Heart transplant is the best treatment for people with end-stage heart failure. Unfortunately, there aren’t enough donor hearts to go around. Many patients die waiting for one.
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But Cleveland Clinic heart transplant specialist Eileen Hsich, MD, has proposed a way to fix the problem. She recently published her recommendations in the medical journal Circulation: Heart Failure.
“There are three parts,” she says. “And we need to do them all at once to be successful.”
Dr. Hsich recommends:
1. Using more organs from “high-risk” donors
Usually, ideal heart donors are younger than age 40 and don’t have any of the following:
- Coronary artery disease
- Structural heart disease
- Human immunodeficiency virus (HIV)
- Hepatitis B or C
- A history of high-risk behavior, such as drug abuse
“Today, we refuse two-thirds of organs because donors don’t meet ideal criteria,” says Dr. Hsich. “This isn’t always necessary.”
Instead of discarding these organs, Dr. Hsich suggests categorizing them as either:
- High-risk, yet usable. For instance, organs from donors with a history of drug use are considered “high risk.” However, risk of getting an infection from a donated heart is less than 1 percent. And other factors may not be as risky as once thought. While diabetes is concerning in male donors, for example, it isn’t in female donors.
- Questionably marginal. Organs are “marginal” when they come from donors older than age 50, with high blood pressure or several other characteristics. But Dr. Hsich notes that there is no proof that these hearts don’t perform well. Just the opposite: Studies show that certain marginal hearts can be restored for a successful transplant.
Some high-risk or marginal hearts may be as good as “ideal” hearts for patients in need. Although the best option is to register more ideal donors, an alternative for immediate improvement in our system is to better use what we have, Dr. Hsich notes.
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2. Shortening the wait list
“The lifeboat will sink if it attempts to hold everyone,” says Dr. Hsich. “We need to set higher standards for getting on the transplant wait list.”
She knows it won’t be easy. But data can help. For example, stats show that people who have kidney disease or use tobacco don’t fare as well with a heart transplant. A ventricular assist device (VAD) could be just as helpful for these patients.
“More people should consider a VAD instead of seeking a heart transplant,” says Dr. Hsich.
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3. Improving how donor hearts are distributed
Women and Hispanics are more likely to die on the wait list than men and whites. Same with patients in certain parts of the U.S.
The Organ Procurement and Transplantation Network has proposed changes to address these and other disparities. It recommends ways to give more transplants to people who need them most urgently.
RELATED: Heart Transplant Recipients Help Others on the Wait List
Eventually we need to create an allocation score, like the one used for lung transplants, says Dr. Hsich. Doing this would be a huge task, however, given all the factors that determine a heart patient’s risk.
“There isn’t just one way to improve our heart transplant system,” says Dr. Hsich. “It will take a combination of increasing the donor pool, reducing the wait list and improving the allocation system.”