Heart transplants save lives. Sometimes, however, a transplanted heart fails, the recipient goes back on the waiting list, and receives another heart transplant, or even a third. Is this fair to other people on the waiting list?
Waiting for a heart transplant can be a miserable experience. When your heart is so damaged that you need a new one, you aren't very likely to have the energy you need to work, to engage in hobbies, to get out and see people, or even to cook your own meals and keep your own house. You may be constantly concerned that you will catch some infection that will bounce you off the list, and you have to stay close to a transplant hospital, ready to come in on just two or three hours' notice when the center finally has a donor heart for you.
The waiting time for heart transplants varies a great deal from location to location. In the UK, it may be as little as six months (on average). In the US, it can be as little as four months or as long as four years. A donor of the right blood type and body size has to be available to provide the heart.
Usually, more than one potential transplant recipient fits the body size and tissue type restrictions, so allocation is made in accordance to pre-defined criteria. In the United States:
- Status 7 patients are people who are temporarily "off the list" because of a change of their condition. Maybe they passed a stress test and their hearts are judged to be strong enough that they do not need a heart transplant. Maybe they have an infection that would put too much stress on a newly transplanted heart, and they need to wait until the infection clears. Maybe they had a fever that isn't explained and they can't go back on the waiting list until it is. Status 7 patients get their place on the list back when their condition worsens.
- Status 2 patients are stable on oral medications, and able to live at home.
- Status 1B patients need intravenous medications, whether at home or in the hospital, or they need a mechanical device to assist the heart.
- Status 1A patients are in the most urgent need for a heart transplant. They are usually in the intensive care unit of the hospital.
As hearts become available, they go to status 1A patients first, then 1B, then 2, and then 7. It's rare for anyone who isn't status 1A or 1B to get a heart.
Patients don't go up the list when someone gets a transplant. The best matches are found in group 1A, and in the unusual event that there is no one in group 1A who is compatible to the donor, the doctors look at whether they can get the donated heart in time to someone in group 1B.
An odd fact about heart transplants is that people whose hearts are "bad" but able to live at home, those in group 2, are actually more likely to die if they receive a heart transplant than if they don't. Among group 1 patients, about 27 percent die before a heart can be found. Some patients, however, get more than one heart transplant.
The Facts About Multiple Heart Transplants
Heart transplants almost always extend life. They just don't give recipients a normal lifespan. About 75 percent of heart transplant recipients live at least three years. About 50 percent live 10 years or more. Around four percent of all transplant recipients develop a condition called allograft vasculopathy, in which the body, despite anti-rejection drugs, rejects and destroys the new heart, so that a second transplant is required. Around 0.4 percent of patients develop this condition twice, requiring a third heart.
Every year, about one in 50 heart transplants is a second, third, or even fourth transplant due to rejection. Success rates for multiple transplant attempts are abyssmal.
At the University of California at Los Angeles, for example:
- 94.5 percent of patients survive their first transplant procedure by at least a month, and 59.9 percent are alive 10 years later.
- 94.1 percent of patients survive their second transplant procedure by at least a month, and 45.8 percent are alive 10 years later.
- 80 percent of patients survive their third transplant procedure by at least a month, but none live as long as five years.
- No patient receiving a fourth heart transplant has lived more than a few months.
Is it fair to give four percent of patients a second, third, or even fourth heart, when over a quarter of potential heart transplant patients will die waiting for their first? Many ethicists do not think so.
Public perception of the fairness of the procedure is clouded by the fact that some famous people get multiple heart transplants, although in theory they are under the same rules as everyone else.
Golfer Erik Compton, for example, has had two transplants. However, there are reasons he has found his way to the top of the list twice. For one thing, he is a professional athlete in good shape other than for his heart. His heart was destroyed by viral cardiomyopathy. He had his first heart transplant at the age of 12. He had his second heart transplant at the age of 28, healthy enough to drive himself to the hospital after he had a heart attack. To the extent of whether the question is "Will this transplant extend life?" the answer in Compton's case seems to have been an enthusiastic yes.
The recipient of the four-time heart transplant at UCLA, it should be noted, was a child. Giving this child a heart did not deprive any adult of the transplant, and children who need transplants are relatively rare. Nonetheless, some philosophers propose that there should simply be a ban on multiple transplants as long as some people are dying while on the waiting list, especially when it is children who are on the waiting list.
In 2015, an eight-year-old girl named Aiyana Lucas received her third heart at Seattle Children's Hospital. Because of her severe heart disease and her age, she went right to the head of the national heart transplant list. She got a new heart, but it failed to pump much at all, and she went right back on a heart-lung machine. She then went back to the head of the national heart transplant list, and got a second heart. That heart also failed, but because she had to go back on the heart-lung machine, again, she got a third.
Nobody expects Aiyana's family or doctors to turn down a fifth, sixth, or seventh heart if they become available.
However, because other children may have died while waiting for their own hearts, the rules are likely to change to prohibit third and fourth heart transplants and to strictly limit second transplants, in the near future in the USA.
Sources & Links
- Caplan, Arthur. How Many Hearts Should One Child Receive? Medscape News. http://www.medscape.com/viewarticle/849989. Accessed 2 September 2015.
- Photo courtesy of hyekab25 via Flickr: www.flickr.com/photos/hyekab25/4908283785
- Photo courtesy of theglobalpanorama via Flickr: www.flickr.com/photos/121483302@N02/14417362179