that rejuvenating the myocardium at the molecular and cellular level can be achieved by gene therapy or stem cell transplantation. Here, we review selected novel modalities that have been shown in preclinical studies to exert beneficial effects in animal models of severe LV dysfunction and seem to have the potential to make an impact in the clinical practice of heart-failure management.

Combined heart-kidney transplantation: a review of recipient selection and patient outcomes

Elevated serum creatinine is a common finding among patients awaiting heart transplantation because of reduced renal perfusion in the setting of severe heart failure as well as overlapping risk factors for chronic kidney disease and heart disease. Patients with significant renal dysfunction preoperatively have worse outcomes with heart transplantation alone compared with those with normal renal function or those with renal dysfunction who undergo combined heart-kidney transplantation. Optimizing organ distribution and patient outcomes after cardiac transplantation requires appropriate recipient selection, including deciding which patients will benefit from combined heart-kidney transplantation. This review focuses on the evaluation of patients with chronic kidney disease awaiting heart transplantation and the outcomes of combined heart-kidney transplantation.

Matching high-risk recipients with marginal donor hearts is a clinically effective strategy

BACKGROUND

The purpose of this study is to determine the clinical outcomes associated with alternate listing transplantation, which utilizes "marginal" donor organs by transplanting them into high-risk recipients who fail to meet the standard criteria for transplantation.

METHODS

The United Network for Organ Sharing provided de-identified patient-level data. Analysis focused on patients undergoing heart transplantation between January 1, 1999, and December 31, 2005 (n = 13,024). High-risk criteria included age more than 65 years old, retransplantation, hepatitis C-positive, human immunodeficiency virus-positive, creatinine clearance less than 30 mL/min, diabetes mellitus with peripheral vascular disease, and diabetes with creatinine clearance less than 40 mL/min. Marginal donor criteria included age more than 55 years, diabetes mellitus, hepatitis C-positive, human immunodeficiency virus-positive, ejection fraction less than 45%, and donor:recipient weight less than 0.7.

RESULTS

Survival in the standard transplant group, defined as non-high-risk patients who received nonmarginal organs, was better than in all other groups (p < 0.001). Alternate listing transplantation patients had the worst survival (p < 0.001). The 5-year survival for the alternate listing transplantation group was 51.4%, compared with 75.1% in the standard transplant group; the standard transplant patients, with the lowest incidence of in-hospital infection (21.1%) and dialysis (7.1%), also had the best transplant hospitalization outcomes (p < 0.001). In contrast, alternate listing transplantation patients had the highest incidence of in-hospital infection (35.4%; p < 0.001). Length of stay during transplant hospitalization was also shortest in the standard transplant group (18.8 days; p < 0.001).

CONCLUSIONS

Alternate listing transplantation is associated with greater morbidity and resource utilization compared with standard transplantation. However, this strategy offers a median survival of 5.2 years to patients who would otherwise be expected to live 1 year, and therefore, may be reasonably applied to expand the benefits of transplantation. Further studies examining the costs and quality of life related to this approach are needed.

Principles for allocation of scarce medical interventions

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and disability-adjusted life-years. We recommend an alternative system-the complete lives system-which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles.

Evidence-based treatment of chronic heart failure

The past two decades have seen a knowledge explosion in the field of cardiovascular diseases, in general, and in the understanding of chronic heart failure (HF) as a complex neurohumoral syndrome in particular. A new staging system for chronic HF has been developed within the last decade to facilitate the evidence-based prescription of medications and medical devices for each of its four stages. The burden of care for patients with chronic HF is substantially provided in primary care settings. Primary care physicians need to understand the underlying pathophysiology of chronic HF, the elements of its evaluation and treatment by stage, and when referral is necessary.

Predicting survival in heart failure

Despite advances in the therapy of cardiovascular disorders, heart failure remains a challenging disease with a dismal prognosis. A plethora of variables have been shown to be related to survival in patients with heart failure. These include heart failure etiology, clinical presentation, ventricular performance, exercise capacity, neurohormones and, more recently, inflammatory and necrosis markers. In this review we briefly list established predictive markers and discuss whether survival can accurately be predicted in this condition.

Improved Health-Related Quality of Life and Functional Status After Surgical Ventricular Restoration

BACKGROUND

Surgical ventricular restoration (SVR) has been shown to improve hemodynamics and survival among patients with coronary artery disease, left ventricular aneurysm, and heart failure. The aim of this study was to investigate functional status and health-related quality of life after SVR.

METHODS

Over a period of 2 years beginning in March 2003, 23 patients with left ventricular aneurysm and depressed left ventricular function were included in a prospective study. Functional status and quality of life was analyzed preoperatively, 6 months postoperatively, and at late follow-up by assessment of New York Heart Association (NYHA) functional class, 6-minute walk test, and the Medical Outcome Study 36-Item Short Form.

RESULTS

There was no early mortality. Before surgery, 17 patients (74%) were in NYHA class III to IV; and 6 months after SVR, 20 patients (87%) were in NYHA class I to II (p < 0.001). At late follow-up, (mean, 22 months postoperatively), all patients alive (n = 20) were in NYHA class I to II. Mean 6-minute walk distance increased by 41 meters (p = 0.06) at 6 months postoperatively and by 57 meters (p = 0.03) at late follow-up. Quality of life, assessed by the physical component summary score of the Medical Outcome Study 36-Item Short Form, improved significantly (p = 0.04) at 6 months postoperatively. A significant and clinically relevant improvement in both physical aspects (+25%, p < 0.001) and mental aspects (+37%, p = 0.003) of quality of life was found at late follow-up.

CONCLUSIONS

Functional status and quality of life improved 6 months after SVR, and the improvement was sustained at late follow-up almost 2 years after surgery.

Palliative care and hospice in advanced heart failure

This paper provides an evidence-based review of the principles underlying palliative care for heart failure (HF), including its pathogenesis, staging, assessment, prognosis, and treatment. Approaches to advanced care planning, symptom management, hospice eligibility, home inotropic infusions, device management and improving the continuum of care in HF are discussed. The reader will be able to recognize advanced HF, use important elements of physical assessment, utilize Web-based prognostic and risk-stratification models, facilitate advance care planning, ensure optimal treatment, manage common symptoms and comorbid conditions, determine hospice eligibility, and consider issues related to withholding or withdrawal of inotropic infusions and devices used in HF refractory to standard treatment. The ultimate goal of palliative care for heart failure is to integrate knowledge of treatment advances and comfort measures and to provide them concurrently in a seamless continuum to patients with late-stage disease.

Outcomes Following Surgical Ventricular Restoration in Elderly Patients With Congestive Heart Failure

Despite the well described benefits of surgical ventricular restoration (SVR) for patients with ischemic cardiomyopathy, the effects of advanced age on outcomes following this procedure have not been well documented. The authors compared outcomes in 69 consecutive patients 65 years and older (n=27) and younger than 65 years (n=42) to determine the utility of SVR in an elderly population with end-stage heart failure. Patients 65 years and older demonstrated significant improvements in ejection fraction (P=.01) and left ventricular end-systolic volume index (P=.07) following SVR, which were similar to the improvements seen in patients younger than 65 years. Sixty percent (15 of 25) of patients 65 years and older in preoperative New York Heart Association class III/IV improved to class I/II at follow-up (P<.0001). Actuarial survival was 68.8% at 2.5 years. Like their younger counterparts, elderly patients demonstrate significant improvements in ventricular function and NYHA class with acceptable survival following SVR.

Indications for Heart Transplantation in Pediatric Heart Disease

Background— Since the initial utilization of heart transplantation as therapy for end-stage pediatric heart disease, improvements have occurred in outcomes with heart transplantation and surgical therapies for congenital heart disease along with the application of medical therapies to pediatric heart failure that have improved outcomes in adults. These events justify a reevaluation of the indications for heart transplantation in congenital heart disease and other causes of pediatric heart failure.

Methods and Results— A working group was commissioned to review accumulated experience with pediatric heart transplantation and its use in patients with unrepaired and/or previously repaired or palliated congenital heart disease (children and adults), in patients with pediatric cardiomyopathies, and in pediatric patients with prior heart transplantation. Evidence-based guidelines for the indications for heart transplantation or retransplantation for these conditions were developed.

Conclusions— This evaluation has led to the development and refinement of indications for heart transplantation for patients with congenital heart disease and pediatric cardiomyopathies in addition to indications for pediatric heart retransplantation.

Psychiatric evaluations of heart transplant candidates: predicting post-transplant hospitalizations, rejection episodes, and survival

The authors assessed the validity of psychiatric evaluations for orthotopic heart transplant candidates with respect to predicting adverse post-transplant outcomes. A group of 108 transplant recipients were followed for an average of 970 days, and pre-transplant evaluations were retrospectively coded for psychiatric risk factors. Previous suicide attempts, poor adherence to medical recommendations, previous drug or alcohol rehabilitation, and depression significantly predicted attenuated survival times. Also, past suicide attempt was associated with a greater risk for post-transplant infection. Assessment and early treatment for these risk factors may reduce post-transplant morbidity and mortality.

Use of the Internet by United States Heart Transplant Centers to Promote Transparency in the Process of Patient Selection

Organ transplantation is an ethically complex technology, in part because organs are very scarce and supply does not meet demand. Organ allocation must use a process that is fair, and the process should be open for public review and revision. We explored the transparency of the heart transplant patient selection process in the United States terming transparency as hospital use of their transplant program Web site to disclose their policies to potential patients. The Web sites of all heart transplant centers belonging to the U.S. Organ Procurement and Transplantation Network were reviewed for content pertaining to patient selection criteria for placement on the transplant waiting list. All 132 heart transplant centers have a Web site that discusses their transplant program; however, 84% (n = 111) do not publish their medical listing criteria on their Web site. Only 15% (n = 20) expressly indicate the requirement for a psychosocial evaluation. Few centers (n = 9) utilize their Web site to discuss use of a formal data review committee to decide which patients to list for transplantation. In order to demystify and correct false assumptions about the transplant listing process, wait listing criteria should be transparent to the public and Internet disclosure can facilitate this end. Our findings lay the foundation for future prospective studies.

Malignant melanoma in a candidate for heart transplantation

A superficial spreading melanoma (Breslow thickness 0.4 mm) was diagnosed in a 65-year-old candidate for heart transplantation due to refractory end stage heart failure. After extensive review of the literature (USA and Europe), no clear guidelines about the management of candidates for transplantation with a previous diagnosis of melanoma were found. As this patient had a 5-year probability of survival higher than 95% and heart transplantation was necessary for saving his life, the final decision was to perform the transplantation. Unfortunately, the patient died of heart failure before a suitable heart became available. This case stresses the need for early and continuous dermatological evaluation of all candidates for solid organ transplantation. Clear guidelines for screening of skin cancer before transplantation are needed.

Validation of peak exercise oxygen consumption and the Heart Failure Survival Score for serial risk stratification in advanced heart failure

The Heart Failure Survival Score (HFSS) and peak exercise oxygen consumption (VO2) accurately assess mortality in ambulatory patients who have advanced heart failure and are referred for initial cardiac transplant evaluation. We investigated the prognostic value of the HFSS and peak VO2 when applied serially to these patients. This study included 227 adults (mean age +/- SD 52 +/- 10 years old) who presented for reevaluation >60 days after initial evaluation (352 +/- 238 days). The HFSS was determined from mean arterial blood pressure, heart rate, left ventricular ejection fraction, serum sodium, peak VO2, heart failure etiology, and width of QRS complex. Survival without reevaluation, United Network of Organ Sharing 1 transplant, or left ventricular assist device was determined by the Kaplan-Meier method with censoring at United Network of Organ Sharing 2 transplant. Survival differed by HFSS stratum (p <0.001) and by peak VO2 stratum (p <0.001). Patients whose HFSS or peak VO2 deteriorated from low risk to medium or high risk had lower survival rates than did patients whose values remained at low risk (p <0.01 and p <0.001, respectively). Patients who started at medium or high risk and improved to low risk tended to have higher survival rates than those who remained medium or high risk (p = 0.06 and p <0.16, respectively). Patients who improved to low risk had a 1-year survival rate of 72% for HFSS and peak VO2. However, patients who improved to low risk and were treated with beta blockers had a 1-year survival rate (89% for HFSS and 83% for peak VO2) comparable to that after transplant (84%). Peak VO2 and the HFSS can be successfully used for serial evaluation of mortality risk in ambulatory patients who have advanced heart failure.

Left Ventricular Assist Devices as Destination Therapy for End-stage Heart Failure

In the therapy of advanced heart failure, left ventricular assist devices represent an exciting new option. The role of mechanical circulatory support is currently limited predominantly by factors related to device durability. The population for whom mechanical circulatory support can be considered as permanent therapy is defined by those for whom improvement in survival and clinical function is expected from current devices. Reported device survival in the range of 50% at 1 year limits the present candidate population to those with greater than 50% mortality at 1 year, who are not eligible for cardiac transplantation, after which survival is 50% at 10 years. Even as we learn to identify these patients who are "sick enough" to warrant device placement and yet "well enough" to survive surgery, the devices and surgical techniques are evolving so that the outcomes are improving and the candidate population is expanding.

Transplant "twins": the experience of sharing transplanted thoracic organs from the same donor

BACKGROUND

Many thoracic transplant recipients who receive organs from the same donor share facilities for 3 months, and are aware that they have received organs from the same donor.

METHODS

A confidential questionnaire including open and closed questions assessed relationships between "twins" and the experience of having a twin. The Significant Others Scale assessed social support. Of 141 heart and 58 lung transplants, 25 pairs of transplant twins were identified. Questionnaires were sent to the 32 surviving twins.

RESULTS

Twenty-six twins responded; 17 had received a heart and nine a lung. The 17 men and 9 women had a mean age of 51 years. Eighteen respondent's "twins" remained alive at the time of participation and eight had died. Sixty-six percent of the both- twin alive group and 43% of one-twin alive group felt they had a special bond with their twin, different from the other relationships that they have experienced. Fifty-six percent of the both-twin alive group and 43% of one-twin alive group felt having a twin enriched their transplant experience. Transplant twins rated social support last behind: the transplant support personnel; close family members; other transplant recipients; and good friends and general practitioners, both in levels of ideal and actual support. Transplant twins showed the largest discrepancy between levels of ideal and actual support than any other individual ranked.

CONCLUSIONS

Being a transplant twin is a special experience that generally enriches the overall transplant experience but having a transplant twin, does not appear to enhance the amount of social support.

Frequency and impact of delayed decisions regarding heart transplantation on long-term outcomes in patients with advanced heart failure

OBJECTIVES

We sought to characterize decisions regarding listing of heart transplant candidates and to determine the impact of delayed listing for a transplant on survival.

BACKGROUND

Evaluation and listing for heart transplantation have evolved over the past decade, with the complex decision process often extending beyond the time of initial review. Little is known about the current impact of decisions and timing of listing on outcomes.

METHODS

Decisions were prospectively recorded during the initial committee discussions regarding patients referred for heart transplant evaluation. Survival and transplantation rates were assessed.

RESULTS

A total of 214 patients were evaluated for heart transplantation (age 49 +/- 11 years, ejection fraction 21 +/- 9%, New York Heart Association class III +/- I, peak oxygen consumption 13 +/- 4 ml/kg/min). At the initial evaluation, 44% of patients were deemed eligible, 25% were potentially eligible, 19% were ineligible, and 12% were deferred. For eligible patients, 37% of patients were listed within 10 days of evaluation, and a total of 71% of patients were ever listed. Regardless of transplantation, the three-year survival rate in eligible patients not listed early was similar to that in patients listed immediately (85% vs. 77%, p = 0.34). Ineligible and potentially eligible patients had a higher three-year mortality rate than did eligible patients if transplantation occurred (51% vs. 17%, p < 0.001) or not (57% vs. 19%, p = 0.04).

CONCLUSIONS

Using current accepted guidelines, many patients referred for transplant evaluation were not considered eligible for transplantation, and those who were eligible were not often listed immediately. Eligible patients not listed initially did well in the long term, and patients with relative contraindications had worse outcomes with or without a transplant.

Heart transplantation

Heart transplantation remains the best treatment option for end-stage heart failure. For patients who are not candidates for transplantation, better medical management and surgical options in heart failure can improve both the length and quality of a patient's life. Continuing research on xenotransplantation and the total artificial heart may decrease the need for human transplantation in years to come and may allow others with severe heart failure to have a chance at living longer.