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Physicians listing patients for heart transplant weigh many considerations
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Patients who are candidates for heart transplantation, and particularly ambulatory patients, often present practitioners with a variety of factors that must be carefully evaluated before listing them, according to a presentation.
According to Mandeep S. Mehra, MD, professor of medicine at the University of Maryland Medical Center in Baltimore, said that cardiologists and practitioners should not only try to adhere to guidelines but should also ask themselves certain guiding questions when considering whether or not to list patients as candidates for heart transplantation.
“As you are considering which patients are to be listed for transplantation, you must ask yourselves if the patient really needs a heart transplant and if they will tolerate the transplant,” Mehra said in his presentation. “Are there competing comorbidities that may influence outcomes for the adverse? Can the ambulatory-listed patient be delisted for cardiac transplantation?”
Mehra said that some tests for potential transplant candidacy like that of pulmonary stress testing may have “undue emphasis” placed upon them; in certain subsets of young patients and in women, other tests such as predicted oxygen consumption could be more appropriate. Mehra also said that one should look to HF survival scores when looking at subsets of prognostic indicator tests.
“One of the critical issues is that whenever there is some kind of discrepancy, particularly for ambulatory patients with advanced HF, one should really consider strongly employing the survival scores that are more standardized,” Mehra said. “It can become difficult at times when you are discussing the need for cardiac transplantation with different colleagues.”
Safety and societal concerns
Another issue Mehra focused on was the safety of patients listed for transplantation. In particular, Mehra noted that a key factor one must consider when listing a patient for transplantation is pulmonary-vascular resistance.
“We know from various series of data that there is the clear discrepancy and an early loss, if you will, in discrimination of outcomes when the pulmonary-vascular resistance at the time of transplantation is high or low,” Mehra said.
Comorbidities, such as cancer within five years prior to transplantation, are also important considerations when listing patients as candidates for transplantation. Although modern cancer treatments like chemotherapy have allowed the status of some patients to change, a practitioner must consider whether exposure to those treatments could heighten the risk for interactions with the transplant and influence potential outcomes.
Another common comorbidity that potential transplant candidates commonly present with is renal dysfunction. Mehra emphasized that it must be evaluated before determining whether or not to list a patient.
“To tackle this situation, first we should perhaps abandon the use of the simple parameter of serum creatinine and move toward more clearly established parameters such as an estimated glomerular filtration rate or creatinine clearance,” Mehra said. “Also, before listing for cardiac transplantation, intrinsic renal disease should likely be excluded.”
Mehra said that a dynamic listing process and allocation criteria were crucial in making determinations about who should receive transplants. The societal implications of allocating hearts are complicated, Mehra noted, and require a working allocation system that could assist physicians in making such determinations.
“One has to be very serious about listing for transplantation,” Mehra said. “There is a notion that this is a scarce resource only to be allocated in those who would derive benefit.” – by Eric Raible
For more information:
- Mehra M. #1344.
- Presented at: American Heart Association Scientific Sessions; Nov. 8-12, 2008; New Orleans.