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An Imperfect Donor Heart Beats No Heart at All

Experts urge relaxing standards to increase transplants

TUESDAY, July 30, 2002 (HealthDayNews) -- With potential heart transplant recipients dying every day because donor organs are not available, the American Heart Association is recommending relaxing some of the rules for what constitutes a transplantable heart.

For example, many centers automatically reject a heart if the donor is over 55. Those hearts should be assessed to determine whether they can be used, says a report by an expert panel appearing in today's issue of Circulation: Journal of the American Heart Association.

Other hearts are rejected because ultrasound shows thickening of the muscle. Maybe a little more thickening should be acceptable, the panel suggests.

And current requirements say that a heart from a man over 45 or a woman over 50 should undergo an angiography examination to be sure that its arteries are clear. Often, a heart is rejected because no cardiologist is available to do the angiography. Such a heart could be used without the test if the donor had no risk factors for heart disease and it matched a donor in urgent need of a transplant, the experts say.

"We know that perfectly good hearts in that age range are rejected because this examination was not performed," says Dr. Jonathan G. Zaroff, co-chair of the meeting from which the recommendations emerged. He is director of the coronary care unit at the University of California, San Francisco.

The list of recommendations is long: Instead of rejecting a heart from a hepatitis-infected person, it should be given to a similarly infected individual. Instead of discarding a heart with a minor valve problem, the fault could be corrected surgically before the heart is implanted. And a heart that has been under stress in the last hours of life might be given treatment to make it transplantable, rather than being automatically discarded.

"Implementing these new recommendations could increase heart donations," Zaroff says. "We think that if the new recommendations are implemented throughout the United States, we are hopeful that an additional 400 to 800 donor hearts could be transplanted with good recipient results."

These are "good proposals," says Dr. O.H. Frazier, director of cardiopulmonary transplantation at the Texas Heart Center and chairman of the thoracic transplant committee of the United Network for Organ Sharing (UNOS), which oversees transplants in this country.

But he adds that his attention is focused on a different problem, one acknowledged by the heart association experts: a majority of the donor hearts that now become available never get to a recipient.

In 2001, 5,296 hearts became available in this country and only 2,275, or 43 percent of them, were transplanted, Frazier says.

There are many reasons behind those numbers, he says. One is time: a liver can wait 24 hours to be transplanted, a kidney 48 hours. The window for a heart is only 12 hours. That means the pool of potential recipients is limited by geography.

Size is another problem. You can't put a very small heart into a very large person, and vice versa, says Frazier, who has done more than 800 transplants since 1982.

He has good words for the heart association committee. "They have done wonderful work in trying to maximize the supply of donor hearts," he says. "But in addition to this, we must concentrate on meeting the logistical problems of proper placement. It's different for the heart than for the kidney or liver. The issues are much more complex."

But Zaroff says that changing just one current rule could increase the results substantially. More than a quarter of all rejections now are based on poor contractile function of the donor heart, he says, and work in England has shown that perhaps 80 percent of those hearts can be harvested after resuscitation, with "excellent" results when they are transplanted.

A spokesperson for UNOS says the organization is modifying its "critical pathway" rules for assessing potential donor hearts, taking the heart association recommendations into consideration.

What To Do

You can learn about heart transplants from the American Heart Association and about transplant donation in general from the United Network for Organ Sharing.

SOURCES: Jonathan G. Zaroff, M.D., assistant professor of medicine, and director, coronary care unit, University of California, San Francisco; O.H. Frazier, M.D., director of cardiopulmonary transplantation, Texas Heart Center, Houston; July 30, 2002, Circulation: Journal of the American Heart Association
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