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Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
Received 6 August 2008; received in revised form 23 August 2008; accepted 23 August 2008.
* Corresponding author. Tel.: +49 5 11/5 32 3435; fax: +49 5 11/ 5 32 84 52. (Email: strueber.martin{at}mh-hannover.de).
Key Words: Heart transplantation • Urgency criteria • Bridge to transplant
Two years ago the Heidelberg Heart Transplant Group published a very optimistic view of the high urgency heart allocation system in Germany allowing for the avoidance of mechanical circulatory support as a bridge to transplant with an excellent patient survival rate.
Now Kamiya and co-workers update their experience over a 7-year period: since 20% of their patients died while waiting as high urgent transplant candidates the parameters required for high urgency listing are analysed to identify a patient cohort for pretransplant mechanical circulatory support (MCS) as a bridge to transplant.
However, it is not the ‘Eurotransplant High Urgency (HU) Heart Transplantation Program’ as stated in the manuscript, but national allocation rules for heart transplantation in Germany, which are carried out by Eurotransplant. This has to be differentiated to allow the correct context of the discussion: Eurotransplant has to maintain an import/export balance for organs between participating countries, so that the available donor organs in a country almost equals the number of donated organs in the country. HU candidates are on a national waiting list and compete for the available grafts. So it seems that the experience from the Heidelberg group cannot be generalised for all German or European centres. Currently all centres have their own algorithms of how long to wait for a heart transplant and when to use MCS. Since all patients are interconnected by the allocation system, the more aggressive use of MCS in one centre may allow earlier transplantation of a HU candidate in another centre and vice versa.
Dr Kamiya's report extends for more than 7 years [1]. Within this time the situation for heart transplant recipients has become much more competitive:
In Germany the waiting list for heart transplantation more than doubled within the last 5 years (from 319 in 2002 to 774 at the end of 2007; www.eurotransplant.nl). The number of available donor organs increased only by less than 10% (from 319 in 2002 to 348 in 2007). Eurotransplant reports that currently more than 80% of all grafts are already allocated to ‘High Urgency’ heart recipients, thus avoiding the need for MCS in these patients. In addition the waiting time for HU candidates increased over the years.
A further question arises when outcome data are included in the discussion: the quality reports for heart transplantation in Germany revealed an increase of in hospital mortality from 17% in 2005 and 2006 to 22% in 2007 (www.bqs-outcome.de). Are we pushing towards the edge of too much risk in accepting marginal donor organs and accepting recipients too sick for transplantation?
Criticism must be allowed regarding the Heidelberg approach on the high mortality of 20% of patients on the HU waiting list: how many of these patients could have been saved with the appropriate use of MCS?
More recent publications [2] show an improvement of survival in patients with left ventricular assist devices using modern rotary pump technology [3]. In terms of survival, the hospital mortality and 1-year survival comes close to what is achieved in heart transplantation in Germany. Therefore, the Heidelberg group is right to say that indications for urgent heart transplantation and MCS have to be discussed. It is also important to notice the conclusion that parameters indicating beginning multiorgan failure decide the fate of the patients. The parameter required for high urgency status focuses on haemodynamics and need for catecholamine support in the absence of severe multiorgan failure. The choice of parameters is questionable to detect early and beginning multiorgan dysfunction. Lietz and co-workers [4] recently published a risk score for the implantation of a left heart assist device, revealing early markers of multiorgan failure having a major impact on the results of LVAD implantation. These observations lead to the question of precise monitoring for patients with chronic heart failure developing early signs of endorgan dysfunction. Here the field seems much wider than the current patient cohort on transplant waiting lists.
This article from Heidelberg may start a discussion beyond the level of individual transplant centres: there are, so far, no good outcome data about the fate of patients with HU status. High urgency criteria for heart transplantation were designed and risk scores for MCS were published. But the aim for working groups in both fields is to establish a consensus of who is going to receive the few donor hearts available and who is to be treated early enough with MCS not only as a bridge to transplant, but as a chronic therapy. The validation of the score suggested by Lietz for a transplant cohort or the design of a new risk score may be possible ways. The demographic development of heart failure, decreasing heart donation and advances in MCS will also be the elements of such discussion.
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