Care and experience can ensure stunning survival rates

Since 1967, 65,000 heart transplants have been carried out all over the world, according to the Registry of the International Society for Heart and Lung Transplantation. Most took place in America and Europe, but there were some in Asian countries as well, including neighboring Turkey. Thanks to new immunosuppressant drugs (for preventing organ rejection), the survival rate is 80 percent in the first year, while approximately half of those patients manage to extend their lives by 10 years. It should be pointed out there are no limits to the survival rate: 10 of this writer’s transplant patients, operated on at Baylor University in Texas, had their life extended by 16-18 years. They raised children and saw grandchildren. They survived, are living today and bless the transplants that brought them back from the dead. At the Onassis Cardiac Surgery Center, transplant patients can allow themselves to feel even more optimistic. Survival rates for the first year are over 90 percent, while 70 percent will still be alive 10 years later, 20 percent above the equivalent rate abroad. This a particularly satisfactory performance given that Greece is in last place in Europe as regards organ donations. Out of a total of 36 heart transplants carried out at the center, 31 survived. How were such stunning results achieved with such a small number of operations? Given that repetition is the mother of learning, survival rates should logically have been lower, but the contrary is the case. Experience, team organization and transparency are the key words here. This writer began the cardiac surgery program at the Onassis Center in 1995. He had personal experience of 180 heart transplants and 55 lung transplants in a decade, during which he ran two transplant programs at Baylor University in Dallas, Texas. Thus the foundations existed. A team of specialists examine the patient inside out and contribute to the final decision on whether the patient should be put on the waiting list. Transplant coordinators – a new institution for the center – ensure round-the-clock supervision of transplant patients and communication between the medical team and the patients. As for transparency – without which any program is doomed, whether slowly or quickly, to a certain death – suffice it to give the example of a young man from Crete: When his mother was finally convinced that there was no cost for the transplant operation, she pulled the ad that advertised her house for sale. State help for the Onassis program is pure myth. Infrastructure (molecular immunopathology and istocompatibility laboratories) and training for coordinators was provided by the Alexander S. Onassis Public Benefit Foundation, in a donation to the center in 1992. Buying time Despite the small number of operations, transplant results were fantastic. This raises the legitimate question: Why aren’t more patients who need transplants – estimated at 50-100 a year – referred to the cardiac surgery center? Why are noteworthy results swept aside for the easy, mechanical solution of implanting assist devices? What do the latter offer and what is their place in the sheaf of treatment options? Since the 1970s, it has been obvious that demand for transplant organs far exceeds global supply. Thus there was a logical reason for artificial hearts, and a permanent implantable device is close to realization. Such a device still has a long way to go. At present, assist devices are used as temporary support for patients who are otherwise in danger of dying, either because there is no transplant organ available or because patients’ condition is so poor that they would not survive a transplant. Assist devices thus avert imminent death and allow the patient to improve enough to allow a transplant in the future. Hence their appellation of bridge-to-transplantation devices. Basically, they buy time. Life is normally extended by one to two years, a period of time in which transplants can be found before complications arise, chiefly infections, which mandate the removal of the device. For patients who do not meet the conditions for transplant operations, assist devices may be the final treatment (known as destination therapy). Survival rates are better compared to patients who only receive pharmaceutical treatment, but do not exceed 25 percent within two years, chiefly due to complications. There appears to be a third category of patients, for whom the assist device rests the heart for a few months and is then removed (known as «bridge to recovery»). There have been encouraging results from pioneering centers, but more information is needed. To conclude, assist devices are a temporary solution for those who have no access to a transplant. Decisions Who decides whether the patient needs a transplant or an assist device? The Central Health Council (KESY), as far back as 1997, recognized the difficulty of such a decision and had the farsightedness to foresee the ills arising from reckless implantation of heart assist devices. It therefore decided that this should be the job of transplant centers in the country which possessed the experts that could decide on whether to settle for an implant instead. The patient, it was correctly decided, needed to be assessed at an organized center which could offer transplants, mechanical assistance or just drug treatment in the absence of the prerequisites for the first two solutions. More recently, a Ministry of Health committee that included this writer made similar recommendations in February 2004. Based on these decisions, the Onassis Cardiac Surgery Center has proceeded with five implants. The patients were at immediate risk of dying due to heart failure in the final stages and had low-output syndrome (when blood flow from the heart, or cardiac output, is low, even though demand for blood is normal). They were also candidates for transplants. The first two, a man of 63 and one of 22, have already undergone successful transplant operations and enjoy a normal life. The other three, two children aged 11 and 13 and one 23-year-old, are still on the devices and are waiting for a transplant. Changing the rules Until now, the rules of the game were clear. Suddenly, however, people have started airing views that transplants are passe, that we will never have enough donors and that transplants are much too expensive for Greece. Some people, utterly unacquainted with transplants, are focusing on the advantages of the mechanical treatment of heart failure, which would mean not having to run around looking for a suitable donor, not having to navigate the reefs of immunosuppressant therapy with all its potential pitfalls and not having to bear the responsibility for the lifelong monitoring of the patient. The lives of doctors are a whole lot easier without selection committees and time-consuming consultations, which nevertheless are valuable for scientific debate and patient safety. The alternative is an uncontrolled system of implants, as was the case in the past with pacemakers, in which the only loser was the patient. The fact that a transplant candidate who gets an assist device instead of a new organ only gains one to two more years of life as against 10 or 15 years appears not to trouble people at all.