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Crisis Awaiting Heart Transplantation Sinking the Lifeboat

Lynne Warner Stevenson, MD1
[+] Author Affiliations
1Advanced Heart Disease Section, Heart and Vascular Center, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Intern Med. 2015;175(8):1406-1409. doi:10.1001/jamainternmed.2015.2203.
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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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Figure 1.
Waiting List for Heart Transplants in the United States, 2005-2014

The total number of patients on the list during a year is the sum of patients carried over from the previous year and the number of patients newly listed minus the number of patients who undergo heart transplant or are removed from the list for other reasons. The consistent discrepancy between the number of patients listed and the number of heart transplants performed has resulted in an “oversold” situation and a gradual increase in the length of the list. Data are from the United Network of Organ Sharing.3

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Figure 2.
Distributions of Patients on the Waiting List for Heart Transplants and of Transplant Recipients by Priority Status

Bar graph indicates the distribution by priority status for patients on the waiting list and for patients who actually received donor hearts. The highest status is 1A, accounting for the majority of patients transplanted. Data are derived from United Network of Organ Sharing.3

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Figure 3.
Allegory of Triage for Patients With End-Stage Heart Failure

More patients are being loaded onto the lifeboats for transplantation than can be saved with donor hearts, and the waters are treacherous. The hot-air balloons offer immediate support in the form of durable ventricular assist devices (VADs) and hope of joining the lifeboats later as they empty out; many patients with VADs survive to transplantation, whereas others die or become ineligible. More modern aircraft are always hovering at the horizon. Although many patients are escorted onto the deck for assignment to lifeboats or hot-air balloons, there are also alternative approaches to supporting good quality of life for as long as possible, and all journeys are uncertain (conception: L.W.S.; artist: Caroline Devereaux).

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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