Medical advances have made it increasingly common for older Americans such as Dick Cheney to receive heart transplants, extending their lives. The shift may make it more difficult for younger patients as aging Baby Boomers compete for available organs, top cardiologists say.
The former vice president received a new heart at the age of 71 on March 24 after being on the list for more than 20 months. Last year, 2,322 heart transplants were performed, including 332 among people older than 65, or about 15 percent, said Joel Newman, a spokesman for the United Network for Organ Sharing, or UNOS, which matches patients to organs.
Doctors are getting more skilled in doing transplants and keeping patients alive with devices that assist failing hearts. The trend may create conflicts as a growing pool of older patients with heart failure, who are otherwise in good shape, compete for the scarce number of donor hearts that become available each year, said Sharon Hunt, a transplant cardiologist at Stanford University in Palo Alto, California.
“If more and more of the older population is on the list, they’re going to crowd out the younger people,” Hunt said in an interview yesterday at the American College of Cardiology meeting in Chicago. “It’s going to be a huge problem, a tough societal issue that is going to get tougher.”
There are 3,163 people on the waiting list for a heart, including 517 who are 65 or older, UNOS’s Newman said in a telephone interview.
“While many transplant programs often begin to reconsider whether someone beyond 70 should be listed, there certainly are programs that do,” he said. “Some do quite a number of them.”
The one-year survival rate for patients 50 to 64 years old is 87.8 percent, higher than the 84.3 percent seen in older patients, according to data from UNOS, which oversees transplant activity in the U.S. At five years, 72.7 percent of the middle- aged patients are alive, compared with 65.4 percent of those 65 and older.
A new heart starts with a committee at the hospital, which decides whether to place a patient on the transplant list after taking into account a variety of factors including need, projected life expectancy after a transplant, and the ability to take the necessary medicines. There is no explicit age limit, and hospitals vary in terms of how aggressive they are about putting older people on this list.
UNOS, based in Richmond, Virginia, uses a computer model to evaluate blood type, body size, tissue type, severity of illness and time on the waiting list to determine which patient is offered a donor organ.
Some 70-year-olds “have no other major illness and could live forever if they had heart transplants, while there are 45- year-olds who have so many other illnesses that even if you replace their heart their longevity is going to be limited,” said Gregory Fontana, chairman of cardiothoracic surgery at Lenox Hill Hospital in New York.
The ages have crept upward as doctors have become more confident about performing the transplants on older people, he said in a telephone interview. Twenty years ago “it was controversial to do someone over 60,” Fontana said. “Nowadays someone who is 62 is a young candidate for transplant.”
Doctors at Cedars-Sinai Medical Center in Los Angeles, where Fontana worked for years, once did a transplant on a 77- year-old, he said. Over time “there has been a general acceptance” of performing more dramatic heart surgery on older and older patients, he said.
There’s no indication Cheney got special treatment, said heart doctors interviewed at the cardiology meeting.
Average Waiting Time
Cheney’s 20-month wait “would be about an average waiting time” for someone of his size and blood type, said Mary Norine Walsh, Medical Director of Heart Failure and Cardiac Transplantation at St. Vincent Heart Center of Indiana. “It doesn’t sound to me like he jumped the queue.”
Cheney may have received an older heart that would not have been considered for a younger person on the transplant list, she said. The former vice president could also have been the only match for a donated heart, which needs to be implanted within a few hours.
There were 31 patients on the list for a heart transplant at Inova Fairfax as of June 30, with a median waiting time of nine months, according to the U.S. Scientific Registry of Transplant Recipients. Eleven received donor hearts at the hospital in 2010, the latest data available, with a 90 percent one year survival rate. None were older than 65.
“The current process of waiting for a heart, being listed for a heart, and how donor organs are handled is the most transparent, clearest process that is really hard to corrupt,” said Mariell Jessup, medical director of the University of Pennsylvania’s heart and vascular center.
“What we say in our circle is that it’s not the age, it’s the mileage,” she said in a telephone interview. “Issues other than age determine how well a patient will do. A 70-year-old that has a heart transplant can expect an excellent probability to live five or 10 years or longer with a superb quality of life, as long as they don’t have other medical problems.”
Cheney, vice president under George W. Bush, has had five heart attacks and received a pump known as a left ventricular assist device two years ago to help keep him alive.
The strategy, keeping a heart-failure patient alive using such a device leading up to a transplant, is “mainstream treatment of advanced heart failure in 2012,” said Randy Starling, head of heart failure and cardiac transplant medicine at the Cleveland Clinic in Ohio. “This is a common scenario that’s playing out every day at transplant centers across around the country.”
‘Frailer and Frailer’
Arthur L. Caplan, director of the Center for Bioethics at the University of Pennsylvania, questioned whether age should have been an issue for Cheney.
“Knowing that he’s had operations on his legs, seeing him become frailer and frailer, it’s fair to wonder did he get a heart ahead of someone else who may have benefitted,” said Caplan, who has advocated for giving preference to younger people needing transplants, in a telephone interview.
“The ethicists will get into this case,” said Eric Topol, a cardiologist and director of the Scripps Translational Science Institute in La Jolla, California, via Twitter. While doing a heart transplant in someone over age 70 is not necessarily wrong, it can be controversial, he said.
“The ethical issues are not that he had a transplant, but who didn’t?” Topol wrote. “Details awaited ….”
Others say using age as a determiner rather than a patient’s health profile may lead to discrimination complaints.
“I’m not sure we have the right to age discriminate,” said Alfred Bove, a cardiologist at Temple University Hospital in Philadelphia, in an interview.
“If we can offer Cheney 10 years of life, and we think the heart is limiting his life expectancy, we don’t feel we have the right to refuse him because of his age.”
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