It may be time to revisit patient selection protocols for heart transplants

As medical therapies for heart failure continue to improve, advanced heart failure specialists and transplant programs must consider individualized approaches for each patient, including in the older adult population.

"There have been over 1,100 older adults transplanted in the last decade, and most recently in 2021, upwards of 150 older adults were transplanted, reflecting about about 5% of the total transplant population. So the first question we asked was, who are we transplanting? Then the next question we asked was, how are older adults that we transplant doing?" Golab said.

Transplant trends and demographics of older adults

Between 2010 and 2021, there was a significant increase in both the total number of heart transplants and the number performed in older adults, according the the United Network for Organ Sharing (UNOS) database the team looked at for data. Golab noted that older adults selected for heart transplants tended to have similar functional statuses compared to their younger counterparts. However, they were more likely to have heart failure due to ischemic cardiomyopathy and a history of prior malignancies. Interestingly, they were less likely to be on dialysis at the time of transplant. Golab said these traits show physicians are pre-selecting the most healthy older adults for transplant. 

"Regarding illness severity at transplant, older adults transplanted are less likely to be on ECMO (extracorporeal membrane oxygenation) or status one to three prior to transplant, meaning the absolute sickest older adults are not being transplanted, possibly because they don't bounce back as well," Golab explained. 

She said these patients were also more likely to have been on inotropes prior to transplant.

Outcomes and survival rates in heart transplants

One-year mortality rates for older adults were slightly higher compared to those under 70 years old (89.2% vs. 91.2%). However, by the five-year mark, this difference in mortality rates disappeared, showing no statistically significant variance between the two groups. It's worth noting that conditional survival at five years for those who survived the first year showed no significant difference between the age groups.

Regarding causes of death, older adults were more likely to succumb to malignancies or infectious diseases post-transplant, while younger adults faced a higher risk of dying from cardiovascular diseases or graft failure. Additionally, older adults experienced fewer acute rejection episodes requiring increased immunosuppression compared to their younger counterparts.

"In terms of post-transplant significant events, there was less likely to be acute rejection requiring increase in immunosuppression in older adults than there were in younger adults," Golab explained.

Implications and future considerations in heart transplant

"So we take away that the absolute number of older adults receiving heart transplants is increasing. We need to figure out how to best care for these older adults," Golab said. She added the challenge traditional protocols governing heart transplant candidacy, particularly in older adults. 

Golab emphasized the need to reconsider these protocols and take a more individualized approach based on a patient's risk profile.

Addressing organ shortages it heart transplants

Golab touched upon the inequity between the number of individuals in need of heart transplants and the limited availability of donor organs. Efforts to address this shortage include exploring wider donor populations, such as donors after circulatory death and Hepatitis C-positive donors.

"NYU was a pioneer in using Hepatitis C positive donors and as physicians, it's our responsibility to advocate for the patient in front of us, but also make sure that they're an appropriate heart transplant recipients," Golab said.