Panel advises easing selection criteria to boost supply of donor hearts
DALLAS, July 30 -- Transplant centers should relax some of the organ selection criteria to increase the supply of transplantable hearts, according to an expert panel of heart transplant surgeons, cardiologists, and organ procurement specialists. The panel's recommendations are published in today's rapid access issue of Circulation: Journal of the American Heart Association.
About 6,000 to 8,000 patients are put on a waiting list for heart transplants each year, but only about 2,500 hearts become available for transplant, according to the statement.
Each year, about 17 percent of patients on the waiting list die before a new heart is available. Only about 39 percent of the potential donor hearts are transplanted.
"Implementing these new recommendations could increase heart donations," says Jonathan G. Zaroff, M.D., who co-chaired the March 2001consensus conference at which the panel met.
Zaroff, an assistant professor of medicine and director of the coronary care unit at the University of California, San Francisco, says the disparity between supply and demand led the panel to re-examine the selection criteria "since we suspected that a number of viable donor hearts were not being used."
Age is often a factor in selecting hearts. Many centers automatically reject hearts if the donor is older than 55. But the panel says that some hearts from older donors could be transplanted, as long as the heart seems to have normal anatomy and function.
Many hearts also are rejected when ultrasound suggests thickening of the heart muscle, which makes the heart work less efficiently. But the panel recommends that hearts with only mild thickening be considered for transplantation.
One recommendation deals with requirements for angiography. Currently, hearts from male donors over age 45 and women over 50 undergo angiography to determine the condition of vessels. It is common to find evidence of narrowed or blocked arteries beginning in middle age, Zaroff says. However, often hearts are rejected because no cardiologist is available to perform the angiography.
"We know that perfectly good hearts in that age range are rejected because this examination was not performed," he says. The new recommendations state that some hearts from men aged 46 to 55 or women aged 51 to 55 should be considered for transplant without catheterization if the donor has no known risk factors for coronary artery disease and if the heart is being matched to a recipient with a relatively urgent need for transplantation.
Another recommendation suggests pairing donor hearts that show evidence of infection with or exposure to hepatitis C (HCV) or hepatitis B (HBV) to similarly infected recipients. Currently, many transplant centers reject donor hearts if surgeons find a minor defect such as a mild to moderate malfunctioning valve. Zaroff says that the surgeon can repair some of these defects just before transplantation.
The panel also recommends some changes as to how potential donors are kept on life support while transplant decisions are made. First, it recommends closely monitoring hydration, oxygen levels and blood counts to minimize heart stress. But even when heart function has been depressed, "we are recommending that the heart should not be immediately discarded," he says. Instead, the heart should be resuscitated and managed with intravenous drugs that help the heart muscle contract more efficiently.
Zaroff says organ procurement organizations and the United Network for Organ Sharing -- the agency that oversees donor organ allocation and maintains the transplant waiting lists -- are considering changing donor management paperwork so that each donor can be assessed for compliance with the new recommendations.
Other consensus conference members were: Bruce R. Rosengard, M.D., conference co-chair; William F. Armstrong, M.D.; Wayne D. Babcock, B.S.N.; Anthony D'Alessandro, M.D.; G. William Dec, M.D.; Niloo M. Edwards, M.D.; Robert D. Higgins, M.D.; Valluvan Jeevanandum, M.D.; Myron Kauffman, M.D.; James K. Kirlin, M.D.; Stephen R. Large, M.D.; Daniel Marelli, M.D.; Tammie S. Peterson, RN; W. Steves Ring, M.D.; Robert C. Robbins, M.D.; Stuart D. Russell, M.D.; David O. Taylor, M.D.; Adrian Van Bakel, M.D.; John Wallwork, M.B.; and James B. Young, M.D.
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