Heart transplantation in the older recipient: has the time come to reconsider our selection policies?

Conservative medical strategies in the aging end-stage heart failure population are unlikely to produce the same benefit as cardiac transplantation(Tx),yet older age remains a contraindication to Tx at many centers for reasons that remain undefined. This study is an attempt to determine if advanced recipient age is a risk factor for early and late morbidity and mortality following cardiac Tx. A total of 440 patients underwent primary Tx between 1/1995 and 8/2000. Sixty-three pts greater than age 65 yrs (66-77 mean=69) were compared to a cohort of 377 pts 65 yrs or less (18-65, mean= 51). Mean follow-up is 38 months. There were no significant differences in gender, LVAD support, or UNOS status pre Tx. Mean donor age for both recipient groups was not significantly different (37 yrs vs 36 yrs). Post-op length of stay (mean days:older 18 vs younger 17) and hospital mortality (4% vs 5%)were similar. Actuarial survival in both groups did not demonstrate any significant differences at 12 months (87% vs 88%), 24 months (83% vs 87%), or 48 months (82% vs 81%)post Tx. Charges associated with this procedure, considerable for both groups, were not significantly higher in the older population ($115,000 vs $114,000). Although, previous reports from multicenter registries have reported an increased risk for death in this older population, this was not shown to be true in our experience, which demonstrated comparable morbidity and mortality with the younger population. The issue of recipient age will likely become more visible and more urgent as increased longevity in the population results in an increasingly older patient seeking transplantation. Patient selection policies will need to be reconsidered in the near future and this debate will likely shift to one of a social, economic,and ethical dilemma rather than clinical outcomes.