Time to Shut Down Low-Volume Heart Transplantation Centers?

SNOWMASS, COLO. — Heart transplantation is one of the greatest operations ever devised—but the number of heart transplant centers in the United States needs to be cut by about two-thirds.

That's the considered opinion of Dr. Bruce W. Lytle, professor and chair of cardiothoracic surgery at the Cleveland Clinic Foundation, who notes that International Society for Heart and Lung Transplantation (ISHLT) data show persuasively that transplant program volume is an independent predictor of survival, both short term and at 5 years.

With more than 140 heart transplant programs now in place in the United States, relatively few centers have a reasonable case volume. In fact, the number of high-volume centers is actually declining as centers compete for the extremely limited number of donor organs.

It's a situation that cries out for national regulation, Dr. Lytle said at a conference sponsored by the American College of Cardiology.

“My guess is that organ allocation and utilization will probably be a lot more efficient under those circumstances. So I'd say in this area we've met the enemy and they is us. This is not a local issue, this is really a national issue,” the surgeon said.

The ISHLT data show that 30-day mortality is doubled at cardiac transplant centers performing fewer than 10 procedures per year. Of all U.S. centers, 45% consistently do fewer than 10 procedures annually, and during a recent 8-year period fully 66% of centers failed to reach the 10-case mark in all 8 years (Ann. Thorac. Surg. 2008;86:1250–9).

“Any normal person can see we need about a third as many transplant programs as we have in America,” Dr. Lytle commented.

Survival 5 years following transplant is currently about 80%, with superb quality of life.

“Cardiac transplantation is really one of the great operations of all time, particularly in this day and age, now that a lot of the immune suppression problems have been dealt with. When we do conservative operations for heart failure, we try to make bad heart failure into better heart failure. Transplantation is the only operation we have that takes someone who is really underwater and can make them absolutely normal. It is a terrific operation,” he said.

The trouble is, from a public health perspective cardiac transplantation is relatively ineffective, Dr. Lytle added. Although an estimated 250,000–300,000 Americans under age 75 have class IIIb/IV heart failure and are thus potential candidates for cardiac replacement therapy, the limited donor organ supply means that only about 3,000 transplants can be done annually.

Mechanical replacement using left ventricular assist devices as destination therapy will have a much greater impact in this population than will organ transplantation, he predicted.

Disclosures: Dr. Lytle reported no relevant financial interests.