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Implantation of the Syncardia Total Artificial Heart
Published on: July 18, 2014
Crisis Awaiting Heart Transplantation: Sinking the Lifeboat
1Advanced Heart Disease Section, Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts.
Insights
Heart transplant numbers remain stable, but expanded criteria and longer waiting lists strain resources. Reducing new listings is proposed to ensure equitable access and manage the scarce donor heart supply.
Area of Science:
- Cardiology
- Transplantation Medicine
- Medical Ethics
Background:
- Heart transplant numbers in the US have remained relatively stable between 1994 and 2014.
- Transplant criteria have broadened to include older patients, those with higher BMI, and individuals with comorbidities like diabetes and smoking history.
- This has led to increased waiting lists and longer waiting times for heart transplantation.
Purpose of the Study:
- To analyze the current state of heart transplantation in the US.
- To discuss the ethical challenges in allocating scarce donor hearts.
- To propose strategies for managing the heart transplant waiting list.
Main Methods:
- Analysis of heart transplant statistics from 1994 and 2014.
- Review of evolving transplant eligibility criteria.
- Discussion of ethical frameworks for organ allocation, including the 'lifeboat dilemma'.
- Examination of patient pathways to transplantation, including the role of ventricular assist devices and geographic relocation.
Main Results:
- Despite stable transplant numbers, expanded criteria have lengthened waiting lists.
- Deterioration to the most urgent priority status is the primary route to transplantation for many.
- Ventricular assist devices, while life-saving, carry risks, and some affluent patients bypass this by relocating.
Conclusions:
- The current system faces challenges due to increased demand and limited supply of donor hearts.
- Physician advocacy for individual patients can exacerbate allocation inequities.
- Reducing new heart transplant listings is suggested to rebalance the waiting list and ensure responsible stewardship of donor organs.
Abstract:
The number of heart transplants performed in the United States was 2177 in 1994 and 2166 in 2014. However, the number of transplant centers has increased, and the criteria for transplants have broadened to include patients 65 years or older, those with a body mass index greater than 30, and more comorbid conditions, such as diabetes mellitus and a history of smoking. As the transplant waiting list has become longer and waiting times have increased, the major route to heart transplants has become deterioration to the most urgent priority status, which accounts for 10% of patients on the waiting list but two-thirds of transplants. Many heart transplant candidates develop life-threatening complications of a ventricular assist device implanted to avert death while waiting. Some affluent patients, however, can afford to temporarily relocate and obtain a transplant in regions where the waiting times are shorter without prior surgery to implant a ventricular assist device. The ethics of allocating hearts for transplant have always recalled the classic lifeboat dilemma of how many people can be allowed to board an already overcrowded lifeboat without sinking the ship and everyone on board. As transplant physicians, we advocate with the best intentions on behalf of our own patients rather than denying transplants to those less likely to benefit. In recognizing our responsibilities as stewards of scarce donor hearts, we should reduce new listings for heart transplants, thus restoring balance to the waiting list and keeping the lifeboat afloat.
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