The decline in heart transplantation in the UK
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2483 (Published 05 May 2011) Cite this as: BMJ 2011;342:d2483
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We read with interest the view of four Newcastle clinicians on how
the UK advanced heart failure service should respond to reducing heart
transplantation (HTx) activity(1). They suggest that (i) that left
ventricular assist devices(LVADs) should subsume the role of HTx as a
destination therapy (ii) that HTx should be restricted to those unsuitable
for LVADs and (iii) that HTx units should be reduced in number. We beg to
differ.
The restraint of donor heart availability has always meant that HTx
could never be a treatment that could deal with the epidemic of heart
failure associated with increasing age(2). HTx has achieved best outcomes
in carefully selected patients with limited co-morbidity(3). Although the
survival following LVAD support as 'destination therapy' is superior to
medical therapy alone in selected patients with advanced heart failure, it
remains substantially inferior to those achieved by HTx and the morbidity
burden (which includes stroke and chronic infection of the implanted
device) is high. Overall survival at 2 years, in patients committed to
destination therapy is now 58%, with improvements largely due to the use
of continuous flow devices rather than older pulsatile pumps (4-6). In,
contrast 2 year survival for heart transplantation exceeds 75% and median
post-transplant survival is 10 years(7) and often higher(8). Therefore,
LVADs cannot yet subsume the role of HTx and suitability for LVAD support
should not be a selection criterion that allows patients with advanced
heart failure who are otherwise suitable for transplant to be denied the
superior therapy. The authors suggest that LVAD destination therapy should
represent a simple alternative to transplant; in contrast, ineligibility
for transplantation with stringent selection criteria is the recommended
policy extant in countries in which LVAD destination therapy is funded(4,
9). For destination therapy to be approved in the UK, commissioners must
be certain of benefit and effectiveness and must identify a funding
envelope that can accommodate an increase in LVAD activity in advanced
heart failure management that would no longer be restrained by donor
availability. In the UK, HTx is currently, only one treatment option
considered by designated advanced heart failure units among other options
including cardiac resynchronization and use of LVADs as a 'bridge' to
subsequent transplantation(10). A change of relative activity between
treatment modalities is not a good argument for provider changes if the
prevalence of the condition is stable or increasing. However, skill
maintenance and recruitment of surgeons capable of HTx is a definite
challenge in the era of the European Working Time Directive.
The crux of the crisis in UK heart transplantation is not the role of
LVADs but our inability to generate more usable donor hearts from the
potential donor pool. Our rate of transplantation per million of
population is four-fold lower than our best-performing international
peers(7). The reasons for this differential activity are unclear but
include in different countries (i) the use presumed consent (ii) the use
of trigger points to ensure brain death testing (iii) required requesting
for donation and (iv) differences in critical care bed numbers. We hope
that the differences do not simply reflect lower levels of altruism in the
UK than elsewhere. In response to the Organ Donation Taskforce Report, the
number of specialist nurses (organ donation) has increased markedly but
the major effect has been an increase in donation after cardiac death not
an increase in donors following brain death (DBD), the source for
transplantable hearts. The specific issues preventing an increase in DBD
donors should be revisited by a reconvened Taskforce.
The current national conversion rate of heart offers to transplants
is relatively low and there is variation between regions. We must ensure
that every possible donor heart is rigorously scrutinized before being
declared unsuitable for transplant. As the donor population becomes older,
the need to investigate donors for coronary artery disease increases and
such assessment needs to become normal rather than exceptional during the
donation process. In addition, there is robust evidence that transplant
team involvement in heart assessment and at an early stage in donor
management increases the likely yield of organs acceptable for
transplant(11, 12). This involvement must be promoted nationally by
organizational changes that re-couple allocation and retrieval to ensure
that apparent marginal heart is fully assessed and by addressing every
issue that frustrates activity.
We owe it to our potential transplant recipients to increase
activity; we owe it to our organ donors and their families to maximize the
benefit of their altruism.
Yours faithfully,
Robert S Bonser MD FRCP FRCS Professor and Consultant Cardiothoracic
& Transplant Surgeon, University Hospital Birmingham NHS Trust,
Edgbaston, Birmingham, B15 2TH
Nicholas R Banner MB FRCP Consultant Cardiologist & Transplant
Physician, Royal Brompton and Harefield NHS Trust, Hill End Road,
Harefield, Middlesex UB9 6JH
Martin Carby MD FRCP Consultant Chest & Transplant Physician,
Royal Brompton and Harefield NHS Trust, Hill End Road, Harefield,
Middlesex UB9 6JH
Saleem Haj-Yahia BSc MD, FRCS, Consultant Cardiothoracic &
Transplant Surgeon, Lead Consultant for Transplantation & Artificial
Heart Surgery Deputy Director for The Scottish National Advanced Heart
Failure Services, The Golden Jubilee National Hospital
Glasgow, Scotland, G81 4HX
Clive Lewis, MB BChir MRCP PhD FFICM, Consultant Cardiologist &
Transplant Physician, Papworth Hospital NHS Trust, Papworth Everard,
Cambridge CB23 3RE
Sern Lim MD MRCP Consultant Cardiologist & Transplant Physician,
University Hospital Birmingham NHS Trust, Edgbaston, Birmingham, B15 2TH
Jorge Mascaro MD, FRCS Consultant Cardiothoracic & Transplant
Surgeon, University Hospital Birmingham NHS Trust, Edgbaston, Birmingham,
B15 2TH
Jayan Parameshwar MD FRCP, Consultant Cardiologist, Deputy Director
of Transplant Service, Papworth Hospital NHS Trust, Papworth Everard,
Cambridge CB23 3RE
Mark Petrie FRCP FESC, Consultant Cardiologist, Director of the
Scottish National Advanced Heart Failure Service, Golden Jubilee National
Hospital, Glasgow, G81 4HX
Marlene L. Rose PhD, FRCPath, Professor of Transplant Immunology,
Imperial College London and Director of Histocompatibility and
Immunogenetics Laboratory, Harefield Hospital, Harefield, Middlesex, UB9
6JH
Andre Simon MD PhD, Director of Transplantation and Consultant
Cardiothoracic Surgeon, Royal Brompton and Harefield NHS Trust, Hill End
Road, Harefield, Middlesex UB9 6JH
John N Townend MD FRCP, Consultant Cardiologist and Transplant
Physician, University Hospital Birmingham NHS Trust, Edgbaston,
Birmingham, B15 2TH
Stephen Tsui MD FRCS, Consultant Surgeon, Director of Transplant
Service, Papworth Hospital NHS Trust, Papworth Everard, Cambridge CB23 3RE
Rajamiyer Venkateswaran MS, MD, FRCS(C/Th) Department of Heart &
Lung Transplantation, University Hospital South Manchester NHS Foundation
Trust, Wythenshawe hospital, Southmoor Road, Manchester, M23 9LT
Simon G Williams MD MRCP, Consultant Cardiologist, The Transplant
Centre, Wythenshawe Hospital, University Hospital of South Manchester NHS
Foundation Trust, Manchester, M23 9LT
Ian C Wilson MD, FRCS Consultant Cardiothoracic & Transplant
Surgeon, University Hospital Birmingham NHS Trust, Edgbaston, Birmingham,
B15 2TH
Nizar Yonan MD, FRCS(C/Th) Professor and Consultant Cardiothoracic
Surgeon, Director, Department of Heart & Lung Transplantation,
University Hospital South Manchester NHS Foundation Trust, Wythenshawe
hospital, Southmoor Road, Manchester, M23 9LT
1. MacGowan GA, Parry G, Schueler S, Hasan A. The decline in heart
transplantation in the UK. Br Med J. 2011;342.
2. Evans RW, Manninen DL, Garrison LP, Maier AM. Donor availability
as the primary determinant of the future of heart transplantation. J Am
Med Assoc. 1986;255:1892-8.
3. Mancini D, Lietz K. Selection of cardiac transplantation
candidates in 2010. Circulation. 2010;122:173-83.
4. Kirklin JK, Naftel DC, Kormos RL, Stevenson LW, Pagani FD, Miller
MA, et al. Third INTERMACS Annual Report: The evolution of destination
therapy in the United States. J Heart Lung Transpl. 2011;30:115-23.
5. Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman
D, et al. Advanced heart failure treated with continuous-flow left
ventricular assist device. New Engl J Med. 2009;361:2241-51.
6. Strueber M, O'Driscoll G, Jansz P, Khaghani A, Levy WC,
Wieselthaler GM, et al. Multicenter evaluation of an intrapericardial left
ventricular assist system. J Am Coll Cardiol. 2011;57:1375-82.
7. Stehlik J, Edwards LB, Kucheryavaya AY, Aurora P, Christie JD,
Kirk R, et al. The Registry of the International Society for Heart and
Lung Transplantation: Twenty-seventh official adult heart transplant
report--2010. J Heart Lung Transpl. 2010;29:1089-103.
8. Hamour IM, Khaghani A, Kanagala PK, Mitchell AG, Banner NR.
Current outcome of heart transplantation: a 10-year single centre
perspective and review. . Quart J Med. 2011;104:335-43.
9. Dickstein K, Vardas PE, Auricchio A, Daubert J-C, Linde C,
McMurray J, et al. 2010 Focused Update of ESC Guidelines on device therapy
in heart failure. Eur Heart J. 2010;31:2677-87.
10. Miller LW, Pagani FD, Russell SD, John R, Boyle AJ, Aaronson KD,
et al. Use of a continuous-flow device in patients awaiting heart
transplantation. New Engl J Med. 2007;357:885-96.
11. Venkateswaran RV, Steeds RP, Quinn DW, Nightingale P, Wilson IC,
Mascaro JG, et al. The haemodynamic effects of adjunctive hormone therapy
in potential heart donors: a prospective randomized double-blind
factorially designed controlled trial. Eur Heart J. 2009;30:1771-80.
12. Dark JH. More and better donors for cardiac transplantation. Eur
Heart J. 2009;30:1690-1.
Competing interests: No competing interests
Sir,
The Newcastle Group (1) highlighted the reduction in heart transplantation
in the UK, not seen amongst our international comparators, and focussed on
the availability of organs and mechanical assist therapies as potential
solutions.
We feel a more important issue is the state of standard "care" for
patients with heart failure (HF) in the UK. Other markers of advanced
care such as device implantation rates are also much lower in the UK. To
receive the advanced (but rationed) therapies for HF, patients have to be
referred, and to be referred they need to see a cardiologist. In the UK we
have yet to manage the first step adequately.
The National Heart Failure Audit for England and Wales reported (2) a 30%
one year mortality for patients admitted with HF in 2009-10 with an in-patient case fatality rate of 10%, considerably worse than in the US or
Europe, where in-patient mortality rates are between 4 and 6.8%.
Only about half of patients admitted in the UK with HF see a cardiologist;
such care is independently associated with a lower in-hospital mortality
rate of 6% versus 12% and a 12 month mortality of 16.2% versus the 32% for
those receiving general medical care.2 Patients admitted under cardiology
received better disease-modifying treatment and were more likely to have
heart failure specialist follow up.
Several initiatives are addressing the problem; the arrival of a
Subspecialty Training Module in Heart Failure, the British Cardiovascular
Society (BCS) initiative for configuration of Coronary Care Units as
Cardiac Care Units to allow wider access for HF patients, updated 2010
NICE guidance which mandates access to a HF Specialist at diagnosis,
during hospitalisation and when severe HF develops, and the imminent NICE
Quality Clinical Standards (and Scottish equivalent) should improve the
standard of care further. Ultimately the creation of Heart Failure Units
might be the best way of delivering optimal care to acute HF patients.
Current European and BCS Standards specify that patients with HF should
have access to a comprehensive service including a consultant cardiologist
who can access transplantation. The reduction in heart transplantation in
the UK is merely a powerful barometer of the overall standard of HF care,
rather than an isolated advanced HF issue. Although providing complex and
high-cost advanced HF care in the safest and most cost effective manner
may mean a reduction in the number of units providing cardiac
transplantation, improved routine HF care may lead to a rise in the demand
for advanced therapies. Indeed, the number of patients on the transplant
waiting list has increased over the last twelve months and is higher than
for the last 10 years (Fig 1).
Providing wider access of heart failure patients to cardiologists might go
a long way to resolving this unmet need.
Theresa A McDonagh Chair BSH,
Andrew L Clark Deputy Chair BSH,
John Cleland Past Chair BSH,
Henry J Dargie Past Chair BSH,
Suzanna M Hardman Chair-Elect BSH.
References
1. Macgowan GA, Parry G, Schueler S, Hasan A. The decline in heart
transplantation in the UK. BMJ 2011;342:d2483. doi: 10.1136/bmj.d2483
2. The national heart failure audit for England and Wales 2008-2009
JG Cleland, T McDonagh,, AS Rigby, A Yassin, T Whittaker,HJ Dargie, on
behalf of the National Heart Failure Audit Team for England and Wales.
Heart. 2011;97(11):876-886.
The decline in heart transplantation in the UK
Competing interests: No competing interests
Having noted the increase in UK organ donor numbers in recent years,
the authors ask why this has not translated into an increase in heart
transplantation.
Part of the answer to this question is that there are actually fewer
donated hearts available for transplantation due to increasing donation
after cardiac death (DCD) activity in the UK over the same period (2000 -
2010)(1). During this time numbers of donors after brain death (DBD) have
fallen by 15% while numbers of DCD donors have risen more than 900%. The
increase in donor numbers is due to an increase in DCD donors who now
constitute 35% of all deceased donors. Hearts for transplantation are not
retrieved during DCD in the UK.
Comparisons to the US are made, showing relatively constant annual
numbers of heart transplants from 2000 - 2008. However there has not been
a corresponding fall in heart availability in the US: DBD activity has
increased by 22% during this period (2). Although DCD numbers have
increased more than 700%, they still constitute only 10.6% of all US
deceased donors.
Of course this does not explain all of the decrease in adult heart
transplantation activity (paediatric transplantation has remained
constant) in the UK over the last 10 years. There may be other factors
that have an impact on the numbers of transplants performed. We know, for
instance, that there are 7% fewer patients on the active heart transplant
list than in 2001(1).
The authors make the point that heart transplantation and ventricular
assist (both as a bridge to transplant and as destination therapy) are
effective therapies that should be made available to adults with end stage
heart failure. However the decline in UK transplantation activity is at
least partly due to changes in organ donation patterns that will not be
solved by more intensive care unit beds.
References
(1)NHS blood and transplant annual report 2009/10. Transplant
activity in the UK.
www.organdonation.nhs.uk/ukt/statistics/transplant_activity_report/curre....
(2)2009 OPTN/SRTR Annual Report 1999-2008.
http://optn.transplant.hrsa.gov/ar2009/201_don-non-hr-beat_dc.htm
The data and analyses reported in the 2009 Annual Report of the U.S. Organ
Procurement and Transplantation Network and the Scientific Registry of
Transplant Recipients have been supplied by UNOS and Arbor Research under
contract with HHS/HRSA. The authors alone are responsible for reporting
and interpreting these data; the views expressed herein are those of the
authors and not necessarily those of the U.S. Government.
Competing interests: No competing interests
Re:The decline in heart transplantation in the UK.
19/7/2011
Dear Editor,
We write in response to several rapid responses to the above editorial
(1). McDonagh and colleagues from the British Society of Heart Failure
call for more specialised care of heart failure in general, and we wholly
support this. In particular, for transplant and ventricular assist device
centres to survive and be relevant, they must be closely integrated with
specialised heart failure care units. Dr Millar states that fewer donor
hearts are available because of changing donation practice, and this point
is well received.
We fully agree with Bonser and colleagues that all transplant centres
should endeavor to increase the number of donor hearts accepted for
transplantation and a number of initiatives aimed at achieving this have
been implemented in Newcastle. The focus of our editorial however, was how
to manage patients with advanced heart failure in the current situation of
few heart transplants. The facts are, that even since writing this
editorial, numbers of heart transplants have decreased even further - for
this financial year as of the 8th July 2011 the number of heart
transplants are down 13% compared to last year, and the number of patients
on the waiting list has increased by 12%
(http://www.uktransplant.org.uk/ukt/statistics/downloads/stats_080711.pdf
www.uktransplant.org). We suggest a re-evaluation of the currently
available modes of advanced heart failure management with one proposition
for example that the current gold standard (i.e. transplantation)
prioritised for those patients in whom ventricular assist devices are
unsuitable. Adequate long term funding for ventricular assist devices in
those patients who are deemed to be suitable candidates for heart
transplantation but cannot receive a heart because of the limited supply
of donors is urgently needed.
In an effort to treat as many suitable patients as possible with
advanced heart failure (including adult congenital patients), we must
utilize both ventricular assist devices and transplantation, and be
prepared to adapt to changing trends in heart transplantation rates and
ventricular assist device technology.
Guy A. MacGowan, Gareth Parry, Stephan Schueler, Asif Hasan
References:
1. MacGowan GA, Parry G, Schueler S, Hasan A. The decline in heart
transplantation in the UK. BMJ 2011;342:d2483. doi: 10.1136/bmj.d2483
Competing interests: No competing interests