Is Dick Cheney just the first of a new wave of older patients who will be receiving heart transplants?  In The Doctor’s World column in Tuesday’s Science Times, Lawrence K. Altman, M.D., chronicled the numerous medical advances that have helped the former vice president, now 71, survive serious heart disease for decades, culminating in perhaps the most miraculous treatment of all: a new heart.  But in the near future, Mr. Cheney’s case is likely to be the exception, not the rule. Transplant centers don’t expect a flood of older patients anytime soon. Most 70-something adults with failing hearts aren’t good candidates for these demanding surgeries, experts say, and in any event, organs are just too scarce.  Each transplant center decides on its own which older patients to accept for transplant and under what circumstances, and policies vary across the country. Some centers, like the Cleveland Clinic and Johns Hopkins Medicine, will operate on patients in their early or even middle 70s. Other centers will not.  Just a decade ago, people 65 and older were routinely rejected for heart transplants at all but a few institutions. But in 2006, the International Society for Heart and Lung Transplantation issued new guidelines saying that heart failure patients should be considered for transplants up to age 70.  The voluntary guidelines reflected advances in transplantation and a growing older population in better health and with longer lifespans than in decades past. The society left open the possibility of transplanting hearts into patients over age 70, as long as recipients were otherwise in very good health.  “Many of these older patients can transition to an even older age while maintaining a very good quality of life. Why would we deny someone that opportunity?” said Dr. Mandeep Mehra, executive director of the Center for Advanced Heart Disease at Brigham and Women’s Hospital in Boston and chairman of the committee that drew up the society’s new criteria.  The new policy has led to a gradual expansion of heart transplants in older patients. But the frequency of these procedures has not risen dramatically, because of an acute shortage of donor hearts, strict eligibility standards for potential recipients and caution at transplant centers that do not want to jeopardize success averages with risky operations.  In 2006, 243 patients age 65 and older in the United States received new hearts; last year, that number was 332, according to data from the national Organ Procurement and Transplantation Network. (Data strictly on patients 70 and older is not available, according to the network.)  As of mid-March, 517 people age 65 and older were waiting for new hearts. In 2011, 55 patients in this age group died before organs became available.  Heart transplantation involves major, invasive surgery and burdensome follow-up care; two dozen biopsies are usually performed on each patient in the first two years alone. So medical centers generally subject people in the 65-plus age bracket to especially rigorous evaluation before approving them as candidates.  To qualify, older men and women are supposed to have well-functioning kidneys, lungs, blood vessels, livers and other organs; good nutritional status and muscle strength; no cancer or chronic illnesses like diabetes; and the ability to comply with demanding self-care regimens after a transplant, including a lifetime of taking powerful immunosuppressant drugs, among other requirements.  Though older heart transplant patients have higher death and complication rates than younger patients, the differences are not substantial when recipients are carefully chosen, transplant surgeons say. At one year, 84 percent of heart transplant patients age 60 and above are alive, compared with 87 percent for younger patients, according to a 2008 study by researchers at Johns Hopkins. At five years, 69 percent of older patients have survived, compared with 75 percent of younger patients.  Researchers at NewYork-Presbyterian/Columbia University Medical Center have examined more recent data from their institution; they found that 87 percent of heart transplant patients 65 to 72 survived one year, and 76 percent were alive at five years. The research, as yet unpublished, was described by Dr. Yoshifumi Naka, director of the hospital’s cardiac transplantation program.  A study to be published in June in the Journal of Heart and Lung Transplantation shows that the oldest heart transplant patients do “quite well” but have a higher risk of infection, most likely because their immune systems are less active than younger patients, according to Dr. Mehra, the publication’s editor-in-chief. All transplant patients take immunosuppressant drugs to prevent rejection of their new hearts, and older patients may be getting overly high doses, he noted.  Another study in the journal, published earlier this year, found that heart transplant patients 60 and older reported greater satisfaction with their quality of life, less stress and depression, and more compliance with follow-up medical regimens than younger patients. Older patients seem to be “a distinct group” with more ability to handle the psychological aftermath of a transplant, said Bruce Rybarczyk of Virginia Commonwealth University and several co-authors. The study was based on survey responses from 555 transplant patients at four medical centers.  Still, debate continues over whether scarce organs should be allocated to seniors rather than to young people. Costs are clearly a consideration, with the average bill for a heart transplant (including preoperative care, the hospital stay, doctors’ care and a year’s worth of immunosuppressant drugs) totaling almost $1 million last year. As Dr. Altman noted, Medicare does pay for these operations.  “Personally, I think we should transplant 18 and younger and then address this issue of the young versus the old, taking care not to exclude older people but making sure that we put more emphasis on transplanting younger people,” said Dr. Jeffrey Punch, chief of transplantation surgery at the University of Michigan Health Systems.  National allocation policies already direct available hearts to patients under age 18, when possible, said a spokesman for the United Network for Organ Sharing.  Some transplant programs are dealing with this concern by trying to match older patients with hearts from older donors that are not appropriate for younger patients.  About 15 years ago, Ronald Reagan U.C.L.A. Medical Center began creating alternative lists of patients who were not considered good candidates for heart transplants because of their age. Instead of turning down patients who needed the procedure, doctors decided to give them donor hearts that had been rejected by other institutions (often from older donors).  “We believe this is an avenue for potentially offering a lifesaving therapy” to older patients without taking hearts from younger patients, said Dr. Abbas Ardehali, director of U.C.L.A.’s heart and lung transplant program. All patients 72 and older go into the alternative transplant program; those who are younger are eligible for hearts from the standard organ pool.  U.C.L.A. has transplanted 260 hearts in people 65 and older, more than any other center, since 1988.  Until last year, NewYork-Presbyterian/Columbia University Medical Center also put all potential heart transplant candidates 65 to 72 years old on alternative lists like those at U.C.L.A. Because data showed that these patients had good outcomes, however, the hospital lifted this requirement and now performs heart transplants on anyone 72 and younger.
Because of changes in medical guidelines, older patients like former Vice President Dick Cheney are now somewhat more likely to receive heart transplants.