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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Heidi Goerler Martin Strueber Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Goerler, H. Articles by Strueber, M. Search for Related Content PubMed Articles by Goerler, H. Articles by Strueber, M. Related Collections Transplantation - heart

Letters to the Editor

Reply to Leach and Evans

Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany

Received 21 January 2009; accepted 24 January 2009.

^_* Corresponding author. Tel.: +49 511 532 2153; fax: +49 511 532 5404. (Email: goerler.adelheid{at}mh-hannover.de).

Key Words: Heart retransplantation • Graft failure • Cardiac allograft vasculopathy • Indications for retransplantation • Guidelines

We thank Leach and Evans [1] for their interest in our recent article on cardiac retransplantation [2]. Because of the increasing scarceness of donor organs the question about the justification of cardiac retransplantation remains a relevant issue. The improving results of cardiac transplantation combined with the ageing population led to an increasing number of long-term survivors after heart transplantation (HTX) who may become candidates for repeat transplantation. Therefore, Leach and Evans ask for ‘definitive evidence based guidelines’ for the allocation of donor hearts in case of retransplantation.

They refer to data of the International Society for Heart and Lung Transplantation (ISHLT), which reported a significantly improved survival after cardiac retransplantation [3]. Regarding those patients who were more than 12 months from the initial transplant procedure and underwent redo HTX between 2002 and 2005, these patients experienced a 1-year survival rate of approximately 85%, the same as primary transplants performed during the same time period. However, these survival data refer to recently performed transplantations in a selected patient population. Looking at the overall results of the ISHLT database, repeat transplantation has been identified as a significant risk factor for long-term mortality after HTX. These results have also been confirmed by other authors [4].

One important step towards a reasonable allocation of donor hearts was the decision against redo transplantation in acute organ failure. For the establishment of evidence based criteria for redo HTX a working group has analysed the results of the ISHLT database. Based on these results they have elaborated and published indications and contraindications for repeat HTX. Exclusion criteria were any kind of malignancy, severe pulmonary hypertension, concomitant end-organ failure (renal, hepatic, pulmonary), and evidence of patient non-compliance. Relative contraindications were severe peripheral vascular disease, severe osteoporosis as well as the patients’ general physical status [5].

These evidence based criteria are helpful. However, they cannot replace the individual decision in every potential candidate for repeat heart transplantation. As Leach and Evans point out, retransplantation remains the only definitive treatment option for coronary artery vasculopathy. Therefore, a decision against repeat HTX might result in the death of the patient. Repeat transplantation belongs to those indications for HTX that are associated with an increased risk of mortality, comparable to patients with temporary circulatory support, ventricular assist device support or ventilatory support [3]. Although, in all these patients the risk of mortality after HTX is significantly elevated, they are not generally excluded from this therapeutic option.

According to our opinion, the final decision and responsibility as to whether or not a patient is a suitable candidate for HTX has to remain in the hands of the transplant surgeon. The decision should be based on evidence based criteria as well as on patient related individual risk factors.

References

1. Leach R, Evans C. Re: Cardiac retransplantation: is it justified in times of critical donor organ shortage? Long-term single center experience. Eur J Cardiothorac Surg 2009;35(5):920.[Free Full Text]
2. Goerler H, Simon A, Gohrbandt B, Hagl C, Oppelt P, Haverich A, Strueber M. Cardiac retransplantation: is it justified in times of critical donor organ shortage? Long-term single-center experience. Eur J Cardiothorac Surg 2008;34:1185-1190.[Abstract/Free Full Text]
3. Taylor DO, Edwards LB, Boucek MM, Trulock EP, Waltz DA, Keck BM, Hertz MI, International Society for Heart and Lung Transplantation Registry of the International Society for Heart and Lung Transplantation: twenty-fourth official adult heart transplantation report. J Heart Lung Transplant 2007;26:769-781.[CrossRef][Medline]
4. Topkara VK, Dang NC, John R, Cheema FH, Barbato R, Cavallo M, Liu JF, Liang LM, Liberman EA, Argenziano M, Oz MC, Naka Y. A decade experience of cardiac retransplantation in adult recipients. J Heart Lung Transplant 2005;24(11):1745-1750.[CrossRef][Medline]
5. Johnson MR, Aaronson KD, Canter CE, Kirklin JK, Mancini DM, Mehra MR, Radovancevic B, Taylor DO, Webber SA. Heart retransplantation. Am J Transplant 2007;7:2075-2081.[CrossRef][Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Heidi Goerler Martin Strueber Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Goerler, H. Articles by Strueber, M. Search for Related Content PubMed Articles by Goerler, H. Articles by Strueber, M. Related Collections Transplantation - heart