Socioeconomic status and heart transplant outcomes

Here is another sad case of disparity among heart transplant recipients. It seems that children of low socioeconomic status tend to have worse health outcomes even after a heart transplant, according to Boston researchers.

The study followed up 135 pediatric patients who received their first heart transplant at Children’s Hospital Boston from 1991-2005. The demographic profile of the study group are:

• 82% were white (110)
• 18 % were non whites (10 black; eight Hispanic; and seven from other racial groups).
• 58% were boys; 42% were girls
• median age is 8.4 years

The researchers grouped the patients based on their socioeconomic status and followed up their outcomes after heart transplantation. One-third (45) of the patients were classified as “low socioeconomic group” and compared to the remaining two-thirds.  The two groups were similar demographically.

The findings show that

• Children from low socioeconomic neighborhoods were 2.4 times more likely to have graft failure after transplant when compared to the controls.
• Minority children were 2.7 times more likely to suffer graft failure when compared to whites.
• Among 9 early deaths during transplant hospitalization, 6 deaths, or 13.3 percent, occurred in the lower socioeconomic group compared to three deaths, or 3.3 percent, in the higher socioeconomic group.
• Survival of the transplanted heart was significantly shorter in the low socioeconomic group at one year, three years, and five years post-transplantation.

The low socioeconomic group also had a higher likelihood of rejection and had a shorter time to death or retransplantation. The study indicates that “low socioeconomic status and non-white race appear to be independent risk factors for worse outcomes.”

Looking closely as to what “lower socioenconomic status” means based on six socioeconomic factors, the following can be used as indicators:

• lower median income;
• lower median value of housing;
• fewer adults with high-school and college education;
• fewer adults in managerial, professional or executive positions; and
• fewer households with rental, interest or dividends as the source of their income.

The reasons for this disparity in health outcomes due to socioeconomic status are not clear but it may be due to difficulty in using medical resources. Because all patients had health insurance coverage and equal access to medical resources, the causes of the difficulty could be at the family and personal level.

Last year, there was another post highlighting the disparity in organ transplantation in relation to ethnicity. That study showed that non-white children are more likely to die while waiting for a heart donor. Clearly, there is a need to delve deeper into the causes of these disparities.  Because I believe that each child deserves a fair chance regardless of skin color or bank account balance.

Photo credit: stock.xchng

               

Race and the chances for a heart transplant

According to a study based on 2006 data from United Network of Organ Sharing in the US, 3,299 American children were on the heart transplant waiting list during an eight-year period up to 2006. Based on their ethnicity, the distribution is as follows:

• 58% white
• 20% black
• 16% Hispanic
• 3% Asian
• 3% others

Does this mean that more white children have heart problems and therefore need more heart transplantation? Actually no. The truth is actually sad and raises concerns about the role of race in health care.

“The most common reasons that children require heart transplants are serious congenital heart defects in children under the age of 1 and cardiomyopathy in those over the age of 10 years. These conditions tend to be equally distributed in children 1 to 10 years old [regardless of ethnicity]. Cardiomyopathy is a serious disease in which the heart muscle becomes inflamed and doesn’t work as well as it should.”

The reason why more white children are on the waiting list is because non-white children have a much higher likelihood of dying while waiting for a heart donor. If we look at the mortality figures, we see a completely different picture:

• Black children had a 60 percent greater chance of dying.
• Hispanics had a 50 percent higher mortality rate.
• Asians and others had a 100 percent to130 percent greater chance of dying.

If split between two ethnic groups white and non-whites, the non-white children clearly have a higher risk of dying before they can have a transplant.

I am mother to two kids who are partly of Asian ethnicity. It is heartbreaking to know that other kids like mine lose their chance for a heart transplant just because of the color of their skin.

However, the reasons for the disparity are many and complex and go beyond just the race issue. They include:

Socioeconomic factors. White children are more likely to belong to higher income families and better health insurance coverage. 58% of black children and 59% of Hispanic children have Medicaid insurance compared to 24% of white children. Those who have Medicaid have 20% higher mortality likelihood.

Cultural factors. Cultural and religious beliefs may play a role in the parents’ attitude towards treatments, including heart transplantation and “bridging therapies” while waiting for a heart donor.

Communication problems. Communications between healthcare providers and the patients (or parents of the patients) may play a big role. Language barriers as well as cultural and socioeconomic barrier can influence the efficiency of communications and therefore can cause delay in decision making.

Other unknown factors may play role and need to be addressed in future studies. However, this disparity due to race is very troubling and should be taken into account by health care providers when treating their young patients.

Photo credit: stock.xchng

               

VADs for children waiting for heart transplant

A ventricular assist device (VAD) is a mechanical device that helps a failing heart to function. The pump-like device can be for short term use only, such as those for patients recovering from heart surgery or those waiting for a heart donor, or they can be for long term use such as those for patients suffering from congestive heart failure or cardiomyopathy. The longest record of a surviving cardiac patient on VAD is 7 years, as reported by the Texas Heart Institute last year. VADs have saved many lives of patients whose hearts are not longer capable of efficiently pumping on their own. VADs are especially used in patients waiting for heart transplantation.

Unfortunately, most VADs are adult-sized and are only suitable to assist adult-sized hearts. But what about those little baby hearts that need help?

It seems that a miniaturized VAD that can be used for children is available in Europe. And pediatricians are hoping that the device will soon be available in the US market

Dr Sanjiv K Gandhi of St Louis Children’s Hospital in Montana reported how he and his colleagues successfully implanted VAD in several children awaiting heart transplant. The implants increased the chances of survival of the children as they wait for the right heart.

In the US, about 400 pediatric heart-transplantation procedures are performed every year. Of these, about 100 recipients are under the age of 1. Heart transplants statistics show that babies are 10 times more likely to die while waiting for a heart compared to adults. As many as 50 babies which are placed on the heart transplant waiting list every year do not survive the wait (Source: Curfman et al., 2008). The use of the miniaturized VAD can lengthen the waiting time while pediatric cardiac patienst await for a heart donor.

Gandhi explains that

“extracorporeal membrane oxygenation (ECMO) has remained the most common form of mechanical support available prior to ventricular assist devices, but the incidence of medium- and long-term bleeding and infectious complications is exceedingly high with ECMO, and neurological impairment is also common. ECMO also restricts patient mobility, impairing physical rehabilitation.”

A 2006 review of data from the Pediatric Heart Transplant Study (PHTS) database indicate that VAD seems to be more successful in patients with cardiomyopathy compared to congenital heart diseases. The bridging time using VAD ranged from 1 to 465 days and the age of the patients ranged from 2 days to almost 18 years old.

Currently, there is an FDA-sponsored study ongoing implanting these tiny devices in American and Canadian children. According to Gandhi, the 70% to 75% survival rate may not sound much but it is definitely better than zero. In many cases, VAD is the only thing that stands between life and death for these patients. However, the doctor laments the fact that a lot of bureaucratic problems in the US hinder fast procurement of the device. For some tiny patients, this delay can mean death.

Photo credit: stock.xchng by planetka

               

Pediatric heart transplants

Many babies are born with heart defects or hearts which are not fully developed. These conditions are called congenital heart defects and are common in babies who are extremely premature or those with Down’s  Syndrome.

It is estimated that 1 in every 100 babies is born congenital heart defect. In the US, about 2 million people of different ages have some form of congenital heart condition. Thanks to medical advances, what were declared as “death sentence cases” half a century ago can now be  corrected surgically.

However, some of these conditions are beyond surgical repair, so that a heart transplant is the only chance for survival.

Pediatric heart transplantation is very complicated because of the urgency of many cases. Only hearts of babies of similar age can be transplanted. There is quite a shortage of pediatric hearts for transplantation and most often the patients die before a suitable heart donor can be found. According to a study by Curfman and colleagues, infants have10 times the risk of dying while waiting for a heart compared to adults. Up to 50 babies which are placed on the heart transplant waiting list everywhere do not survive the wait.

According to the same study, about 400 heart transplants are performed in children and adolescents in the US every year. In approximately two-thirds of all cases, the cause of heart malfunction is inoperable congenital heart disease. The remaining one third are due to advanced cardiomyopathy.

Of the 400 pediatric heart transplantations performed annually, about 100 are in infants under the age of 1 year. The 15-year survival rate among these infants is greater than 50%, increasing to 80% among those who survive for the first 5 years after transplantation. Thus, cardiac transplantation in infants is a highly successful procedure that has saved the lives of many babies with terminal heart disease.

A new study described 3 cases of infants implanted with heart from other infants pronounced dead based on cardiac death criteria. (For a review of cardiac death criteria, check out this previous post.) This report may trigger 2 things: a) hope for patients waiting for a heart

b) ethical questions on death criteria.

If indeed, lost heart function is reversible even after death, so that even a “dead” heart can be restarted again to beat in another person’s body, then there is hope for many heart patients out there that more heart transplants can be performed. But if a supposedly “dead” heart be revived, are we giving up too early on the donor’s chances of survival? In other words, are we saving one life at the expense of another?

I am for organ donation. I have an organ donor card that I carry with me all the time. I am also a mother of 2 young children and like all parents, I wouldn’t want to be in a situation when I have to sign over a family member’s organ to another person. However, it could also happen that I would be on the waiting end of the chain - waiting for organ procurement for a chance for a loved one to live longer.

The line between life and death is blurred and never easy to define. And even the most advanced of technologies can never answer the question.

               

Cardiac death and heart transplant - the ethical and clinical questions

In the recent issue of the New England Journal of Medicine, several articles discuss different aspects of heart transplantation. One interesting aspect is about reversing the irreversible - donating hearts after cardiac death.

It used to be that organ donation can only occur after cardiac death, e.g. after a donor’s heart has completely stopped. Organs such as kidneys can then be transplanted from the donor to the recipient. However, this posed a challenge for heart transplant since the donor’s heart is dead and has irreversibly stopped, and is therefore not viable for transplantation anymore.

In recent years, the concept of brain death came up - irreversible loss of brain functioning. This opened new possibilities for organ donation - especially heart donation. However, the heart remains to be the main source of vital signs and cardiac death is still one of the most common way of defining clinical death. There are, however, some recent reports of hearts from “dead” donors that were successfully transplanted and restarted in recipients bodies. This sparked some ethical as well as clinical questions.

According to Robert M. Veatch, professor of medical ethics at the Kennedy Institute of Ethics, Georgetown University

“…when can death be pronounced on the basis of loss of heart function? Death must be permanent. Clinicians sometimes carelessly speak about patients who experience “clinical death” only to be “brought back to life” by means of cardiopulmonary resuscitation.

The fact that a transplanted heart could be restarted in another body does not indicate permanency. Was the heart donor really dead?”

Where do we actually draw the line between life and death, be it cardiac death or brain death?

A 1993 protocol for the procurement of organs from adults by the University of Pittsburgh Medical Center defines cardiac death when the heart has stopped for 120 seconds, on the basis of the claim that autoresuscitation had never occurred after that period.

There are, however, varying opinions as to how long should one wait before cardiac death is declared. It is possible to restart a heart physiologically by means of external stimulation even beyond the period of 120 seconds. Some experts believe in waiting for 10 minutes or longer. Others would go for 5 minutes.

To put things into perspective, let’s look at some statistics on heart transplant from the American Heart Association:

• 2,192 heart transplants were performed in the US in 2006; 2,125 in 2005.
• In the US, 74.2% of heart transplant patients are male; 68.4% are white; 20.0% are aged 35 to 49 and 55.3% are aged 5 to 64.
• As of June 15, 2007, the five-year survival rate was 72.3% for male heart transplant recipients and 67.6% for females. 

Clearly, heart transplant have saved thousands of lives since the first successful procedure was performed in 1968. However,  if more lives were to be saved, the definition of life and death have to be resolved.

Next in this series: pediatric heart transplants

Photo credit: bizior

               

CVD News Watch for the Weekend 18 July 2008

Your weekend news…Happy reading!

CVD Lifestyle Watch

Alaskan Eskimos’ high rates of artery plaque could be from high smoking

According to a study reported in Stroke: Journal of the American Heart Association, Alaskan Eskimos have significantly higher rates of fatty plaques in their arteries compared to the general American population. And this is most probably due to unhealthy lifestyles, especially the high incidence of smoking in this ethnic group.

Traditonally, CVD rates are low among American Eskimos. Recent lifestyle changes such as smoking, less physical activity, less consumption of fish and higher consumption of food rich saturated and trans fats have changed all these.

 

CVD Weight Watch

Evidence for behavioral susceptibility theory of obesity

Is appetite a factor in obesity? In this study on children, those with reduced satiety responsiveness and higher response to food cues tend to have higher body mass index (BMI) and waist circumference. See the abstract of this study in this month’s issue of the American Journal of Clinical Nutrition.

 

CVD Patient Watch

Transplant recipient completes Yosemite ascent

She has done it again! The most sporty of all heart transplant recipients, Kelly Perkins, added Mt. Yosemite to her list of captured peaks last June 29, msnbc reports. I will write an in-depth feature of Kelly’s feats in a future post.

 

CVD Nutrition Watch

Popular Fish, Tilapia, Contains Potentially Dangerous Fatty Acid Combination

The fish that we are eating are supposed to be good for the heart. This recent report, however, brings bad tidings. The polyunsaturated fatty acids (PUFAs) ratios in popular fish such as catfish and tilapia may actually be bad, even dangerous to our health and are possibly pro‑atherogenic. However, other fish such as the Atlantic salmon and trout are contains the ideal PUFA ratios that are good for our heart. More about this in the Journal of the American Dietetic Association.

 

CVD Treatment Watch

DNR order could impact on hospital HF treatment

DNR stands for “Do not resuscitate” - doctors’ orders to withhold cardiopulmonary resuscitation from a patient. Sounds ominous but this order often appears in many patients’ hospital charts for valid reasons. Check it out at MedWire News.

 

CVD Medical Device Watch

Mini ECG gets heart attack rehab patients mobile

Compliance and completion of cardiac rehabilitation programs remains a big problem, with drop out rates of as high as 80%.This unique ‘Cardiomobile’ monitoring system might just be the answer and is currently being tested among cardiac patients. It enables them to perform six-week walking exercise rehabilitation program anytime, anywhere while having their heart signals, location and speed monitored in real time (ScienceDaily).

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