Heart Transplant Paradox: Long Waiting List but Declining Donor Heart Acceptance by Hospitals

Heart failure requiring transplantation is on the rise internationally. However, there is a new paradox that has cropped up in the USA. Despite the increasing heart failures the acceptance of hearts by transplanting centers is declining. This means more patients are dying on the waiting list.

In a new study published in the American Journal of Transplantation titled “National decline in donor heart utilization with regional variability: 1995–2010,” the authors Kiran K. Khush, Jonathan G. Zaroff, John Nguyen, Rebecca Menza, and Benjamin A. Goldstein observe a striking decline in the use of available donor hearts for transplantation in many regions. The paper is to be published online on 10 February 2015.

“We, as a heart transplant community, are using a small fraction of available donor hearts for transplantation, and we have become more conservative over the past 15 to 20 years in terms of donor heart acceptance,” says lead author Dr. Kiran Khush, MD, MAS, of the Stanford University School of Medicine. Dr. Khush observes that this finding is troubling given the national donor heart shortage and a growing number of critically ill patients awaiting heart transplantation.

In this study, Dr. Khush and her colleagues examined and analyzed national trends in donor heart acceptance for transplantation by analyzing data from the Organ Procurement and Transplantation Network for all potential adult cardiac organ donors between 1995 and 2010. There was a significant decrease in donor heart acceptance from 44 percent in 1995 to 29 percent in 2006, and subsequent increase to 32 percent in 2010. Older donor age, female sex, and medical conditions predicted non-acceptance of hearts from donors. Donor age and medical conditions increased over time, with an associated decrease in acceptance of hearts from donors with undesirable characteristics.

The analysis also demonstrated regional variability in donor heart utilization across the United States, showing that some regions have been using a relatively higher proportion of donor hearts than others. This suggests that donor heart acceptance practices are not standardized and indicates a need for clinical guidelines for donor heart acceptance, along with more intense efforts to increase the use of donor hearts in areas with relatively low utilization rates.

The investigators note that government agencies have a very high level of scrutiny of transplant centers and this may have the unintended consequence of making transplant centers more “risk averse” and consequently less likely to use marginal donor hearts for transplantation.

In an exclusive interview with Medindia, Dr. Kiran Khush shared insights from the study.

Excerpts from the interview:

Is this an international trend or just happening in the USA?
This study solely examined donor heart acceptances practices in the USA from 1995-2010; as such, we are unable to comment on data from non-US countries.

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Are there any acceptable guidelines for accepting hearts in the USA?
There are currently no standardized, evidence-based donor heart acceptance guidelines in the US. This is largely due to the lack of adequately-powered and well-designed research studies on donor heart suitability for transplantation. As such, currently donor heart acceptance criteria are often transplant center-specific.

Is there a bit of defensive medicine here by transplant centers fearing the outcomes from marginal hearts?
Yes, as mentioned in the Discussion of the manuscript, there is heavy scrutiny of transplant center outcomes by CMS (Centers for Medicare and Medicaid Services) and insurance carriers, such that transplant centers with higher-than-expected mortality may be placed on “probation” or may have insurance contracts revoked. This in turn can make transplant centers “more conservative” in terms of donor heart acceptance, as they avoid donors with one or more high-risk features, thereby reducing use of available donor hearts—a valuable and increasingly scarce resource.

Commenting on this study, Dr. Sumana Navin, Course Director of MOHAN Foundation, an NGO that works for promoting organ donation in India said that, “The scenario is even worse in India, as there is less than 10% utilization of hearts. However, in Tamil Nadu, the utilization was 30% in 2014” She also added that, “at present only heart valves are used and most hearts are wasted as there are no proper waiting lists and hospitals seldom run heart failure clinics.”

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India’s leading heart transplant surgeon, Dr. K R Balakrishnan, Director - Cardiac Sciences at Fortis Malar, Chennai said that “There is a reluctance to accept anything but a ‘perfect’ organ in many centres in the world which results in wastage.” He also added, “We have been more aggressive in India and accepting marginal donors and support the organ after the transplant, if needed, on ECMO (extracorporeal membrane oxygenation) for a few days.”

Recently Dr. Balakrishnan and his team helped save the life of a critically ill Russian toddler Gleb Kudriavtsev who received a heart transplant in Fortis Malar, Chennai. Gleb had been waiting for a donor and on 18 December, 2014 the team at Fortis received a donor alert from Manipal hospital, Bangalore. A team evaluated the heart and it was harvested and finally airlifted via a charter flight to Chennai. The transplantation surgery took place successfully on 19 December.

Newer techniques to improve the quality of the organ outside the body are still in the experimental stage and much research is required before it is acceptable to the transplanting community.