Advanced medical therapy does not render heart transplantation obsolete for ambulatory end-stage heart failure patients: a debate.

A definition of advanced medical therapy for end-stage heart failure is a complex concept. In my mind, it includes not only the proven pharmacotherapy, but also implies a persistent individualized effort on the part of caregivers and educators to optimize each patient. Thus, optimally, when a patient reaches the “end stage,” he has been followed by a true expert in heart failure management who has treated him over the course of the natural history of his disease with digitalis, diuretics, an angiotensin-converting enzyme (ACE) inhibitor and/or an angiotensin receptor blocker, aldactone, and carvedilol or a beta-blocker. He has had frequent visits to a clinic specializing in heart failure, and he has received special education that enables him to be a good patient and adjust his own therapy. Unfortunately, cardiologists see only 17% of the heart failure population in the USA (data from the American Heart Association) and there are very few dedicated heart failure clinics. This leaves the average end-stage heart failure patient in a difficult situation. Also, it raises some doubt as to the hypothesis that all end-stage heart failure ambulatory patients can be better treated with medical therapy than with transplantation. Most ambulatory end-stage patients are unlikely to be in an advanced heart failure program. Thus, much that is written of these programs serves as a model, but is not a true description of the end-stage ambulatory patient population in the USA. The proposition that transplantation is “obsolete” in end-stage ambulatory patients implies that survival and lifestyle in this group of patients at this stage in their natural histories are equal to survival and lifestyle of cardiac recipients. For lifestyle, the claim is over-inflated because we know that 80% to 90% of cardiac recipients return to New York Heart Association (NYHA) functional class I. In addition, we all have witnessed “supernormal” physical performance in some inspired cardiac recipients that, by definition, could never be possible in end-stage heart failure patients. Ambulatory end-stage heart failure patients in functional class III or IV or in United Nations Organ Sharing (UNOS) class II cannot return to supernormal physical activity in the absence of a miraculous cure. Only by changing their class due to spontaneous remission or improved medical therapy can they return to limited or normal activity. Of course, in any large group of ambulatory heart failure patients, some will do well. In 1990, a study was published1 suggesting that exercise capacity in cardiac recipients and heart failure patients on sustained medical therapy is about the same with peak oxygen consumption in the range of 16 to 17 ml/kg per minute. Unfortunately, the implications of this report are limited by the method of selection of the medical patients. Twenty (14% of the initial group) 6-month survivors of medical therapy were selected from an initial group of 146 heart failure From the University of Arizona Sarver Heart Center, Tucson, Arizona, USA Submitted August 16, 2000; accepted November 29, 2000. Reprint requests: Jack G. Copeland, MD, Cardiothoracic Surgery, University of Arizona Sarver Heart Center, 1501 North Campbell Avenue, #4402, Tucson, Arizona 85724-5071. Telephone: 520-626-6339. Fax: 520-626-4042. E-mail: jgc@ u.arizona.edu J Heart Lung Transplant 2001;20:725–728. Copyright © 2001 by the International Society for Heart and Lung Transplantation. 1053-2498/01/$–see front matter PII S1053-2498(01)00247-9