Heart transplants - an optimistic view "Despite adverse publicity and the dismal statistics of the total, world-wide experience, (heart transplantation) remains the preferred treatment for patients suffering from pump failure due to irreversible diffuse myocardial disease." One would associate enthusiasm and optimism with Professor Christinan Barnard, and his latest review (from which the above is a quotation) of the pres. nt status of heart transplantation strikes an optimistic note, backed up by some facts and figures.1 He sees the alternative, the use of mechanical devices for total replacement of cardiac function, as presenting such problems as will likely delay their clinical application for at least 10 years. Three questions must be asked before contemplating heart transplantation: Is the patient ill enough to warrant the operation? Can the patient's symptoms be controlled with some other surgical procedure or further intensive medical treatment? Is the disease too advanced for successful transplantation? The last of these three questions was the one never asked at first; hence some disappointments. Factors have now been recognized that make a successful transplant unlikely, such as the inability of the new heart to adapt rapidly to abnormal hemodynamics in the recipient, and the high risk of fatal complications in a seriously debilitated patient. As regards the first of these, a distinguishing feature seems to be a high pulmonary vascular resistance due to atherosclerosis. As regards the second factor, that of debilitation, it seems that these patients tolerate immunosuppressive drugs poorly. Recent pulmonary infection must also be seen as a contraindication to operation. In donor selection the team must try to rule out conditions such as infections or cancer that might be transferred to the recipient, they must ensure ABO compatibility but not necessarily HL-A compatibility; the latter seems of little prognostic value. Needless to say, the donor heart must be normal, and it should be shown that the donor heart is able to maintain

normal circulation in the donor without support once blood volume has been replaced. Even with present knowledge, the immunologic attack on the donor heart cannot be prevented but only blunted by the use of a steroid, azathioprine and antilymphocyte or antithymocyte serum. The author outlines the practice in his department, which he regards as sound, in that none of the long-term survivors has shown clinical evidence of moderate or severe rejection. Rejection has all the features of an inflammation. Its diagnosis is based on electrocardiographic evidence such as a decrease in QRS voltage, clinical evidence such as a right ventricular diastolic gallop sound, ultrasound evidence of increase in right ventricular diameter or of increase in left ventricular wall thickness, and histologic changes as demonstrated by transvenous cardiac biopsy. Results of transplantation, says Barnard, should be evaluated against the background of worldwide pessimism of doctors and laymen alike for this form of treatment. He refutes the objections that the mortality is unacceptably high, that the technique is experimental and should be suspended, and that the transplant patient becomes a chronic invalid. Of the 26 patients alive 1 year or more after transplantation in March

1974 most had resumed a normal life. This must be set against the experience of similar patients treated medically alone; the longest survival of a patient in Barnard's area who was considered suitable for transplant and refused was 55 days. Of the nine patients with a transplant by the Barnard team in 7 years, four lived more than 18 months and two are currently alive after 3½ and 5½ years respectively. With modern criteria for patient and donor selection these figures would have been much better. In 1972 the Shumway group was obtaining a 1-year survival of 50% as a result of better selection. Today expectation of life should be even more favourable, with a 5-year survival in the region of 30%, certainly better than for some cancer operations and not far behind those for cadaver kidney transplantation.2 Cost of a transplant is not prohibitive and indeed a successful transplant will in the long term cost the patient less than treatment of continued heart failure. Professor Barnard is therefore at a loss to understand the current pessimism and believes that transplantation has a definite place in cardiac surgery. References 1. BARNARD CN: The present status of heart transplantation. S Air Med J 49: 213, 1975 2. DoNG E .ia, GRJEPP RB, STINsON EB, Ct al: Clinical transplantation of the heart. Ann Surg 176: 503, 1972

CME SUPPLEMENT CONTINUING EDUCATION PROGRAMS FOR PHYSICIANS IN CANADA The Canadian Medical Association will be publishing its first semiannual supplement to the Journal listing the continuing medical education courses available to physicians in Canada. This directory will be published at the end of July and will cover the period from Sept. 1 to Dec. 31, 1975. All subscribers to CMAJ will receive the supplement free of charge. Nonsubscribers may obtain copies of this issue from:. ELI ULLY & CO. (CANADA) LTD. 3650 Danforth Ave. Scarborough, Ont. Box 4037, Terminal A Toronto 116, Ont. CMA JOURNAL/MAY 3, 1975/VOL. 112 1037