Summer 2008

Heart Failure — Determining Optimal Treatment

Treatment of end-stage heart disease is no longer limited to heart transplantation. New options for earlier interventions serve as a bridge to transplantation or may mitigate the need for a transplant.

Knowing when transplantation is appropriate can be seen as part of a continuum that can vary for each patient. In some cases, transplantation is considered an option sooner than in the past, or patients are considered candidates who were not previously eligible for transplant. With all of these variables, UCSF's approach is to integrate services for patients with progressive heart disease. Most patients can continue to be managed primarily at home.

"We'd like to see heart patients earlier, so that we have more options for treatment," says Charles Hoopes, M.D.,; surgeon and director of the UCSF heart and lung transplant programs. "We see transplant as just one therapeutic modality. With our integrated program, there are a lot of options that allow us to change end-stage heart disease—to delay or prevent transplant if we see them early enough."

The UCSF cardiothoracic transplant programs conduct more than 60 thoracic transplants annually, and candidacy for heart transplantation is assessed on an individual basis. If a patient has a progressive, potentially fatal heart disease that substantially impairs quality of life and daily function, he or she may be considered for a heart transplant.

"Some see transplant as a last resort for end-stage heart disease, but we see it more as a quality-of-life issue," says Hoopes. "We want to give back a normal cardiopulmonary function status commensurate with their age. If a patient is 40 years old and can't play tennis or walk on the beach, that's an indication for a heart transplant, in my opinion."

Although there are established criteria for candidacy, UCSF has few absolute contraindications. Because UCSF is an academic medical center, the program has greater access to organs as well as high-tech devices, so fewer patients are ruled out.

UCSF transplant surgeons have treated patients with HIV, Chagas' disease, congenital heart diseases, heart and lung blocks, and those requiring simultaneous heart and kidney transplants. Patients may be turned away if they have septicemia, hepatitis B or C, an active malignancy, or the expectation that a noncardiac disease would result in death in less than five years.

Collaboration and Early Referral

Treatment is both comprehensive and integrated to treat a wide range of cardiac patients. The program offers a weekly clinic, enabling patients to see all necessary specialists—including cardiologists and surgeons—in one visit.

"The decision to transplant is collective and represents the balance of interests between responsible utilization of a shared, limited resource and appropriate patient need," says Hoopes. "Heart transplantation as an operation should not exist outside an integrated heart failure service and an active mechanical circulatory assist program."

Hoopes recommends early referral to UCSF, well before end-stage heart failure, for optimal outcomes. He says that heart failure is a continuum, and where each patient exists on the continuum determines the program's management strategies.

The UCSF cardiothoracic transplant program, which began in 1989, is growing. During the first decade, surgeons in the program operated on roughly 20 patients per year. In the last three years, however, the program has averaged 60 thoracic transplants per year, about one every six days. Last year, surgeons in the program conducted 55 transplants.

"In the future, my suspicion is that we will increase the transplant numbers by 12 to 15 cases per year; we should not be going any lower than 70," says Hoopes. "I also suspect that we will do an increasing number of mechanical circulatory support devices in the next five years, and that will become a more integrated part of our transplant process."

Who's a Candidate For a Heart Transplant?

  • Patients with progressive, potentially fatal heart disease that substantially impairs quality of life
  • Patients who are not moribund and whose transplant is likely to prolong life with a better than 50 percent chance of survival for at least five years
  • Patients without involvement of a major physiological system that would preclude surgery or indicate a poor potential for rehabilitation
  • Patients having a psychological assessment, family support and social arrangement that indicate ability to adhere to a strict, long-term post-transplantation medical regimen
  • Patients who do not have alcohol or substance abuse problems

To contact Charles Hoopes, M.D., call (415) 353-1606.

Related Information

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