Survival Data Show Viability of Transplants in Older Patients

Major Finding: Relative to sexagenarians, septuagenarians had both shorter unadjusted median survival (8.5 vs. 9.8 years) and predicted median adjusted survival (8.15 vs. 9.83 years), although most of the difference between groups appeared to result from a difference in the first year.

Data Source: A retrospective cohort study of 18,534 patients aged 60 years or older who were on the waiting list for heart transplantation.

Disclosures: Dr. Goldstein reported that he had no relevant financial disclosures.

SAN DIEGO – Heart transplant recipients in their 70s have outcomes that are generally similar to those of their counterparts in their 60s, new data show.

In a retrospective study of 18,534 wait-listed older adults, the rates of posttransplantation complications in septuagenarians were much the same as those in sexagenarians, except that the former were in fact less likely to experience rejection. And on average, the septuagenarians lived roughly 8 years after getting their new heart, which is not much shorter than the 9.8 years seen in sexagenarians, according to results reported at the meeting.

“Selected septuagenarians – and I underscore the word selected – with advanced heart failure derive great benefit from heart transplantation,” said lead investigator Dr. Daniel Goldstein. “This is not every 70-year-old [who is] going to walk into your office.”

The findings raise the thorny ethical issue of expanding age limits on eligibility for heart transplantation, as organs are scarce and every heart given to an older adult is one that is not given to a young person, he noted.

One approach would be to limit transplantation to those septuagenarians who have the best risk profile. Another would be to use an alternative list, as first tested by the University of California, Los Angeles, whereby older recipients are given hearts that are typically rejected by transplant centers.

“I don't see being able to do this without having an alternative list situation. UCLA is the perfect model,” asserted Dr. Goldstein, a cardiothoracic surgeon at the Montefiore Einstein Center for Heart and Vascular Care at Montefiore Medical Center in the Bronx, N.Y. “It would be hard to get an 18-year-old donor and give the heart to a 70-year-old, but if you take in a heart that nobody else wants, I think it's a little more palatable.”

With the aging of the population and the epidemic of heart failure among older adults, this dilemma is likely to intensify, he noted.

Centers generally use an age cutoff of 65 years for cardiac transplantation eligibility. But an informal survey of centers in the New York City and New Jersey areas suggests that “there is great variability in who we think is too old for transplantation,” he said. “It's clear that more centers are doing away with chronological age criteria.”

In the study, the investigators analyzed data from the UNOS (United Network for Organ Sharing) database for 1987-2010, first looking at trends among 18,534 adults aged 60 years or older put on the waiting list for a primary, single-organ heart transplantation. Results showed that “in the current era, septuagenarians are being transplanted more frequently, without a doubt,” Dr. Goldstein said. The number undergoing transplantation increased almost every year, and their median age was 71 years.

For age-group comparisons, the investigators restricted analyses to the years 1998-2010, a period when the data became robust and contemporary medical and surgical practices were in use, he explained.

Relative to the 5,807 sexagenarians who underwent transplantation during this period, the 332 septuagenarians who did were generally similar in terms of a wide range of comorbidities and risk factors, with a few exceptions.

Patients in the older group were more likely to be male and nondiabetic and, in terms of acuity, were less likely to be on a ventricular assist device and more likely to have the lower status 2 priority at transplantation.

With respect to recipient-donor matching, the septuagenarians were more likely to have a donor who was not an identical ABO match and who died from intracranial hemorrhage. Also, their donors were older.

In findings that Dr. Goldstein called “quite eye opening,” there were no differences between septuagenarians and sexagenarians in most posttransplantation complications (rejection during hospitalization, stroke, length of hospital stay, and receipt of a pacemaker) or in cause of death. The former were less likely to be treated for graft rejection in the first year (19% vs. 32%).

In a multivariate analysis, an age of 70 years or older was a significant risk factor for death (hazard ratio, 1.29).

Relative to sexagenarians, septuagenarians had both shorter unadjusted median survival (8.5 vs. 9.8 years) and predicted median adjusted survival (8.15 vs. 9.83 years), although most of the difference between groups appeared to result from a difference in the first year.

“I was rather surprised” by the 8-year value for the septuagenarians. “That's a very important number,” commented Dr. Goldstein.

“While survival is comparatively reduced, it still exceeds by a lot what we currently see with mechanical support therapy,” he said.

In a final analysis that was restricted to patients who survived the first year post transplantation, patients aged 70 years or older no longer had an increased risk of death, compared with their counterparts aged 60-69 years.

View on the News

Consider Ethics, Consequences

The boundaries of reasonable medical care are being pushed daily, and it now appears that heart transplantation can be done safely with acceptable survival in septuagenerians. Do these recipients receive the same posttransplant survival benefit as sexagenerians? Not quite, but it's pretty close. The small survival differences between the septuagenarians and sexagenerians suggest that age (and perhaps selection bias) should allow for older patients to be considered, in certain circumstances, as candidates. What sets organ transplantation apart from other heroic interventions (e.g., experimental chemotherapy for patients with metastatic cancer) is that donor organs are an exquisitely limited commodity. The ethics of increasing the recipient pool by including older patients must be considered, and this change may have significant consequences for younger patients on the wait list.

DR. SUDISH MURTHY is an ACS fellow and surgical director of the Center for Major Airway Disease at the Cleveland Clinic.

Vitals

Major Finding: Relative to sexagenarians, septuagenarians had both shorter unadjusted median survival (8.5 vs. 9.8 years) and predicted median adjusted survival (8.15 vs. 9.83 years), although most of the difference between groups appeared to result from a difference in the first year.

Data Source: A retrospective cohort study of 18,534 patients aged 60 years or older who were on the waiting list for heart transplantation.

Disclosures: Dr. Goldstein reported that he had no relevant financial disclosures.

SAN DIEGO – Heart transplant recipients in their 70s have outcomes that are generally similar to those of their counterparts in their 60s, new data show.

In a retrospective study of 18,534 wait-listed older adults, the rates of posttransplantation complications in septuagenarians were much the same as those in sexagenarians, except that the former were in fact less likely to experience rejection. And on average, the septuagenarians lived roughly 8 years after getting their new heart, which is not much shorter than the 9.8 years seen in sexagenarians, according to results reported at the meeting.

“Selected septuagenarians – and I underscore the word selected – with advanced heart failure derive great benefit from heart transplantation,” said lead investigator Dr. Daniel Goldstein. “This is not every 70-year-old [who is] going to walk into your office.”

The findings raise the thorny ethical issue of expanding age limits on eligibility for heart transplantation, as organs are scarce and every heart given to an older adult is one that is not given to a young person, he noted.

One approach would be to limit transplantation to those septuagenarians who have the best risk profile. Another would be to use an alternative list, as first tested by the University of California, Los Angeles, whereby older recipients are given hearts that are typically rejected by transplant centers.

“I don't see being able to do this without having an alternative list situation. UCLA is the perfect model,” asserted Dr. Goldstein, a cardiothoracic surgeon at the Montefiore Einstein Center for Heart and Vascular Care at Montefiore Medical Center in the Bronx, N.Y. “It would be hard to get an 18-year-old donor and give the heart to a 70-year-old, but if you take in a heart that nobody else wants, I think it's a little more palatable.”

With the aging of the population and the epidemic of heart failure among older adults, this dilemma is likely to intensify, he noted.

Centers generally use an age cutoff of 65 years for cardiac transplantation eligibility. But an informal survey of centers in the New York City and New Jersey areas suggests that “there is great variability in who we think is too old for transplantation,” he said. “It's clear that more centers are doing away with chronological age criteria.”

In the study, the investigators analyzed data from the UNOS (United Network for Organ Sharing) database for 1987-2010, first looking at trends among 18,534 adults aged 60 years or older put on the waiting list for a primary, single-organ heart transplantation. Results showed that “in the current era, septuagenarians are being transplanted more frequently, without a doubt,” Dr. Goldstein said. The number undergoing transplantation increased almost every year, and their median age was 71 years.

For age-group comparisons, the investigators restricted analyses to the years 1998-2010, a period when the data became robust and contemporary medical and surgical practices were in use, he explained.

Relative to the 5,807 sexagenarians who underwent transplantation during this period, the 332 septuagenarians who did were generally similar in terms of a wide range of comorbidities and risk factors, with a few exceptions.

Patients in the older group were more likely to be male and nondiabetic and, in terms of acuity, were less likely to be on a ventricular assist device and more likely to have the lower status 2 priority at transplantation.

With respect to recipient-donor matching, the septuagenarians were more likely to have a donor who was not an identical ABO match and who died from intracranial hemorrhage. Also, their donors were older.

In findings that Dr. Goldstein called “quite eye opening,” there were no differences between septuagenarians and sexagenarians in most posttransplantation complications (rejection during hospitalization, stroke, length of hospital stay, and receipt of a pacemaker) or in cause of death. The former were less likely to be treated for graft rejection in the first year (19% vs. 32%).

In a multivariate analysis, an age of 70 years or older was a significant risk factor for death (hazard ratio, 1.29).

Relative to sexagenarians, septuagenarians had both shorter unadjusted median survival (8.5 vs. 9.8 years) and predicted median adjusted survival (8.15 vs. 9.83 years), although most of the difference between groups appeared to result from a difference in the first year.

“I was rather surprised” by the 8-year value for the septuagenarians. “That's a very important number,” commented Dr. Goldstein.

“While survival is comparatively reduced, it still exceeds by a lot what we currently see with mechanical support therapy,” he said.

In a final analysis that was restricted to patients who survived the first year post transplantation, patients aged 70 years or older no longer had an increased risk of death, compared with their counterparts aged 60-69 years.

View on the News

Consider Ethics, Consequences

The boundaries of reasonable medical care are being pushed daily, and it now appears that heart transplantation can be done safely with acceptable survival in septuagenerians. Do these recipients receive the same posttransplant survival benefit as sexagenerians? Not quite, but it's pretty close. The small survival differences between the septuagenarians and sexagenerians suggest that age (and perhaps selection bias) should allow for older patients to be considered, in certain circumstances, as candidates. What sets organ transplantation apart from other heroic interventions (e.g., experimental chemotherapy for patients with metastatic cancer) is that donor organs are an exquisitely limited commodity. The ethics of increasing the recipient pool by including older patients must be considered, and this change may have significant consequences for younger patients on the wait list.

DR. SUDISH MURTHY is an ACS fellow and surgical director of the Center for Major Airway Disease at the Cleveland Clinic.

Vitals

Major Finding: Relative to sexagenarians, septuagenarians had both shorter unadjusted median survival (8.5 vs. 9.8 years) and predicted median adjusted survival (8.15 vs. 9.83 years), although most of the difference between groups appeared to result from a difference in the first year.

Data Source: A retrospective cohort study of 18,534 patients aged 60 years or older who were on the waiting list for heart transplantation.

Disclosures: Dr. Goldstein reported that he had no relevant financial disclosures.

SAN DIEGO – Heart transplant recipients in their 70s have outcomes that are generally similar to those of their counterparts in their 60s, new data show.

In a retrospective study of 18,534 wait-listed older adults, the rates of posttransplantation complications in septuagenarians were much the same as those in sexagenarians, except that the former were in fact less likely to experience rejection. And on average, the septuagenarians lived roughly 8 years after getting their new heart, which is not much shorter than the 9.8 years seen in sexagenarians, according to results reported at the meeting.

“Selected septuagenarians – and I underscore the word selected – with advanced heart failure derive great benefit from heart transplantation,” said lead investigator Dr. Daniel Goldstein. “This is not every 70-year-old [who is] going to walk into your office.”

The findings raise the thorny ethical issue of expanding age limits on eligibility for heart transplantation, as organs are scarce and every heart given to an older adult is one that is not given to a young person, he noted.

One approach would be to limit transplantation to those septuagenarians who have the best risk profile. Another would be to use an alternative list, as first tested by the University of California, Los Angeles, whereby older recipients are given hearts that are typically rejected by transplant centers.

“I don't see being able to do this without having an alternative list situation. UCLA is the perfect model,” asserted Dr. Goldstein, a cardiothoracic surgeon at the Montefiore Einstein Center for Heart and Vascular Care at Montefiore Medical Center in the Bronx, N.Y. “It would be hard to get an 18-year-old donor and give the heart to a 70-year-old, but if you take in a heart that nobody else wants, I think it's a little more palatable.”

With the aging of the population and the epidemic of heart failure among older adults, this dilemma is likely to intensify, he noted.

Centers generally use an age cutoff of 65 years for cardiac transplantation eligibility. But an informal survey of centers in the New York City and New Jersey areas suggests that “there is great variability in who we think is too old for transplantation,” he said. “It's clear that more centers are doing away with chronological age criteria.”

In the study, the investigators analyzed data from the UNOS (United Network for Organ Sharing) database for 1987-2010, first looking at trends among 18,534 adults aged 60 years or older put on the waiting list for a primary, single-organ heart transplantation. Results showed that “in the current era, septuagenarians are being transplanted more frequently, without a doubt,” Dr. Goldstein said. The number undergoing transplantation increased almost every year, and their median age was 71 years.

For age-group comparisons, the investigators restricted analyses to the years 1998-2010, a period when the data became robust and contemporary medical and surgical practices were in use, he explained.

Relative to the 5,807 sexagenarians who underwent transplantation during this period, the 332 septuagenarians who did were generally similar in terms of a wide range of comorbidities and risk factors, with a few exceptions.

Patients in the older group were more likely to be male and nondiabetic and, in terms of acuity, were less likely to be on a ventricular assist device and more likely to have the lower status 2 priority at transplantation.

With respect to recipient-donor matching, the septuagenarians were more likely to have a donor who was not an identical ABO match and who died from intracranial hemorrhage. Also, their donors were older.

In findings that Dr. Goldstein called “quite eye opening,” there were no differences between septuagenarians and sexagenarians in most posttransplantation complications (rejection during hospitalization, stroke, length of hospital stay, and receipt of a pacemaker) or in cause of death. The former were less likely to be treated for graft rejection in the first year (19% vs. 32%).

In a multivariate analysis, an age of 70 years or older was a significant risk factor for death (hazard ratio, 1.29).

Relative to sexagenarians, septuagenarians had both shorter unadjusted median survival (8.5 vs. 9.8 years) and predicted median adjusted survival (8.15 vs. 9.83 years), although most of the difference between groups appeared to result from a difference in the first year.

“I was rather surprised” by the 8-year value for the septuagenarians. “That's a very important number,” commented Dr. Goldstein.

“While survival is comparatively reduced, it still exceeds by a lot what we currently see with mechanical support therapy,” he said.

In a final analysis that was restricted to patients who survived the first year post transplantation, patients aged 70 years or older no longer had an increased risk of death, compared with their counterparts aged 60-69 years.

View on the News

Consider Ethics, Consequences

The boundaries of reasonable medical care are being pushed daily, and it now appears that heart transplantation can be done safely with acceptable survival in septuagenerians. Do these recipients receive the same posttransplant survival benefit as sexagenerians? Not quite, but it's pretty close. The small survival differences between the septuagenarians and sexagenerians suggest that age (and perhaps selection bias) should allow for older patients to be considered, in certain circumstances, as candidates. What sets organ transplantation apart from other heroic interventions (e.g., experimental chemotherapy for patients with metastatic cancer) is that donor organs are an exquisitely limited commodity. The ethics of increasing the recipient pool by including older patients must be considered, and this change may have significant consequences for younger patients on the wait list.

DR. SUDISH MURTHY is an ACS fellow and surgical director of the Center for Major Airway Disease at the Cleveland Clinic.

Vitals