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Rebuilt Hearts are Transplanted
Organ Transplant Association, 2002 Annual Winter Symposium
8-12-01 by Jonathan Leake and Tom Robbins - The Sunday Times BRITAIN
SURGEONS faced with a shortage of transplant organs are repairing and
reconditioning damaged and diseased hearts in order to save dying patients.
Such organs would have been seen as too risky to transplant until recently, but growing
waiting lists caused by a shortage of donors have forced doctors to make the best use of
the organs available.
"I've repaired four hearts before transplanting them and they're all working well," said
Professor John Dark, of the Freeman hospital in Newcastle, one of the pioneers of the
techniques. "Three needed coronary bypasses before I could pass them on to their new
owners, 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 elsewhere
in the body is attached to the heart in order to bypass the blockage.
One of the patients saved by Dark's 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. "Dark
said one of the valves and an artery on this heart were iffy, but they could be fixed," said
Gilbert. "He said if I didn't want to risk it I could wait until a better heart came along. If
I'd said no I wouldn't be here now."
At the end of June there were 4,873 people in Britain awaiting kidney transplants and 426
people waiting for heart or lung transplants. Lack of donors - exacerbated by a decline in
the number of people killed on the roads - meant that last year only 1,823 kidney
transplants and 348 heart or lung transplants were carried out.
While the complex reconditioning work on hearts carried out by Dark remains extremely
rare, 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 have
been transplanted so far. Experts say sub-optimal transplants perform well in 85-90% of
cases, only marginally less than the general 90% success rate for ordinary transplants.
"If we can't always give you a Mercedes, then perhaps we can give you a Ford Mondeo
which will do much the same job," said Chris Rudge, medical director of the United
Kingdom Transplant Support Service Authority (UKTSSA), the National Health Service
body that oversees transplants. "They are all second-hand after all. But that isn't to say
there's not plenty of mileage left in them."
Damaged Goods - By Paul Engstrom, writer and editor in Sebastopol, Calif. - Special to
The Washington Post, Page HE08 6-26-01 After suffering a second heart attack, Eugene
Steele faced a real do-or-die decision: Accept a heart transplant or wait for congestive
heart failure to take its toll. A no-brainer, you'd think – except the only heart available to
the retired electronics manager from Oxnard, Calif., was one from a 63-year-old stroke
victim. Steele, then 67, knew his chances of leapfrogging a long list of younger
candidates for a more pristine organ were almost nil.
He didn't hesitate. Before the transplant, doctors at the UCLA Medical Center performed
a 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 and
reconditioned – heart seems to be functioning normally. He recalls that he wasn't too
concerned back then about receiving a less-than-perfect organ. "It didn't bother me at all.
I'm 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 that
receiving an old or even defective kidney, liver, heart or pancreas is a better bet than
waiting for an ideal organ that may never become available. Hoping to help meet the
burgeoning demand for transplants, which outstrips supply by more than 3 to 1, surgeons
in the Washington area and in other parts of the country are implanting donor organs that
only a decade ago were deemed too old or damaged or otherwise unusable. Now such
organs – called "extended criteria" organs – are routinely transplanted, giving longer life
and new hope to recipients, many of whom are elderly.
"If you've got a patient who's already between 60 and 70 years old, waiting five years on
dialysis means they're not going to be a very good candidate when their time comes" for a
kidney transplant, says Jimmy Light, director of transplant services at Washington
Hospital 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 California
Kidney Transplant Center in Santa Rosa, "Everybody is pushing the envelope" on donor
organs that in the past would have been discarded as unsuitable.
Many physicians, patients and patient advocacy groups are cautiously applauding the
approach – because it boosts supply.
"Anything that will expand the donor pool is bound to benefit patients, and therefore is
something we would support," says Stewart Van Scoyoc, a lobbyist for the Patient
Access to Transplantation Coalition in Washington. Manikkam Suthanthiran, editor of
the journal Transplantation, estimates that using marginal organs may reduce demand by
roughly 10 to 15 percent – "not a trivial amount," he says.
But the practice also raises a host of difficult ethical questions. These include: How much
of a say do patients have – or should they have – in the decision to transplant a marginal
organ? What are the standards for selecting and using such organs? Should those
standards 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 two
decades. One is the refinement in organ-rejection drugs. For example, several new
immunosuppressants are now available in addition to cyclosporine, the breakthrough
agent that made its debut in the late 1970s. Doctors can use precise combinations of these
drugs to target specific parts of the immune system in a way that makes the body less
likely to reject implanted tissue while exposing the patient to less toxicity.
Better infection management, more experience on the part of surgeons and careful
selection of organ donors and recipients have also helped make it possible to relax
transplant criteria. Last year, surgeons performed about 22,800 transplants in the United
States – nearly 1,200 more than in 1999. But demand has grown at an even faster rate. As
of 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. Each
day, 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 tougher
enforcement of drunk driving laws. Fewer such deaths means fewer potential donors.
Kidneys are the most frequently transplanted major organ, followed by livers, hearts and
pancreases. Lung, kidney-pancreas, intestine and heart-lung transplants are performed as
well.
What makes an organ marginal varies with the organ. A less-than-ideal kidney may be
one that, because the donor is in his fifties or sixties, can't filter waste products from the
blood as well as it once did, or whose vessels have deteriorated over time. Yet the kidney
still 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., received
a well-worn but acceptable kidney at Washington Hospital Center at age 70 – from his
wife, Ruth, who was 71. His other option was ultimately to go on dialysis three times a
week, an expensive and disruptive regimen, while waiting up to four years for an organ
from a younger donor. "My sense was that if there were a transplant possibility, I might
not get a prime kidney, which would only have been fair," Payne says. "When you get to
be 70, you don't 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 doesn't necessarily mean the liver will malfunction after transplant, as surgeons once
feared. Even livers with hepatitis are usable, though only in recipients who already have
the infectious disease, says Johann Jonsson, director of the abdominal transplant program
at Inova Fairfax Hospital in Falls Church. "The liver might not be as good as one from a
20-year-old healthy person," he says, "but it's still a lifesaving operation" for someone
with hepatitis. "Especially in the last five years," Jonsson adds, "we've gotten more
aggressive 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 by
hypertension drugs called vasopressors. Such pancreases are acceptable if, before
transplant, close inspection shows the damage isn't too great and the vasopressors are
flushed, says Robert Corry, director of pancreas transplantation at the University of
Pittsburgh Medical Center.
Many considerations – including medical urgency, time spent on a waiting list, blood
type, 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 to
this already complex matter.
It's difficult to gauge the overall success of this surgical approach because transplant
circumstances and the different types and status of organs vary so much. So far,
researchers comparing the performance of marginal and ideal organs have generally
studied only a small number of organs at single transplant centers. Still, most studies
paint 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 years
after they had received either a marginal or "non-marginal" pancreas at his center. In the
same journal and year, researchers in Madrid wrote that three of four livers from donors
in 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 is
raising a few ethical flags. For one thing, not all transplant centers or surgeons tell
patients beforehand that they will get a marginal organ, says Arthur Caplan, director of
the Center for Bioethics at the University of Pennsylvania in Philadelphia. "There are a
few programs where you know that older organs and older recipients are being used. But
in other cases, if an organ comes from someone who's not quite as healthy or if the organ
has been damaged a little bit when taken [from a donor], people just don't discuss it, to
put it bluntly," says Caplan. He attributes the hush-hush attitude partly to surgeons who
"relish autonomy" and "don't want their judgment interfered with." Indeed, surgeons have
a great deal of discretion in deciding if a donor organ is usable and appropriate for a
given patient, based on their experience and expert judgment.
Sugeng Sukolono, 42, a clothing salesman in Alexandria, says he was "pretty
disappointed" to learn after he received two kidneys at Georgetown University Hospital
last September that both organs had come from a donor older than 50. One of the kidneys
later failed and was removed. The remaining kidney, while it's not functioning perfectly,
is working well enough that Sukolono has time to ponder his next course of action. He
may have to return to dialysis or undergo another transplant. "Now it is getting a bit
better," he says. "But my energy level isn't as high as it was when I was on dialysis."
Marc Lorber, a surgery professor at Yale University in New Haven, Conn., and president
of the American Society of Transplant Surgeons, says his peers – at least those in New
England – are getting better at telling recipients up front about the stakes. He cites one
organ procurement organization that has a separate waiting list for patients who agree to
accept a marginal organ. This arrangement, Lorber explains, not only keeps patients wellinformed, but also speeds the transplant process when organs become available because
the related issues have been resolved.
Another concern for Caplan is the lack of objective national standards to guide the
selection and use of all marginal organs. Practices vary, he says, from one region to
another. And he says no one appears to be tracking outcomes on a large scale so
physicians will know over the years which procedures work best under which
circumstances. "[That] should be mandatory when you're pushing the frontier." Medical
centers around the country do send a wide variety of transplant data to the Scientific
Registry of Information on Transplant Recipients, maintained by the University Renal
Research and Education Association in Ann Arbor, Mich. But so far data in the registry
about marginal organs cover only kidneys.
For his part, Lorber says he's convinced the benefits of using marginal organs outweigh
the risks as long as surgeons proceed cautiously and do their absolute best to match
donors and recipients. He points out, for example, that transplant teams are paring the
amount of time between removal and transplantation of organs, which, especially in the
case of less-than-ideal organs, makes success more likely.
But some patients, at least, still have reservations. Glen Greenwood, a 43-year-old
freelance artist, didn't learn he would get a normal kidney but only a partial pancreas –
one that had been damaged by gunshot wounds – until after he had traveled from his
home in Midland, Tex., to the University of Texas Medical Branch at Galveston. A
longtime diabetic, Greenwood had seen his health deteriorate by the time he underwent
the kidney-pancreas transplant in August 1999. He describes dialysis as "hell – I'd rather
be outright dead." The donated pancreas subsequently failed, so now he takes insulin four
times a day as he weighs his options. Though Greenwood isn't pleased with the transplant
outcome, he's also convinced he couldn't have tolerated any more dialysis, which caused
chronic nausea and constipation. "If I had been told it was a partial pancreas, I might
have reconsidered," he says. "But I was desperate." © 2001 The Washington Post
Company
Policies in Europe on "marginal quality" donor livers.
Lancet 1994 Nov 26;344(8935):1480-3
Mirza DF, Gunson BK, Da Silva RF, Mayer AD, Buckels JA, McMaster P.
Liver and Hepatobiliary Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK.
Shortage of donor livers has led several liver transplant centres to widen their definition
of liver donor suitability. We have assessed the function of liver grafts from "marginal"
donors and attitudes to use of such organs. Over an 18-month period, livers used in 30 of
213 consecutive liver transplantations in Birmingham, UK, came from marginal donors
(history of alcoholism, abnormal liver function test results, drug overdose that included
paracetamol, advanced cardiovascular disease, sepsis, lengthy hypotension [systolic
blood pressure < 80 mm Hg for > 1 h], high-dose inotropic drug use). 16 of these donors
had been refused by other UK liver transplant centres, 11 on medical grounds. The
controls were grafts retrieved from "good" donors (n = 183) during the same period. All
30 grafts showed satisfactory early function but had greater day 1 (p = 0.004) and peak
serum aspartate aminotransferase (p = 0.0008) values than control grafts. Graft and
patient 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 the
details of these 30 donors was sent to the 80 centres in the European Liver Transplant
Group, 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 centres
were less selective, with a significantly lower refusal rate (p = 0.03). These results
indicate that, because of existing liver donor criteria within Europe, usable donor livers
are being unnecessarily refused on medical grounds.
Publication Types: Clinical Trial
PMID: 7968124 [PubMed - indexed for MEDLINE]