Elderly patients with heart failure and men with treated prostate cancer are among those who have been historically denied heart transplantation. Now, under new guidelines co-authored by the Johns Hopkins Medical Director for Heart Transplantation and issued in September by the International Society for Heart and Lung Transplantation (ISHLT), they should be considered.
"People who once would die because they did not qualify now have a chance to get a new heart," says Stuart Russell, M.D., who served on the ISHLT committee revising the guidelines. "Research now suggests they are actually good candidates," he adds.
ISHLT guidelines, which date back to 1992 and were last updated in 1997, restricted access for cancer patients who have been tumor free for less than five years or had weakened immune systems from cancer therapy that precluded them from taking anti-rejection drugs for a transplanted organ. The new recommendations allow some people with slow-growing or treated cancers to qualify, and they raise the qualifying age cap from 65 to 70.
Support for the new criteria comes from research confirming that transplant recipients over age 65 have an 85 percent survival rate one year post-transplant. After 10 years, he says, 50 percent are still alive.
"Too often, people suffering from heart failure and cancer give up on the prospect of a long, productive life, thinking they have exhausted all treatment options possible, and even their primary physicians are not aware that transplantation is a viable option," says Russell.
The updated criteria follow changes in 2002 guidelines for organ donation, which permitted transplantation of hearts from those over 50, even when the hearts were enlarged or the arteries feeding it were clogged, provided the clot was removed. And they are likely to increase demand for already scarce donor organs.
As of Sept. 1, at least 2,885 Americans were on the national waiting list for a heart transplant, according to the United Network for Organ Sharing. Up to 20 percent of those on the list will die while waiting, Russell notes.
The guidelines reaffirm ISHLT’s view that demand for transplantation is unlikely to ever be fully met and that more resources are needed to slow down the progression of heart failure and prevent the need for transplant surgery in the first place.
Russell says new drugs, implantable defibrillators and pacemakers, and smaller heart pumps can assist a weakened heart for longer periods, or until a new donor organ becomes available.
He estimates that the relaxed guidelines could result in up to 15 more heart transplants for patients served by Hopkins in southeastern Pennsylvania, Maryland and northern Virginia, none of whom would have qualified for an organ under the old restrictions. Nationally, he estimates, up to 400 more patients could now qualify and receive a new heart.
