SPECIAL ARTICLE
Heart transplantation in the Netherlands: quo vadis?
J.H. Kirkels, N. de Jonge, C. Klopping, J.R. Lahpor, L.A. van Herwerden, A.H.M.M. Balk, A.J.J.C. Bogers, AYP.W.M. Maat, P.A.F.M. Doevendans
Heart transplantation is limited by the lack of donor organs. Twenty years after the start of the Dutch transplant programmes in Rotterdam and Utrecht the situation has even worsened, despite efforts to increase the donor pool. The Dutch situation seems to be worse than in other surrounding countries, and several factors that may influence donor organ availability and organ utilisation are discussed. The indications and contraindications for heart transplantation are presented, which are rather restrictive in order to select optimal recipients for the scarce donor hearts. Detailed data on donor hearts, rejected for transplantation, are shown to give some insight into the difficult process of dealing with marginal donor organs. It is concluded that with the current low numbers of acceptable quality donor hearts, there is no lack of capacity in the two transplanting centres nor is the waiting list limiting the number of transplants. The influence of our current legal system on organ donation, which requires (prior) permission from donor and relatives, is probably limited. The most important determinants ofdonor organ availability are: 1. The potential donor pool, consisting of brain dead victims of (traffic) accidents and CVAs and 2. Lack of consent to a request for donation. J.H. Klrkels N. de Jonge C. Kiopping J.R. Lahpor LA. van Herwerden P.A.F.M. Doevendans Department of Cardiology, University Medical Centre, Utrecht, the Netherlands A.H.M.M. Balk A.JJ.C. Bogers A.P.W.M. Maat Erasmus Medical Centre, Rotterdam, the Netherlands
Correspondence to: J.H. Kirkels Department of Cardiology, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands E-mail:
[email protected]
Netherlands Heart Journal, Volume 14, Number 12, December 2006
The potential donor pool is remarkably small in the Netherlands, due to relatively low numbers of (traffic) accidents, with an almost equal number of CVA-related brain dead patients compared with neighbouring countries. Lack ofconsent can only be pushed back by improved public awareness of the importance of donation and improved skills of professionals in asking permission in case there is no previous consent. (NethHeartJ2006;14:425-30.) Keywords: heart transplantation, Netherlands From a quantitative point of view, heart transplantation hardly contributes to the huge problem of heart failure. Nevertheless, the subject is appealing to cardiologists, cardiac surgeons as well as patients. The quality oflife after heart transplantation can be excellent ifpatients have been selected careftilly, and survival over 20 years is possible. The Dutch programme for heart transplantation started in the mid-1980s (1984 in Rotterdam and 1985 in Utrecht), after a long period of decision-making by the government. Aprerequisite for the start and reimbursement ofthe programme was the use of strict and similar protocols and yearly evaluation and reporting to the Ministry of Health. Organ donation is also strictly regulated in the Netherlands. Specific legislation (WOD, Wet op de Orgaan Donatie, 1998) has three goals: to regulate the fair allocation of organs, to protect personal integrity and to facilitate and expand organ donation. It was hoped that, even with continuation of the 'opting-in' system (permission required), an intensive public awareness programme would raise the number ofavailable donor organs.' In spite of all efforts, however, none of initiatives so far have resulted in an increase in heart transplants. On the contrary, the number has decreased in recent years, as it has in all other countries over the world; as a result waiting time and waiting list mortality are increasing. The decrease in heart transplant numbers has raised the question whether all potential donor hearts are being used in an optimal manner. Numbers (per million
425
Heart transplantation in the Netherlands: quo vadis?
Table 1 Contraindications for heart transplantation. * Severe irreversible pulmonary hypertension (PVR >400 dynes sec cm5, or TPG >15 mmHg despite optimal vasodilators) * Infectious disease * Irreversible renal insufficiency * Irreversible hepatic insufficiency * Complicated diabetes * Diffuse vascular disease * Previous malignancies with risk of recurrence * Severe pulmonary disease * Other systemic diseases * Obesity * Lack of compliance / substance abuse PVR=pulmonary vascular resistance, TPG=transpulmonary gradient.
inhabitants) in neighbouring countries have always been higher (although also decreasing) but, paradoxically, the number of lung transplantations is increasing.2 In this artide, we will discuss some transplantation-related issues which may contribute to a better understanding ofthe problem. Indication and contraindicatlons for heart transplantation The indication for heart transplantation can be summarised as follows: end-stage heart disease with functional class NYHA III-IV despite optimal treatment otherwise, including catheter and conventional surgical options. Objective measures for functional capacity are peak VO2
