Thoracic Transplant Recipients -- January 1998
CAUSES OF LATE FAILURE
AFTER HEART TRANSPLANTATION: A TEN-YEAR SURVEY
Pietro Gallo et al, Cardiac transplant Units of Italy
The continuous improvement in heart transplantation outcome over
the past 20 years has assessed orthotopic heart transplantation as an
efficient therapy. Nevertheless, a significant amount of death could
still be avoided if the causes were better understood. The
distribution of the causes of death of heart transplant recipients
varies substantially according to the survival interval; accordingly,
short-term and long-term survivors deserve separate consideration.
- Data from the Registry of the International Society for Heart
and Lung Transplantation about the causes of death of long-term
survivors are largely incomplete and presently not usable. On the
contrary, the Italian Cardiac Transplantation Program is
particularly!suitable for performing a multicenter mortality study
because it permits the collection of data from a homogeneous
population, Which undergoes the same monitoring procedures. The aim
of this study was to gain an insight into the late failures of heart
transplant recipients during the first decade of heart
transplantation in Italy (1985 to 1995).
PATIENTS AND METHODS
We studied all the recipients who died or underwent
retransplantation at least 2 years after the grafting procedure. The
patients underwent surgery in the 12 heart transplantation units
that have been functioning in Italy for a period long enough to meet
the follow-up requirements of the present study. All the recipients
were treated with a similar immunosuppressive procedure (induction
therapy followed by triple therapy with cyclosporine, prednisone,
and azathioprine) and monitored with the same schedule of
- The study was set up by the first author by sending to the
pathologist in charge of all the Sections of Cardiovascular
Pathology a questionnaire for each patient who had either died or
undergone retransplantation a minimum of 2 years after surgery. Data
about the 97 recipients who died and the 12 who underwent
retransplantation were collected and subsequently analyzed. Deaths
and retransplantations of long-term survivors were subdivided by
time intervals as follows: late (>2 years, <5 years) and
belated (>5 years).
- Data about patients who had died or had undergone
retransplantation within 2 years after surgery, which ~ been used
for comparison purposes, have been derived from previous surveys on
the same patient population. Deaths and retransplantation of
short-term survivors had been subdivided by time intervals as
follows: preoperative (within 1 month after surgery), early (>1
month, <3 months), and intermediate (>3 months, <2 years).
- Because of the shortage of donors, retransplantation could be
equated to a death in terms of denying another patient the
opportunity of undergoing transplantation. Moreover, because late
retransplantation is usually reserved for patients with graff
vascular disease, the only way to estimate the real impact of this
transplant-associated condition is to include deaths and
retransplantations under the common heading of "failures,"
as was done in this study. Depending on the circumstances, data are
accordingly given in the text as percentages of either deaths or
Source of Data
- This analysis of late and belated failures deals with the
records of 12 patients who underwent retransplantation and 97
patients who died. The data from the former group were derived from
the pathologic examination of the explanted heart; the information
about the latter came mainly from the postmortem examinations, which
were performed in 56 of 97 patients (58%). In the remaining cases
autopsy was impossible because the patient died at home (usually
suddenly) or in peripheral hospitals. The primary cause of death
could be assessed on pathologic or clinical grounds in 85 of 97
cases. The statistical analysis of these data will accordingly refer
to the 85 known deaths and to the 12 explanted hearts (97 transplant
failures in total).
Analysis of the Causes
of Death and Organ Loss in Long-term Survivors
- Data are summarized in Figure 1. The single most common cause of
late graft failure (47.4%) was graft vasculopathy, which was
responsible for 34 of 85 deaths and for all the retransplantations.
- Tumors caused, respectively, 20.6% and 23.5% of late failures
and deaths. The most common neoplasia was lung cancer, which was the
definite cause of death in seven recipients and the putative cause
of an additional patient dying of a disseminated malignancy. The
histologic typing of the neoplasia could be ascertained (at surgery,
biopsy, or autopsy) in five of seven cases and proved to be
adenocarcinoma in four and a squamous cell carcinoma in one. Second
in frequency were non-Hodgkin lymphomas (6.2%), followed by tumors
of the central nervous system (2.1%), Kaposi's sarcoma, carcinoma of
the tongue, gastric cancer, and cholangiocarcinoma of liver (1.0%
- The third most common cause of late failure was represented by
the emergence or recurrence of retransplantation diseases such as
systemic atherosclerosis (6.2%), diabetes (1.0%), and amyloidosis
(1.0%). Fatal infections accounted for 4.7% of deaths only and were
represented by bacterial pneumonia in all the cases. Another 4.7% of
deaths was caused by the development of "iatrogenic"
transmissible diseases such as viral hepatitis, leading to
posthepatitic liver cirrhosis (3.5%), or acquired immunodeficiency
syndrome (1.2%). Late acute rejection was held as the cause of death
in 2.3% of patients.
- A 54 year-old man underwent transplantation for dilated
cardiomyopathy. As a result of a postoperative aortic dissection,
his aorta was replaced with a prosthesis. Ninety-two months later an
anastomotic pseudoaneurysm and rupture ensued, and the patient died
of hemorrhagic shock. Because of this chain of events, the death has
been ascribed to the original postoperative complication.
- Finally, miscellaneous conditions such as chronic kidney failure
(two cases), necrotizing pancreatitis, sclerosing cholangitis,
Creutzfeldt-Jakob disease, and a car accident (one case each) were
grouped under the "others" heading.
Distribution of the
Causes of Late Failure by Survival Intervals
- The occurrence of graft vasculopathy as a cause of graft failure
rose only slightly from the late (>2 years, <5 years) to the
belated (>5 years, <10 years) periods, accounting for 46.1%
and 48.9 % of failures, respectively. However, if death and organ
loss are considered separately, the trend in long-term survivors is
inversed, with the number of deaths consistently falling from the
late (40.4%) to the belated period (28.9%), and the
retransplantation frequency conversely rising from the late (5.8%)
to the belated period (20.0%).
- Tumors were more frequent in the late period (28.6% of deaths)
than in the belated period (16.7%). Tumors such as Kaposi's sarcoma,
carcinoma of the tongue, gastric cancer, and cholangiocarcinoma of
liver were exclusively observed as a cause of death in the late
- Apart from recurrent amyloidosis, the other pretransplantation
diseases were exclusively represented or more frequent in the
belated period. Fatal infections and transmissible diseases showed
the same prevalence in the two considered time intervals, and acute
rejection was never registered as a cause of death in the belated
Distribution of the
Causes of Late Failure by Reason for Transplant
- Graft vasculopathy was more frequent among patients undergoing
transplantation for ischemic heart disease (54.3%) than for any
other reason (40.4%), but the difference did not attain statistical
significance. Conversely, tumors as a whole were rarer among the
patients undergoing transplantation for ischemic heart disease
(10.9% vs 30.6%), and this difference attained statistical
significance. It is meaningful and statistically significant that
conditions such as sudden death, systemic atherosclerosis, and
diabetes were more frequent among the recipients undergoing
transplantation for ischemic heart disease (21.7% vs 6.1%).
Source of Data
- The postmortem examination rate observed in this study is
substantially lower than the one (86%) registered in a previous
survey of short-term survivors performed on the same study
population. This can be attributed to the fact that short-term
survivors are mostly inpatients and are accordingly more likely to
undergo an autopsy than long-term survivors.
Analysis of the Causes
of Death and Organ Loss in Long-term Survivors
- It is common knowledge that graft vasculopathy is the most
frequent single cause of death in long-term survivors. In the
Italian experience the graft vascular disease has been the leading
cause of death since the intermediate period, and it has resulted in
most of the retransplantations, confirming that it represents the
major hazard for long-term surviving heart transplant recipients,
out of proportion to kidney and liver transplant recipients.
- Sudden death at home is a common occurrence in long-term
survivors. Hearts with graft vasculopathy very often display
features such as hypertrophy and disarray of myocytes and
substitution scarring that can account for electrical instability.
Accordingly, late sudden death in recipients known to be affected by
chronic rejection was considered a putative consequence of graft
vascular disease from a statistical standpoint.
- Tumors were the second most common cause of death in this series
of long-term survivors (23.5% of deaths). In addition to the 20
patients who died of a malignancy, four patients, who died of
unrelated causes (mainly of graft vascular disease), were found to
have cancer (renal cell carcinoma, urinary bladder carcinoma,
Kaposi's sarcoma, and lung cancer.)
- Tumors such as non-Hodgkin' s lymphomas and Kaposi's sarcoma
have been definitively connected with the effects of the
immunosuppressive therapy, but they represented only a minority of
the neoplasms appearing in our series (6.9% and 1.1% of deaths,
respectively). Lung cancer seemingly should not bear any
relationship with transplantation, but its actual frequency,
especially the high prevalence of a specific histologic type (such
as adenocarcinoma), in heart transplant recipients is too high to be
merely coincidental, All eight patients who either died of lung
cancer or were found to be affected by this tumor (an eighth patient
who died of graft vascular disease) were men, with a mean age of
52.9 years (range 46 to 60 years). They had undergone
transplantation for either dilated cardiomyopathy (5 of 8) or
ischemic heart disease (3 of 8) and died after a mean follow-up
period of 4.9 years. Two patients underwent operation, and three
died with a widely disseminated pattern of metastases. Another
patient died of a malignancy infiltrating pleural serous membrane,
mediastinum, and retroperitoneum, but a primary site in the lungs
could not be ascertained. Patients who died of non-Hodgkin's
lymphomas were conversely younger (40 to 50 years, mean 46.4), one
of them was female, none of them had undergone transplantation for
ischemic heart disease (dilated cardiomyopathy in two, valvular
heart disease in two, and restrictive cardiomyopathy and
arrhythmogenic cardiomyopathy in one), and they had died after a
slightly longer follow-up period (5 .5 years on average). Patients
who died of or were found to be affected by "other"
malignancies were mainly male (9/10), had an intermediate mean age
(50.1 years, range 3 to 66), had undergone transplantation for
different reasons (dilated cardiomyopathy in six, ischemic heart
disease in three, and a cardiac fibroma in one), and had died after
the shortest follow-up period (4.4 years on average).
- The spectrum of diseases resulting in death in short-term
recipients is relatively limited. For this reason, and for the sake
of comparison, studies on long-term survivors tend to list a
considerable number of different causes of death as "other,"
that is, ascribed to a composite group of diseases that are
seemingly non-related to the transplantation itself. Actually, only
a minority of them are really coincidental: several other deaths are
due to the emergence or recurrence of pretransplantation diseases
(such as systemic atherosclerosis, diabetes, or recurrent
amyloidosis); other causes of death, as the development of either a
posthepatitic cirrhosis or acquired immunodeficiency syndrome, are
probably due to some kind of transmission and could be considered as
"iatrogenic" diseases. These conditions were related to
transplantation but could have been connected with any other form of
- Fatal infections are infrequent occurrences in late survivors.
In our series, all of the infections were bacterial and, in keeping
with other authors' observations, they affected the respiratory
- Untreatable acute rejection is no longer frequent in the late
period. In one of our cases, acute rejection was the consequence of
voluntary withdrawal of the immunosuppressive therapy. Before a
diagnosis of late acute rejection is made, attention must be paid to
discern it from the effects of graft vasculopathy, such as the
concurrence of ischemic myocyte necrosis with lymphocytic
infiltration, the so-called "aggressive fibrosis that can mimic
the features of acute rejection.
Distribution of the
Causes of Late Failure by Survival Intervals
- Given the limited life expectancy of patients after heart
transplantation, determination of the causes of late failure, that
is that these events can potentially be modified, is an important
issue. However, the comparison among published data is hindered by
the different definitions of long-term survivors used in the
literature. They have been defined as patients surviving for more
than 2 years, 1 year, 3 months, 2 months, or even 1 month after
transplantation. In addition to this, most studies limit themselves
to a 5 year follow-up period, and little is known of patients who
die after longer time intervals. They supposedly die of the same
causes, but this has not been truly ascertained. This is why this
study makes a difference between late and belated failures. The
major dissimilarities between the two time intervals regarded graft
vascular disease (responsible for more deaths and fewer
retransplantations in the late than in the belated period), acute
rejection (absent in the belated period), tumors (less frequent in
the belated period), and the emergence of pretransplantation disease
that prevails in the belated period (13.9% vs 6.1% of deaths): death
was due to diabetes in one case (a 50-year-old male patient who
underwent transplantation for ischemic heart disease and died 6
years after transplantation of diabetic nephropathy) and systemic
atherosclerosis in six. These patients died of either a ruptured
atherosclerotic aneurysm of the abdominal aorta (two men, 54 and 60
years old, respectively, who underwent transplantation for ischemic
heart disease and dilated cardiomyopathy, died after more than 5
years) or stroke (four men, 5 1 to 60 years old, three of four of
whom underwent transplantation for ischemic heart disease, died
after 3, 4, 6, and 9 years). It is worth noting that these patients
were all men in their fifties and, as will be underlined later, five
of seven of them had undergone transplantation for ischemic heart
- Expanding the comparison between survival intervals to the
entire follow-up period, several noteworthy observations can be
made. Graft vasculopathy may be evident as early as 3 months after
transplantation, and, conversely, it may cause the recipient's death
22 years later. In the Italian experience, the frequency of graft
vasculopathy as a cause of graft failure has progressively risen
from 6% of the early period to 42% (intermediate), 46% (late), and
49% (belated), and, if sudden death at home were considered along
with graft vasculopathy, the number of failures directly or
indirectly attributable to a graft coronary disease would further
rise from 9% (early period) to 43% (intermediate), 50% (late), and
58% (belated). The inverse trend of retransplantation and deaths
from the late to the belated time interval underlines an attitude to
giving a second chance to patients who have survived for more than 5
years but opens the ethical problem of priorities in organ
assignment that is made harder to solve by the shortage of donors.
- In the Italian experience, tumors (Figure 3) have been a cause
of death since the early period (3%), and their frequency has
progressively risen in the intermediate and late periods (17% and
29%, respectively), being almost halved (17%) in the belated span of
time. Lung cancer caused a fairly constant rate of deaths: 7% in the
intermediate period, 10% in the late, and 5% in the belated period.
Also non-Hodgkin's lymphomas displayed a relatively uniform
frequency: they already represented a cause of death in the early
period (3%) and were subsequently responsible for 3%, 6%, and 8% of
deaths, respectively, in the intermediate, late, and belated
periods. As previously observed, Kaposi's sarcoma occurred only in
the intermediate period, even if one patient in this series died of
this neoplasia in the late period 2 years after the onset of the
- In the Italian experience, the overall percentage of deaths for
infections fell from the early (31%) to the late period (4%) because
of the disappearance as a cause of death of the viral fungal, and
protozoal diseases. On the contrary the rate of fatal bacterial
infections remained almost unchanged in the various time intervals
(8% in the perioperative period; 6%. early; 7% intermediate 4% late;
4% belated). In the late periods, indeed, all the fatal infections
were represented by bacterial pneumonia.
- Acute rejection represents a life-threatening hazard in the
first 6 months after surgery. In the Italian experience, it caused
9% of the perioperative deaths and 19% of the early deaths.
Subsequently, the percentage of deaths resulting from acute
rejection fell to 5 % and 4% in the intermediate and late periods,
respectively, and no additional deaths were attributed to an acute
rejection in the belated period.
Distribution of the
Causes of Late Failure by Reason for Transplant
- The assessment of risk factors for graft vasculopathy has drawn
conflicting results, even if undergoing transplantation for ischemic
heart disease has been frequently associated with the development of
this condition. Also in our series, the patients who had undergone
transplantation for ischemic heart disease and subsequently had
development of a graft vasculopathy were more numerous than those
who underwent transplantation for any other cause, especially
dilated cardiomyopathy, but the difference did not attain
statistical significance. It was to be expected that dying as a
result of systemic atherosclerosis and diabetes was much more common
among patients who underwent transplantation for ischemic heart
disease, which reopens the discussion about the opportunity of
giving priority to patients with cardiomyopathy as heart transplant
recipients. On the contrary, the observation that tumors develop
more rarely among patients who undergo transplantation for ischemic
heart disease, although confirmed by other investigations, remains
difficult to explain.
- This study has confirmed that the distribution of the causes of
death of heart transplant recipients substantially varies according
to the survival interval, and that there is a difference, too,
between the late (>2 years, <5 years after surgery) and
belated (>5 years) periods. Graft vasculopathy is the most
frequent single cause of transplant failure in both the late and
belated periods; in the latter, the organ loss (need for
retransplantation) becomes almost as significant as death. A sudden
death at home is a frequent occurrence in long-term survivors and
could be tentatively attributed to the myocardial disarray and
scarring that is often observed in graft vascular disease.
- The mortality rate for tumors is highest in the late period,
with non-Hodgkin's lymphomas showing a fairly constant prevalence in
the different periods. Kaposi's sarcoma does not seem to develop in
the late period, but its effects can last until this period. In
addition to these tumors, which are commonly associated with an
immunosuppressive therapy, an unexpected and unexplained high number
of lung cancers, especially metastasizing adenocarcinomas, have been
noticed in this series. In the belated period, and especially in
patients not undergoing. tranplantation for cardiomyopathy, death is
frequently due to the emergence or recurrence of pretransplantation
- Long-term survivors of heart transplantation can also die of
complications such as a transmissible disease, which can be
connected to any kind of major surgery. Fatal infections are limited
to bacterial and are infrequent in long-term survivors. Finally,
acute rejection is no longer a cause of death in late survivors,
unless the patient voluntarily discontinues the immunosuppressive
- J. of Heart & Lung Transplantation
Vol. 16, No. 11,Nov '97 pp. 1113-21
SHALALA WANTS ORGAN
- By Laura Meckler - Associated Press Writer
- WASHINGTON (AP 12/17/97) -Concerned about lower-than-expected
survival rates at some organ transplant centers, the secretary of
Health and Human Services is asking for an explanation.
- Forty-three programs that transplant hearts, livers or kidneys
had low survival rates between 1988 and 1994, including 29 whose low
rates continued through 1994, the Department of Health and Human
- "I know you share my concern," HHS Secretary Donna
Shalala wrote to the director of the United Network for Organ
Sharing, which runs the nation's transplant program.
- UNOS plans to review the 29 programs whose low rates extended
- Shalala asked the organ sharing network to explain, within 30
days, whether any of these programs have been reviewed before and if
not, why not. She also asked whether these programs shared any
characteristics and asked UNOS to explain how it planned to assist
- Releasing the list, officials warned it was only one piece of
information patients should consider when choosing an organ
transplant center. And they cautioned that some excellent programs
may show up on the list.
- "This is another tool available to patients that we hope
will be helpful," said Mary Ann Wirtz, spokeswoman for the
- The report, produced every three years, offers a wealth of
information about every transplant program in the country. Overall,
it showed patient survival rates improving for every type of
- The list includes a few very large programs, such as University
of Alabama, which performed 1,652 kidney transplants between 1988
and 1994. Its survival rate was just barely below expected, and
government officials said it illustrated why patients should not
take this list as gospel.
- "You'd never say the University of Alabama is anything but
a quality center," said Charlotte Mehuron, an HHS spokeswoman.
- To compile the list, United Network tracked the percentage of
organs that are still functioning a year after being transplanted.
It then calculated each program's expected survival rate, taking
into consideration a variety of factors such as age and health of
- The 43 programs identified Tuesday had one-year survival rates
that were below the expected rate between 1988 and 1994. In each
case, the difference was statistically significant.
- Five of them had closed by 1992, and others may have closed
since then. Nine programs improved their survival rates during
1992-94 and were performing at least as well as would be expected.
- That left 29 programs that merited further review, HHS said.
- Following a similar report in 1994, analysts identified 15
programs that warranted further study. Of those, four stopped
performing transplants, 10 programs showed improvement and one
program remained under review.
- Hospitals on the list contacted Tuesday generally said they had
instituted improvements to their programs since 1994, the last year
covered by the report. Sacred Heart Medical Center in Spokane,
Wash., determined it needed to modify its post-transplant drug
program, said Dr. Robert Golden, director of kidney transplant
program. Its statistics then improved, he said.
- "I think its a good tool for hospitals to look at how
they're doing," he said. "Patients will use this as a
starting point when they evaluate a center to ask more questions and
become more fully informed."
Organ Transplant Centers
- By The Associated Press
- Transplant programs whose one-year graft survival rates are
below expected, given a variety of factors. The rate indicates what
percent of transplanted organs were still working a year later.
- The first column of numbers is the transplants performed by each
center between 1988 and 1994. The second column is the actual
survival rate. The third column is the expected survival rates.
- Programs designated with an "x" had survival rates in
1992-94 that still were below expected and are subject to review.
- The source is the 1997 Report of Center Specific Graft and
Patient Survival Rates, produced by the United Network for Organ
Sharing under a contract from the Department of Health and Human
- KIDNEY PROGRAMS
xUniversity of Alabama Ho1652 80.4 83.5
- xGood Samaritan Regional,528 81.0 86.3
- xMemorial Medical Center, 78 78.2 85.9
- xBrigham and Women's Hosp369 74.5 81.8
- xBorgess Medical Center, 152 76.7 86.8
- Grace Hospital, Detroit 61 52.0 77.6
- St. Luke's Hospital, Kans223 78.5 83.3
- Pitt County Mem Hospital,147 76.4 84.3
- xNew York Hospital, New Y356 78.6 84.1
- xSt. Anthony's Hospital, 136 66.6 83.0
- xGeisinger Medical Center227 76.1 81.3
- xHermann Hospital, Housto627 77.6 82.5
- xLatter-Day Saints, Salt 463 79.4 84.4
- xSacred Heart Medical Cen180 77.2 84.3
- Swedish Medical Center, S288 78.5 84.4
- HEART PROGRAMS
xColumbia Presbyterian, D49 69.4 82.4
- xHines VA Hospital, Hines38 60.5 82.6
- xKosair Children's Hospit22 36.4 67.5
- xHarper Hospital, Detroit14 55.1 81.8
- Depaul Medical Center, Br2 0.0 85.8
- MenDrab Medical Center, K5 20.0 77.3
- North Carolina Baptist, Wll 63.6 84.9
- xBuffalo General Hospital63 60.3 85.1
- xPresbyterian Hospital, N502 75.9 81.1
- xUniversity Hospitals, Cl23 65.2 83.2
- Children's Hospital, Oklal5 40.0 66.6
- xSt. Christopher's Hospit36 44.4 72.7
- The Methodist Hospital, H200 72.5 80.8
- Baylor University Medical123 74.8 81.7
- xJohn L. Doyne Hospital, 40 70.0 82.2
- LIVER TRANSPLANT PROGRAMS
- xGood Samaritan Regional,65 55.6 77.4
- xYale New Haven Hospital,35 54.3 71.4
- xJackson Memorial Hospital63 56.2 68.4
- xTampa General Hospital, 10 30.0 78.0
- University of Chicago 496 55.4 62.4
- xRush Presbyterian, Chica318 57.9 63.5
- Presbyterian Hospital, Ne6 7.7 72.5
- xDuke University Medical 163 56.4 73.0
- xUniversity of Pennsylvan152 58.8 71.6
- Children's Hospital, Phil78 51.3 61.5
- xThe Methodist Hospital, 42 45.0 69.5
- xWilford Hall, Lackland A59 59.3 75.0
- Columbia Henrico Doctor's5 20.0 77.3
Open Letters to UpBeat
- Dear Friends,
I greatly regret to inform you that as is
not unusual for long term heart transplants,
I have developed cancer. In my case it is
located in the throat. A great many wonderful
and very professional people have helped
me try and grasp this ugly situation and
make a decision as to what treatment
course to follow. I have selected a program that
- Just what effect this treatment may
have on me, and my ability to keep UpBeat
on a schedule with quality content is yet
to be learned - I shall try very hard, first to
get well, and also to keep the newsletter
going. Should the situation turn even nastier
than it already is, give me a bit of a
break on the schedule over the next 3 or 4 months.
- One more thing - this event has
proved to me one more time that the field of
transplantation has the friendliest, most
professional, and most caring individuals in
Don S. Marshall, Tx 1/8/88, Loma Linda
P.O. Box 482
Mathews, Virginia 23109
- January 15, 1998
- Ms. Susan Hirsch, Public Relations
2929 Allen Parkway, Suite 1109
Houston, TX 77019
- Dear Ms. Hirsch:
- I received a heart transplant at Loma
Linda in California ten years ago this month. It has been a
wonderful event that has allowed me to take part of many events in
my family as a basically normal person.
- Just recently, as is not unexpected in
patients who have been immunosuppressed over a relatively long
period, I developed cancer of the larynx. We now live in Virginia as
an expense expedient, yet it became an obvious medical conclusion
that I should return quickly to Loma Linda for a consult as to the
best possible treatment of this disease.
- As we live on disability income, the fares
quoted for an immediate departure were just not within our
reasonable means. However, I remembered that I had heard of a
connection between the American Organ Transplant Association and
Continental Airlines. My wife made a call to them, as I can no
longer talk well, and within 36 hours we had a ticket voucher for
the entire trip!
- This program to service people in
legitimate health need is simply outstanding. I put together a
newsletter for thoracic transplant recipients with a small but
widely distributed mailing list in all 50 states and 4 foreign
countries. I can assure you that in a future issue (as soon as I get
some chemotherapy behind me) Continental Airline' s "heart"
will be brought to the fore.
- Again sincere thanks.
- Don S. Marshall
MAN REGAINS VOICE AFTER
- By John Affleck - Associated Press Writer
- CLEVELAND (AP 1/9/98) -- A man who lost his voice in a
motorcycle accident 19 years ago rasped "Hello" and "Hi
Mom" just three days after the first larynx transplant since
- Timothy Heidler, 40, could be speaking in a normal voice in five
months or less, doctors at the Cleveland Clinic said Friday.
- In a 12-hour surgery on Sunday, Heidler received the larynx,
part of the trachea and 70 percent of the throat of an unidentified
- The surgery, last performed in 1969 in Belgium, is causing some
controversy in the medical community over the risks vs. the benefits
of transplanting a non-vital organ. Undergoing major surgery is
always risky, and the body could later reject the transplanted
organ, requiring more surgery to have it removed.
- "I think there will be some folks that will perhaps say we
shouldn't do it, but I'm not one that ascribes to that," said
Dr. Marshall Strome, leader of Heidler's surgical team.
- "I think that if people want to be normal, or as normal as
they can be, and are willing to make the sacrifices to make it
happen, we're here to serve the population," Strome said.
- Heidler's larynx was destroyed when he crashed his motorcycle on
the way to firefighter training school. He spent years recovering
from his injuries and currently is unemployed. The clinic on the way
to firefighter training school. He spent year on the way to
firefighter training school. He spent years recovering f on the way
to firefighter training school. He spent years recovering from his
injuries and currently is unemployed. The clinic on the way to
firefighter training school. He s on the way to firefighter training
school. He spent years recovering from his i on the way to
firefighter training school. He spent years recovering from his
injuries and currently on the way to firefighterrg, Pa., volunteered
for the surgery last year after being informed of the risks of
infection and organ rejection.
- "Tim is very verbal, very bright; very motivated,"
Strome said. "He clearly understood what he wanted to have
- Heidler is taking anti-rejection medicine, but he'll live with
the risk of rejection for at least another five years. Strome
believes there is a 70 percent chance the larynx will still be
functioning by then.
- Strome and other experts in head and neck surgery said the last
larynx transplant was performed on a cancer patient who died not
long afterward. Strome said articles written about that transplant
indicate the operation failed to re-establish the patient's voice.
- Strome said Heidler's operation may open the door for other
accident victims, people with large benign growths on the larynx and
long-term cancer survivors whose larynxes were destroyed by the
- But other doctors reserved judgment, saying that the success of
the operation won't be known for years.
- If there are serious complications or rejection, doctors will
question the value of replacing an organ that people can live
without; said Dr. Michael Johns, editor of the professional journal,
"The Archives of Otolaryngology-Head and Neck Surgery."
- If not, the operation could be a valuable new procedure.
- "School will be out until the long-term report on this,"
- In my present condition, l'm real partial to this guy. DM\
TRANSPLANT SURVIVAL RATE
UP - U.S. GOVERNMENT
- WASHINGTON (Reuters 12/12/97) More people are surviving organ
transplants and living longer after transplant surgery thanks to
better care, the U.S. Health and Human Services (HHS) department
- Once an organ recipient survives the first year after the
dangerous transplant surgery, the patient is more likely to remain
- For example, the HHS said that 94.3 percent of kidney recipients
-- an all-time high -- and 91 percent of pancreas transplant
patients now survive their organ transplant surgeries.
- The HHS' s three-year survey of more than 97,000 transplant
patients showed "excellent" survival rates for those who
lived a year past their transplants.
- "For this group, three-year patient survivals range from
75.9 percent for lung recipients to 81.2 percent for heart-lung, to
more than 90 percent for kidney, liver, heart and pancreas,"
HHS said in a statement.
- "This report with data on nearly 100,000 transplants is a
clear indication that transplantation is a lifesaving treatment,"
said Claude Fox, acting administrator of the department's Human
Resources and Services Administration.
- "Information like this is important in helping patients
make informed medical decisions in consultation with their
- But despite the encouraging figures there are still problems,
one being a lack of organs donated for transplant.
- "With the success of organ transplantation, the need for
organs is growing much faster than the number of donated organs,"
Fox said. "The waiting list is now more than 55,000."
- By Alice Ann Love - Associated Press Writer
- WASHINGTON (AP 12/18/98) -Gravely sick people whose hearts have
stopped but whose brains are alive could help solve the shortage of
transplant organs, but rigid protective standards are needed,
medical experts advised the government Thursday.
- "If the estimates are accurate, non-heartbeating donors
could represent an increase of at least 1,000 organ donors each
year," said Dr. John Potts, director of research at
Massachusetts General Hospital in Boston. "To ensure that these
patients receive proper care, however, it is critical that all
transplant organizations adopt a consistent approach that respects
the wishes of patients and families."
- Potts led a study presented by the Institute of Medicine to the
Health and Human Service Department, which requested the research
earlier this year.
- "This could be a significant source for expanding organ
donation, but not unless the public understands it," said HHS
spokesman Campbell Gardett.
- People whose hearts have stopped -most often because of a
traumatic injury from a car accident, homicide or suicide -but whose
brains can be kept working by life-support equipment, account for
only about 1 percent of all organ donors.
- To be successful, organ recovery from such patients must take
place quickly, and the opportunity is easily lost if family members
can't be reached for consent.
- Organ recovery from patients who are brain-dead is far more
common, because their beating hearts can continue to preserve other
organs indefinitely while complicated emotional and ethical
decisions are made.
- But with more than 50,000 sick Americans on waiting lists for
organ transplants -more than 4,000 of whom died still waiting last
year -- federally supervised organ procurement organizations have
become increasingly aggressive about pursuing those whose hearts
- In some cases, hospitals have taken steps to preserve organs in
such patients -possibly causing pain or hastening their deaths --
before family members could be found to give consent.
- Of 63 federally supervised organ-procurement organizations,
researchers found fewer than half have written standards for dealing
with such cases -- and even those vary widely and are not
- "Everything happens in a mad rush," said Dr. Roger C.
Herdman, the Institute of Medicine's senior scholar. "This is a
medically and ethically complex situation... you should think about
this before you do it."
- The institute recommended in its report Thursday that the
following national standards be established to ensure ethical
practices and public trust in organ donation programs:
- --Discussion of organ donation with family members should take
place only after the family has made an independent decision to
withdraw life support.
- --A five-minute wait should be required after life support is
withdrawn and before organ recovery begins to ensure a patient's
heart would not resume beating on its own.
- --The doctor who declares death should not be involved in any
way with an organ-procurement organization.
- --Families should be allowed to attend the death of organ donors
and should not be
- required to bear any costs associated with the donation.
- The institute also recommended that decisions about whether to
use organ-preserving medical procedures on patients who are not
brain dead should be made only with family consent, unless
non-consensual intervention is specifically allowed by law.
- The District of Columbia, Virginia, and Florida have such laws.
FDA PANEL SUPPORTS HEART
- GAITHERSBURG, Md. (Reuters 1/15/98) A federal Food and Drug
Administration advisory panel has voted unanimously in favor of
giving marketing approval for a drug to help prevent rejection of
- The agency is not bound by its panels' decisions but it
generally follows their advice.
- CellCept, made by Swiss firm Roche Holding Ltd. and known
generically as mycophenolate mofetil, is already approved for kidney
transplants and is already in wide use for heart surgery as well.
Once the agency approves a drug for one use, doctors commonly
prescribe it for other, non-approved uses.
- The panel made the recommendation Wednesday despite some
reservations that Roche reconfigured results after a first analysis
showed no real difference between CellCept and a comparison drug,
azathioprine, which is commonly used but not approved for heart
- Even though Roche's analysis was questioned, many panelists --
including Lawrence Hunsicker of the University of Iowa Hospitals,
chairman of the United Network for Organ Sharing -- said there were
some kernels of hope in the Roche study.
- "It looks as though patients survive better,"
- Roche re-analyzed data to exclude 72 patients who were too sick
after transplant to take an oral medication. That might have biased
results, said the FDA and some panelists. FDA reviewer Michael
- "Performing several analyses gives multiple chances to
MISTAKE STOPS JAPAN
- TOKYO (AP 1/6/98) -- Failure to properly fill out an organ donor
card prevented a man from becoming the first person in Japan to
donate a heart and liver under a new law designed to make organ
- In the first test of the law, a man in his 50s who died last
month had indicated he wanted to donate his organs, but neglected to
specify when, Kazuhiro Shigeto, an official at the Japanese Health
Ministry, said today.
- Shigeto said the donor card allowed three choices for donation:
after brain death, after heart failure, or not at all. He said new,
easier-to understand cards were now being issued.
- Under the new law, enacted in October, Japan joined the rest of
the industrialized world in legally recognizing brain death, making
heart, lung and liver transplants much less problematic.
- Japan's previous law said a person could be declared dead only
at the moment when the heart stopped beating. But in many cases, the
vital organs have deteriorated too much by that point to transplant
- implementation of the controversial law has been hindered by
cultural attitudes, a lack of donors and a scarcity of transplant
experience among doctors.
- Even if the potential donor, whose name has not been released,
had properly completed the card, the hospital where he died did not
have Health Ministry authorization to handle organ donations from
brain dead donors, Shigeto said.
- As a result, only his kidneys and corneas were donated after his
heart stopped beating.
PIONEERING HEART SURGEON
- By Paul Harris - Associated Press Writer
- CAPE TOWN, South Africa (AP 12/3/97) -- Thirty years after
performing the world' s first heart transplant, pioneering surgeon
Christiaan Barnard says he never expected to be famous.
- Since Barnard performed the operation on Dec. 3, 1967, he has
been in the media spotlight, the recipient of awards from around the
world, able to hobnob with such celebrities as Princess Diana.
- "We really did not see it as a big event," Barnard,
75, told The Associated Press on Tuesday. "We did not even take
photographs of the operation that night."
- A transplant museum opens today at the Groote Schuur Hospital in
Cape Town, where Barnard put the heart of road accident victim
Denise Darvall into the chest of 55-year-old Louis Washkansky.
- Washkansky lived for 18 days before his body rejected the heart.
But the operation created instant headlines worldwide and gained
Barnard international fame. His one regret is that he did not hire
an agent to deal with the publicity.
- "That was the most difficult part, trying to handle all the
publicity," he said.
- Doctors already had transplanted livers and kidneys by the time
Barnard and his team attempted their operation. But the heart, with
its poetic imagery of life and love, caught the public and
- Dark-haired Barnard, who looks 10 years younger than his age,
said he saw it as just another part of the body.
- "We didn't see the heart as the seat of the soul. The
cessation of the heart did not mean the end of life. We knew that,"
- After Washkansky died, Barnard and his team persevered with
their innovative surgical procedure.
- His second transplant patient, Philip Blaiberg, lived for 18
months after the operation and the survival time of patients has
increased ever since. Now 90 percent of patients survive the
operation with an 85 percent chance of living for a year and a 70
percent to 75 percent chance of lasting five years.
- Barnard's longest-surviving patient, Dirk van Zyl, lived with an
implanted heart for 23 years before dying last year of diabetes
unrelated to his heart condition.
- What was pioneering 30 years ago is now commonplace, with more
than 40,000 transplants having been performed.
- Barnard predicted that someday human hearts will be grown
artificially to suit patients, using genetic engineering techniques
that already can produce human skin.
- "There is now tremendous progress in genetic engineering
and it may be possible eventually to grow a human heart," he
- Barnard, the son of a clergyman, grew up in Beaufort West, a
small town in the dusty Karoo semi-desert region of South Africa.
Last month, the town opened the Chris Barnard Museum, where his
numerous honorary degrees and overseas awards are now displayed.
- Last month, he received an honorary doctorate in Ukraine and
delivered lectures in Switzerland, France and Italy.
- Despite the International recognition, Barnard said that the
highlight of his career was performing operations on children with
abnormal hearts, with each operation requiring different techniques
- "That was real surgery," he said.
Barnard lives in Cape Town after retiring in 1987.
Last year, his third wife, Karin, who at 33 is less than half
her husband's age, gave birth to his sixth child.
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