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Mortally ill patients and excellent survival following cardiac transplantation
Insights
Cardiac transplantation is a viable option for terminally ill patients. A specialized protocol improved survival rates, demonstrating success in critically ill heart failure patients.
Area of Science:
- Cardiology
- Transplantation Medicine
- Critical Care
Background:
- Cardiac transplantation resumed in 1980 at the University Health Center of Pittsburgh.
- Initial recipients were New York Heart Association Functional Class IV, some ambulant.
- Identification of a subset of terminally ill patients with specific physiological markers.
Purpose of the Study:
- To evaluate the feasibility and outcomes of cardiac transplantation in terminally ill patients.
- To develop a therapeutic protocol to support critically ill patients awaiting transplantation.
- To reconsider and expand selection criteria for cardiac transplant candidates.
Main Methods:
- Selection of patients based on New York Heart Association Functional Class IV and specific physiological criteria (systolic arterial pressure < 80 mm Hg, cardiac index < 2 L/min/m2, urine output < 20 ml/hr, impaired mental function, decreased peripheral perfusion).
- Development and implementation of a therapeutic protocol to maintain peripheral perfusion and organ function.
- Actuarial survival analysis at 30 months for different patient groups.
Main Results:
- Actuarial survival at 30 months was 75% for terminally ill patients and 67% for less critically ill patients.
- Combined actuarial survival for 77 patients was 67% at 30 months.
- Of 33 critically ill patients, 29 were alive and active by January 1985.
Conclusions:
- Cardiac transplantation can be successfully performed in terminally ill patients with severe hemodynamic compromise.
- A dedicated therapeutic protocol is crucial for stabilizing critically ill patients awaiting transplantation.
- Expanded selection criteria improve outcomes for a broader range of end-stage heart failure patients.
Abstract:
Cardiac transplantation was resumed in 1980 at the University Health Center of Pittsburgh. Generally accepted criteria for selection of patients were used, one being the expectation that survival would not reach 6 months. All of the initial recipients were in New York Heart Association Functional Class IV, but many were ambulant. We soon saw patients who were more clearly terminally ill. They were characterized by a systolic arterial pressure of less than 80 mm Hg, a cardiac index of less than 2 L/min/m2, evidence of reduced blood flow as indicated by urine output of less than 20 ml per hour, impaired mental function, and signs of decreased peripheral perfusion. The initial success of cardiac transplantation in these patients prompted us to reconsider selection criteria to include them among less strikingly ill candidates and to develop a therapeutic protocol designed to maintain peripheral perfusion and adequate renal and hepatic function until transplantation could be accomplished. Actuarial survival at 30 months for the group of terminally ill patients was 75% compared with 67% for the less critically ill group. Actuarial survival at 30 months for the combined group of 77 patients was 67%. Twenty-nine of the 33 mortally ill patients were alive and active at the time of writing, January, 1985.