MODULE 9 AC Rebuilt Hearts are TransplantedOrgan Transplant Association, 2002 Annual Winter Symposium8-12-01 by Jonathan Leake and Tom Robbins - The Sunday Times BRITAINSURGEONS faced with a shortage of transplant organs are repairing andreconditioning damaged and diseased hearts in order to save dying patients.Such organs would have been seen as too risky to transplant until recently, but growingwaiting lists caused by a shortage of donors have forced doctors to make the best use ofthe organs available."Ive repaired four hearts before transplanting them and theyre all working well," saidProfessor John Dark, of the Freeman hospital in Newcastle, one of the pioneers of thetechniques. "Three needed coronary bypasses before I could pass them on to their newowners, and an abnormal valve in the fourth had to be replaced."Bypasses are needed when a coronary artery, through which blood flows to the heart,becomes blocked or too narrow to be effective. Instead, a length of vein from elsewherein the body is attached to the heart in order to bypass the blockage.One of the patients saved by Darks surgery was John Gilbert, 67, from Skelton,Cleveland. He had been on the waiting list for a heart transplant for more than two years,and was moved to the top of it after his heart stopped and had to be restarted twice. "Darksaid one of the valves and an artery on this heart were iffy, but they could be fixed," saidGilbert. "He said if I didnt want to risk it I could wait until a better heart came along. IfId said no I wouldnt be here now."At the end of June there were 4,873 people in Britain awaiting kidney transplants and 426people waiting for heart or lung transplants. Lack of donors - exacerbated by a decline inthe number of people killed on the roads - meant that last year only 1,823 kidneytransplants and 348 heart or lung transplants were carried out.While the complex reconditioning work on hearts carried out by Dark remains extremelyrare, other surgeons are beginning to carry out repair work on other transplant organs,including livers and kidneys. No records exist of how many "sub-optimal" organs havebeen transplanted so far. Experts say sub-optimal transplants perform well in 85-90% ofcases, only marginally less than the general 90% success rate for ordinary transplants."If we cant always give you a Mercedes, then perhaps we can give you a Ford Mondeowhich will do much the same job," said Chris Rudge, medical director of the UnitedKingdom Transplant Support Service Authority (UKTSSA), the National Health Servicebody that oversees transplants. "They are all second-hand after all. But that isnt to saytheres not plenty of mileage left in them."
Damaged Goods - By Paul Engstrom, writer and editor in Sebastopol, Calif. - Special toThe Washington Post, Page HE08 6-26-01 After suffering a second heart attack, EugeneSteele faced a real do-or-die decision: Accept a heart transplant or wait for congestiveheart failure to take its toll. A no-brainer, youd think – except the only heart available tothe retired electronics manager from Oxnard, Calif., was one from a 63-year-old strokevictim. Steele, then 67, knew his chances of leapfrogging a long list of youngercandidates for a more pristine organ were almost nil.He didnt hesitate. Before the transplant, doctors at the UCLA Medical Center performeda single bypass on the donated heart to improve its function. More than five years later,Steele feels healthy and strong, and his new – or, more accurately, previously used andreconditioned – heart seems to be functioning normally. He recalls that he wasnt tooconcerned back then about receiving a less-than-perfect organ. "It didnt bother me at all.Im pretty realistic," says Steele. "I realized that whatever I got was going to be gravy."Like Steele, a growing number of transplant patients and their doctors are wagering thatreceiving an old or even defective kidney, liver, heart or pancreas is a better bet thanwaiting for an ideal organ that may never become available. Hoping to help meet theburgeoning demand for transplants, which outstrips supply by more than 3 to 1, surgeonsin the Washington area and in other parts of the country are implanting donor organs thatonly a decade ago were deemed too old or damaged or otherwise unusable. Now suchorgans – called "extended criteria" organs – are routinely transplanted, giving longer lifeand new hope to recipients, many of whom are elderly."If youve got a patient whos already between 60 and 70 years old, waiting five years ondialysis means theyre not going to be a very good candidate when their time comes" for akidney transplant, says Jimmy Light, director of transplant services at WashingtonHospital Center. "One way to shorten the wait is to trade off donor quality."Says James Palleschi, a transplant surgeon and co-founder of the Northern CaliforniaKidney Transplant Center in Santa Rosa, "Everybody is pushing the envelope" on donororgans that in the past would have been discarded as unsuitable.Many physicians, patients and patient advocacy groups are cautiously applauding theapproach – because it boosts supply."Anything that will expand the donor pool is bound to benefit patients, and therefore issomething we would support," says Stewart Van Scoyoc, a lobbyist for the PatientAccess to Transplantation Coalition in Washington. Manikkam Suthanthiran, editor ofthe journal Transplantation, estimates that using marginal organs may reduce demand byroughly 10 to 15 percent – "not a trivial amount," he says.But the practice also raises a host of difficult ethical questions. These include: How muchof a say do patients have – or should they have – in the decision to transplant a marginalorgan? What are the standards for selecting and using such organs? Should thosestandards differ according to the age of a recipient? For now, there are no fixed answers.
The easing of transplant criteria owes a lot to medical advances within the last twodecades. One is the refinement in organ-rejection drugs. For example, several newimmunosuppressants are now available in addition to cyclosporine, the breakthroughagent that made its debut in the late 1970s. Doctors can use precise combinations of thesedrugs to target specific parts of the immune system in a way that makes the body lesslikely to reject implanted tissue while exposing the patient to less toxicity.Better infection management, more experience on the part of surgeons and carefulselection of organ donors and recipients have also helped make it possible to relaxtransplant criteria. Last year, surgeons performed about 22,800 transplants in the UnitedStates – nearly 1,200 more than in 1999. But demand has grown at an even faster rate. Asof mid-June, nearly 77,000 people were on the national waiting list for an organ,according to the United Network for Organ Sharing (UNOS), a Richmond-based private,nonprofit group that maintains the list under contract with the federal government. Eachday, according to UNOS, an average of 15 of those people die.Exacerbating the organ shortage has been the decline in recent years of highway deaths,thanks partly to laws requiring seatbelts, airbags and motorcycle helmets – and tougherenforcement of drunk driving laws. Fewer such deaths means fewer potential donors.Kidneys are the most frequently transplanted major organ, followed by livers, hearts andpancreases. Lung, kidney-pancreas, intestine and heart-lung transplants are performed aswell.What makes an organ marginal varies with the organ. A less-than-ideal kidney may beone that, because the donor is in his fifties or sixties, cant filter waste products from theblood as well as it once did, or whose vessels have deteriorated over time. Yet the kidneystill has enough "tread" to enable an elderly recipient to live out her remaining years.In February 2000, Joseph Payne, a retired math professor in Charlottesville, Va., receiveda well-worn but acceptable kidney at Washington Hospital Center at age 70 – from hiswife, Ruth, who was 71. His other option was ultimately to go on dialysis three times aweek, an expensive and disruptive regimen, while waiting up to four years for an organfrom a younger donor. "My sense was that if there were a transplant possibility, I mightnot get a prime kidney, which would only have been fair," Payne says. "When you get tobe 70, you dont want to take a kidney away from a healthy 30-year-old."A marginal liver might be one with excess fat from an obese donor. In recent years,experts have learned that while too much fat makes it difficult to store the organ for long,it doesnt necessarily mean the liver will malfunction after transplant, as surgeons oncefeared. Even livers with hepatitis are usable, though only in recipients who already havethe infectious disease, says Johann Jonsson, director of the abdominal transplant programat Inova Fairfax Hospital in Falls Church. "The liver might not be as good as one from a20-year-old healthy person," he says, "but its still a lifesaving operation" for someonewith hepatitis. "Especially in the last five years," Jonsson adds, "weve gotten moreaggressive in trying to use livers that previously were not considered."
Defective donor hearts include those that first need a bypass – sometimes more than one– while marginal pancreases may be slightly scarred, fibrous, fatty or damaged byhypertension drugs called vasopressors. Such pancreases are acceptable if, beforetransplant, close inspection shows the damage isnt too great and the vasopressors areflushed, says Robert Corry, director of pancreas transplantation at the University ofPittsburgh Medical Center.Many considerations – including medical urgency, time spent on a waiting list, bloodtype, organ size and genetic makeup – go into matching a donor and recipient.Determining if a less-than-ideal organ is suitable for transplant adds another wrinkle tothis already complex matter.Its difficult to gauge the overall success of this surgical approach because transplantcircumstances and the different types and status of organs vary so much. So far,researchers comparing the performance of marginal and ideal organs have generallystudied only a small number of organs at single transplant centers. Still, most studiespaint a promising picture. In a 1999 paper published in Transplantation, for example,Corry reported no significant difference in the survival of 137 patients about two yearsafter they had received either a marginal or "non-marginal" pancreas at his center. In thesame journal and year, researchers in Madrid wrote that three of four livers from donorsin their eighties were performing well seven, 16 and 24 months after transplant.Full Disclosure? As the practice of using marginal organs becomes more widespread, it israising a few ethical flags. For one thing, not all transplant centers or surgeons tellpatients beforehand that they will get a marginal organ, says Arthur Caplan, director ofthe Center for Bioethics at the University of Pennsylvania in Philadelphia. "There are afew programs where you know that older organs and older recipients are being used. Butin other cases, if an organ comes from someone whos not quite as healthy or if the organhas been damaged a little bit when taken [from a donor], people just dont discuss it, toput it bluntly," says Caplan. He attributes the hush-hush attitude partly to surgeons who"relish autonomy" and "dont want their judgment interfered with." Indeed, surgeons havea great deal of discretion in deciding if a donor organ is usable and appropriate for agiven patient, based on their experience and expert judgment.Sugeng Sukolono, 42, a clothing salesman in Alexandria, says he was "prettydisappointed" to learn after he received two kidneys at Georgetown University Hospitallast September that both organs had come from a donor older than 50. One of the kidneyslater failed and was removed. The remaining kidney, while its not functioning perfectly,is working well enough that Sukolono has time to ponder his next course of action. Hemay have to return to dialysis or undergo another transplant. "Now it is getting a bitbetter," he says. "But my energy level isnt as high as it was when I was on dialysis."Marc Lorber, a surgery professor at Yale University in New Haven, Conn., and presidentof the American Society of Transplant Surgeons, says his peers – at least those in NewEngland – are getting better at telling recipients up front about the stakes. He cites one
had been refused by other UK liver transplant centres, 11 on medical grounds. Thecontrols were grafts retrieved from "good" donors (n = 183) during the same period. All30 grafts showed satisfactory early function but had greater day 1 (p = 0.004) and peakserum aspartate aminotransferase (p = 0.0008) values than control grafts. Graft andpatient survival at 1 year in the two groups was similar (72% vs 73% and 80% vs 82%,respectively). To assess attitudes to marginal donor livers, a questionnaire outlining thedetails of these 30 donors was sent to the 80 centres in the European Liver TransplantGroup, and 60 replied. Median immediate refusal rate of the marginal donors was 7/30(range 0-18) and median outright acceptance rate was only 11/30 (1-26). Larger centreswere less selective, with a significantly lower refusal rate (p = 0.03). These resultsindicate that, because of existing liver donor criteria within Europe, usable donor liversare being unnecessarily refused on medical grounds.Publication Types: Clinical TrialPMID: 7968124 [PubMed - indexed for MEDLINE]