Ethical implications of heart transplantation in elderly patients

T he results of cardiac transplantation in patients over 69 years of age reported by Blanche and associates [J Thorac Cardiovasc Surg 2001;121:532-41] demonstrate that short-term survival can be achieved in a very select, small group of such patients. As the authors have stated, the statistical comparison of this small group of older patients to younger recipients is problematic because the selection process was not uniform for both groups of patients. These data do not justify the elimination of older age as a selection criterion for cardiac transplantation, because most reports identify increased recipient age as a risk factor for post-transplantation mortality. Expanding the upper age limit will result in a further distortion of the current recipient demand/donor supply dilemma and will produce an increased mortality for all patients awaiting cardiac transplantation. The article by Blanche’s group does raise many important moral, ethical, and practical issues related to the treatment of patients with end-stage heart disease. The concept of an alternative list for older patients seems rational but in turn introduces many theoretical and practical concerns. Use of marginal donor hearts for high-risk recipients seems likely to result in reduced recipient survivals both in the immediate post-transplantation period and in the long term. The actuarial survival for patients after all other cardiac surgical operations is influenced by the age of the patient, and there is no logical reason why cardiac transplantation should be different. There are also factors associated with long-term immunosuppression in older patients that could be expected to adversely influence survival and quality of life. The number of cardiac donors in this country has remained static over the past 10 years despite intense efforts at public education and the aggressive expansion of acceptable donor criteria. Therefore, some upper age limit must be used to prevent further increases in mortality rates for patients awaiting transplantation. Moreover, the upper age limit used by most programs is merely a guideline for selection. Age alone rarely disqualifies patients from consideration. Chronologic age certainly does not strictly correlate with physiologic age in every case. The challenge for transplant physicians is to establish objective parameters that accurately predict the recipient’s response to the trauma of the operation and the need for lifelong immunosuppression. The development of more specific immunosuppressive drugs and the establishment of effective immune tolerance protocols have the potential of reducing the complications associated with immunosuppression that seem to be more frequent and severe for elderly patients. The future implementation of immunosuppressive strategies based on pharmacogenomics may permit the customization of drug therapy guided by the patients’ genetic profiles and would be particularly beneficial for elderly patients. Society must balance the issue of reducing death on the waiting list with survival outcome after transplantation. The expansion of the donor supply with the use of marginal hearts could reduce the chance of death for patients awaiting transplantation. If the results of marginal donor hearts used for transplantation in patients on alternative lists are comparable with the current results with nonmarginal donor hearts, then those hearts should be used for the lower-risk patients who are currently dying on the regular waiting list. The reality is that for the foreseeable future the From the Department of Cardiothoracic Surgery, Stanford University School of Medicine, Falk Cardiovascular Research Center, Stanford, Calif.