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Jan F Gummert, Heart Transplantation in Bad Oeynhausen, Germany: The Heart Transplant program at the Heart and Diabetes Center Bad Oeynhausen, University Hospital, Ruhr - University Bochum University, Germany, European Heart Journal, Volume 38, Issue 46, 07 December 2017, Pages 3411–3413, https://doi.org/10.1093/eurheartj/ehx698
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This article is dedicated to all the valued past and present members of the HDZ NRW heart failure team.
Since the first successful human heart transplantation by Barnard in South Africa in 1967,1 this treatment option has evolved as the gold standard for terminal heart failure patients2 with the introduction of cyclosporine A in 1980.3
In the Heart and Diabetes Center Nord Rhine-Westphalia (HDZ NRW), a University Hospital of the Ruhr—University Bochum (RUB), Germany, the first human heart transplantation (HTx) was performed in March 1989.4 In parallel, a very active mechanical circulatory support (MCS) program was established to address the shortage of donor organs in Germany existing at that time.
From the very beginning, the organization of the heart transplant program met the highest quality standards which allowed a rapid increase in volume. During the first year of the program in 1989, 39 patients were transplanted, in 1991, only 2 years after the program started, a record of 148 patients received a donor heart (Figure 1). By December 2016 more than 2290 hearts were transplanted at the HDZ NRW. Due to increasing donor organ shortage, the annual number of transplantations subsequently decreased during the following years but remained stable between 70 and 90 transplants per year, thereby still remaining the largest heart transplant Centre in Germany. This high number of annual transplantations is also a reflection of the currently large waiting list in our Centre.
Seven patients were older than 75 years (with a mean survival of 6 years after HTx), the youngest 2 days old, and donor age ranged from 1 day to 72 years. The leading heart failure diagnosis was cardiomyopathy in 53%, followed by ischaemic heart disease in 38%, valvular disease in 5%, congenital heart disease in 3%, and re-transplantation in 2% of the patients.
The Bad Oeynhausen strategy
Key factors for this successful heart transplantation program was a dedicated transplant department with specifically trained nursing staff for the transplant program and a specialized team of physicians available 24 h per day. Social workers, nutritionists, and physiotherapist are also an integral part of this program. In addition, a very active group of patients is supporting the transplant program with individual patient support and general educational activities. The transplantation ward accommodates 26 patients in single rooms to care for pre- and post-operative heart transplant patients. Invasive haemodynamic monitoring, intra-aortic balloon pump (IABP), dialysis, and respirator treatment is available. In fact, this has been a form of ‘prototype’ for the nowadays so-called heart failure units.
Heart transplantation co-ordinators are responsible for organizing every aspect of organ procurement in addition to other tasks to ensure perfect logistics, to achieve a maximum of three transplantations on the same day. Only a limited number of cardiac surgeons could procure donor organs enabling the accumulation of considerable expertise for these persons. From the early days on, it was the goal to set up a ‘high volume’ program in order to gain the necessary experience for high quality. The early introduction of a ventricular assist device (VAD)/total artificial heart (TAH) program was crucial to deal with the looming donor organ shortage.
Later, a specialized psychology service for transplant patients was added, to deal with the psychological aspects of terminal heart failure patients as well as to provide continued support for long-term transplant patients. With the advent of different immunosuppressive drugs an individualized immunosuppressive therapy5,6 was introduced to further improve the long-term outcome. With this strategy, a continuous successful heart transplant program for adults as well as children was able to be established. The long-term survival for different time periods after the first heart transplantation (re-transplantation excluded) is shown in Figure 2.
The era of organ shortage—struggling for the best treatment strategy
The scarcity of donor organs has affected all transplant programs in Germany including the heart transplant program in Bad Oeynhausen. The mean waiting time for High Urgency (HU) status patients on the waiting list in our Centre was 13 days until the year 2003 and increased up to 140 days in 2012, and currently averages 90 days throughout the last 3 years. The percentage of HU transplantations was 20% in the year 2000 and 90% in 2015, which equals the average figures for Germany. This development illustrates the current dilemma in heart transplantation. Since the patients on HU status are required to be treated in an intensive care unit (ICU), our Centre has doubled its ICU capacity to accommodate these patients in recent years.
Another effect of donor organ shortage was the increase of VAD/TAH implantations. In 2005, 52 VAD/TAH were implanted, since 2009 more than 100 VAD/TAH have been implanted annually. The current debate for the best time-point for implanting a VAD is ongoing since reliable data are still missing. The ongoing Early VAD trial will help to close this gap and facilitate decision making.
In the absence of other data our Centre currently follows the strategy that heart transplantation is still the best option for eligible terminal heart failure patients. Therefore, we still offer patients—whenever possible—the opportunity for heart transplantation via a HU-status who are on continuous inotrope therapy. Our recent data demonstrate that this strategy can be successful even in the circumstances of long ‘HU’ waiting times.
Less than 50% of all transplanted patients have the need for prior VAD support. The proportion of patients transplanted from the elective ‘T’ list is as low as 10–15% but the individual waiting time is unpredictably long. One important aspect of this strategy is a minimal possibility to receive a ‘status T’ heart transplantation in a bridge to transplant setting. Most patients will not have a realistic chance for an elective (status T) transplantation after VAD implantation anymore. One year after VAD implantation only 1% of patients are transplanted with ‘T’—status in our program. In response to this situation patients must be informed in advance that the ‘bridge to transplant’ option for every patient is not a realistic one in Germany any more. For VAD patients only life-threatening complications such as thrombo-embolic events, device infection or technical device failure make them eligible for a HU status for heart transplantation. In addition, one has also to accept a below average post-transplant outcome in this patient cohort.
In the case of biventricular heart failure and subsequently needed biventricular support, VAD implantation is certainly not the best choice. For approximately 30% of our patients, biventricular heart failure excludes them from being eligible for standard VAD implantation. These patients probably benefit most by ‘HU’ heart transplantation as the primary therapy. However, if these patients cannot be stabilized with continued administration of inotropes and/or intra-aortic balloon counter-pulsation (IABP), a VAD/TAH implantation is usually considered in this patient cohort. In our view, the greatest difficulty in times of limited donor organs and unforeseeable waiting times is to pick the correct therapeutic strategy, HU status or VAD implantation, for every individual patient. These decision processes rely on the expertise and experience of the entire heart failure team at the HDZ-NRW.
Mechanical circulatory support and heart transplantation
Heart transplantation and MCS are both important treatment options in heart failure patients. However, the lifetime of mechanical support systems is not comparable to transplantation, even though the early outcomes have markedly improved. We believe that MCS programs should currently be preferably situated in active transplant centres or should have a close collaboration with such a Centre to ensure the best possible treatment option for each individual patient. If long-term MCS therapy continues to evolve this may change in the future.
Future perspectives of heart transplantation in Germany
Unfortunately, the number of donor organs has stabilized at a very low level, with less than 300 heart transplantations per year being currently performed in Germany. Despite all efforts it will be very difficult to increase this number in the near future. Therefore, it will be necessary to further reduce the number of active heart transplant programs to allow a sufficient number of transplants for each Centre to ensure a high quality of the program.
However, we still believe—in contrast to other experts in this field—that transplantation is still the most important option for terminal heart failure patients. Despite much progress in the field of mechanical circulatory support since 2000, the heart failure community is currently waiting for a ‘true next generation’ device addressing the burning problems of current devices—high stroke rate, the necessity of a drive line, infections, and gastrointestinal bleeding.
For most patients, the quality of life is still better after a successful heart transplantation which is also our own personal motivation to battle for organ donation, thus increasing the number of donor organs to help these patients in desperate need for a heart transplant.
Conflict of interest: none declared.
References
References are available as supplementary material at European Heart Journal online.