Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Cardiac transplantation in the elderly: It takes a heart to give oneMay 21, 2011 07:51 EDT
In 1999 my patient and friend Luther Waldo Meredith sensed that God's hand was poised to make the final entry in his book of life, a death writ after five long years of congestive heart failure. PND, orthopnea, and extreme dyspnea on exertion mercilessly loomed over this deeply religious and gentle family man. Pump failure was the ever-present "death angel," an unwelcome but constant companion. Just as the last few grains of fine white sand were sifting through his 70-year-old hourglass, he turned to me and said, "I've had a good life, but if you could find a way to help me stay around a little longer, I'd appreciate it." His family members and I breathed a sigh of relief when he finally gave us the green light to proceed with a transplant evaluation. Perhaps selfishly, neither his family nor I were willing to concede defeat in our five-year battle as his allies. In 1994, after having received lytic therapy in a timely fashion with complete resolution of ST-segment elevation, his left ventricle had been mortally wounded. Later it was revealed he had ignored a similar bout of pain that heralded his first heart attack in 1993. With an EF of 30%, a 70% lesion in his LAD, and 2+ MR, we embarked on a long, complex, and nearly impossible journey toward normal life expectancy. Because of his worsening heart failure we subjected him to balloon angioplasty out of desperation, hoping he would be among the lucky 15% who might exhibit some improvement despite a lack of viability on his nuclear scan. In 1998, we implanted an ICD. In 1999, after scores of episodes of congestive heart failure refractory to the "new drug" carvedilol, he agreed to consider "the 'T' word" (transplant). It wouldn't be easy by any stretch of the imagination due to challenging geographics and logistics. In addition, there were moral and ethical issues that swirled around the topic of cardiac transplantation in the elderly, questions that remain very much a consideration to this day.
|Have you signed your donor card?|
According to a recent heartwire story on the topic of cardiac transplant, 17 211 cardiac transplantations were performed between the years 2000 and 2011 in the US. At most centers, the upper age limit is considered to be 65 years. Despite the fact that older transplant patients do well, with a 90% survival rate at one year and a 50% survival rate at 10 years, older patients still aren't offered transplant as an option very often. Although they experience fewer rejection episodes, have a similar incidence of CMV infections as younger recipients, and require less immunosuppression, there is an often unspoken deterrent: practitioners ask themselves, "Should I attempt to obtain a heart for my elderly patient who has lived a full life and potentially avert a heart from a younger patient who has much more living to do?"
As Waldo's cardiologist, I admit I felt a small twinge of guilt as I inquired about the possibility of a transplant for a 70-year-old man, but my guilt paled in comparison to his family's desperation. A donor heart is very much like a fumbled football. There are scores of potential patients who are diving for it; therefore, only the best suited should be allowed to walk away with it. Despite Waldo's age of 70 years, he otherwise seemed very well suited. He hadn't smoked for 30 years. He didn't drink or utilize illicit drugs. No patient was more compliant with sodium and fluid restriction, and he took all of his medications. His wife and family were supportive. His only issues were on paper, which included his age and his marginal renal function, with a serum creatinine of 1.7. At first, I sheepishly asked for a "less-than-perfect" donor heart but the programs I dealt with were unenthusiastic about that option. Eventually he was turned down by all three local centers due to a marginal 24-hour urine study result. Just as we were about to concede defeat, Dr Stacy Davis, a heart-failure specialist formerly at Vanderbilt University, suggested I send him to Cleveland Clinic for a Dor procedure. Waldo jumped at the chance. What drowning man wouldn't?
After what seemed to be a successful operation, including a mitral-valve repair, coronary bypass grafting, and Alfieri stitch, an intra-aortic balloon pump was placed and Waldo was transferred to the recovery room. He crashed with hypotension and pulmonary edema minutes later and was hastily taken back into the OR for an LVAD implant as a last-ditch effort. In no time, thanks to Dr Patrick McCarthy and his team, he was up and around in the ICU in his usual good humor. Two weeks later, the ultimate gift, the essence of theatrical comedy and tragedy, came to Waldo. A 14-year-old old boy was irreparably injured in a traffic accident in Michigan. On June 17, 1999, because of the generous gift of life given by a grieving family in the throes of anguish, 70-year-old Luther Waldo Meredith began a new life with his new 14-year-old heart.
Moderate grade 3A rejection complicated his postoperative course and by July 21 an increase in antirejection meds was required. He developed diabetes and later complained of fatigue and irritability. An unusual mold was identified in his lungs and was treated with itraconazole, but a diffuse macular rash appeared on his chest surrounding his median sternotomy incision. Later, sternal debridement was required and a prolonged course of itraconazole, vancomycin, and levofloxacin was planned. On December 26, just five months after his transplant and five years after the heart attack that wrecked his life, he "walked to McDonald's to visit with friends," an 11-year ritual that persisted until two weeks ago.
I read of Waldo's death in the Glasgow Daily Times last week. He apparently came into our hospitalist program and was rapidly transferred to a tertiary center. I called Nancy, his wife, a couple of days later and then his daughter, Janet, who is a nurse. They were tearful as they reminisced about all of the battles we had fought together. They related that he developed GI symptoms, dehydration, and renal failure. He had a bleeding issue, the details of which are unclear. What is remarkable about Waldo was that he remained alert, awake, and was never intubated, and just as he had always been very much in charge of his affairs throughout life, he soundly navigated his family through his death. While on multiple pressors he declined dialysis, and with his family at his side, he directed his physicians to discontinue all of his blood-pressure–supporting medications. With his daughter cradling him in her arms, he told his family goodbye, comforting them and telling them that he was going to a better place and that he was ready. Then peacefully he fell asleep, passing into yet another life, 11 wonderful years after his heart transplant. "He died with such grace," Janet told me and said that in those 11 years he saw his grandchildren get married, one get accepted to medical school, and another complete a nursing degree. He was blessed with a wonderful companion in his beautiful wife Nancy and a huge community of friends and other family members.
I asked a local transplant coordinator, Greg Bell of Jewish Hospital in Louisville, KY, about the topic of transplantation in the elderly. He told me that patients over the age of 65 continue to be highly selected. He assures me that the determining factors as to who receives a heart include issues such as critical status and length of time the patient has been listed. His team performed 18 transplants last year, but with very few donors available, procedural volume in many centers is declining. There is also the impact of LVAD availability, and destination therapy that can ease some of the crisis seen in the world of supply and demand, but with fewer hearts available, even fewer elderly patients will get the same chance that Waldo enjoyed. Dr Christiaan Barnard, who performed the world's first heart transplant in 1967, said, "The prime goal is to alleviate suffering and not to prolong life. And if your treatment does not alleviate suffering, but only prolongs life, that treatment should be stopped." I think Waldo and Dr Barnard would have gotten along beautifully. They shared the same philosophy that helped Waldo make the right decisions every step of the way.
Another famous Barnard quote should really take us to the tipping point to impact the crisis of supply and demand in cardiac transplantation. He said, "It is infinitely better to transplant a heart than to bury it to be devoured by worms." Check your donor card today and give the gift of life not only to the Waldos of the world, but to ensure an opportunity for all of the 2500 or more other human beings with lives to live who are waiting. Remember, it takes a heart to give one, and because of that, I'm sure Waldo would have passed his along to someone else if he could have.