Leading Causes and Preventable Nature of Heart Transplant Surgery

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• Common Indications for Heart Transplant
• Ischemic Heart Disease and Transplants
• Idiopathic Dilated Cardiomyopathy
• Other Causes for Heart Transplantation
• The Tragedy of Preventable Heart Failure
• A Significant Public Health Challenge
• Full Transcript

Common Indications for Heart Transplant

Dr. Pascal Leprince, MD, a leading transplant surgeon, outlines the primary reasons patients require a heart transplant. The indications vary significantly by age group. For pediatric patients, the main indication for a heart transplant is congenital heart malformation. Dr. Leprince clarifies that his center at Pitié-Salpêtrière Hospital does not perform pediatric cardiac surgery, with institutions like Necker Hospital in Paris handling those complex cases.

Ischemic Heart Disease and Transplants

In adult patients, ischemic heart disease is a leading cause of terminal heart failure. Dr. Pascal Leprince, MD, states that this etiology accounts for approximately 40% of heart transplant cases. This condition develops in patients with coronary artery disease who suffer a myocardial infarction (heart attack). The damage from the heart attack leads to progressive heart failure that eventually becomes unmanageable with medication or other interventions, making a transplant the only viable life-saving option.

Idiopathic Dilated Cardiomyopathy

The other major cause for heart transplantation is idiopathic dilated cardiomyopathy. Dr. Pascal Leprince, MD, explains that this condition represents 40-45% of adult transplant cases. The term "idiopathic" means the exact cause is unknown, though a significant number of these cases are familial or linked to a specific genetic mutation. In this condition, the heart muscle becomes weakened and enlarged, preventing it from pumping blood efficiently. Combined, ischemic and idiopathic causes represent 85-90% of all reasons an adult needs a new heart.

Other Causes for Heart Transplantation

Beyond the two primary causes, Dr. Pascal Leprince, MD, identifies several other conditions that can lead to end-stage heart failure. These include amyloidosis, a disease where abnormal proteins build up in organs and tissues, impairing heart function. Other reasons include arrhythmic cardiomyopathy and hypertrophic cardiomyopathy that has progressed to severe heart failure. While these conditions are less common, they are equally serious and often necessitate a heart transplant as the definitive treatment.

The Tragedy of Preventable Heart Failure

A critical point Dr. Pascal Leprince, MD, emphasizes is the preventable nature of many heart transplant cases. He reveals that in his cohort at Pitié-Salpêtrière Hospital, 25 to 30% of patients have terminal heart disease because they did not follow treatment advice that could have prevented their condition from progressing. This is particularly striking given France's advanced and accessible healthcare system, where the cost of medical care for the patient is minimal. The failure to adhere to medications or lifestyle changes, such as avoiding excessive alcohol consumption, directly leads to avoidable heart failure.

A Significant Public Health Challenge

Dr. Pascal Leprince, MD, discusses this issue as a major public health challenge, not a simple patient oversight. He notes that socio-economic and intellectual disparities create barriers to care, even when access is readily available. Patients may not understand the importance of taking pills or the severe health consequences of certain behaviors. Dr. Leprince confirms that cardiologists and public health experts observe higher rates of heart failure in areas of greater Paris with lower socio-economic status. This highlights a systemic need for better patient education and outreach to prevent terminal heart failure before a transplant becomes necessary.

Full Transcript

Dr. Anton Titov, MD: Heart transplantation. You run one of the largest departments in Europe for heart transplantation. It was published that you do more than 90 heart transplants per year. What are the most common indications today for heart transplantation? Maybe by age group.

Sometimes we look at children. The main indication is congenital heart malformation. Medical second opinion is important.

Dr. Pascal Leprince, MD: We don't do any children's heart surgery here at the Salpetriere Hospital. Other hospitals in Paris, Necker Hospital, perform pediatric cardiac surgery.

When we go to adults, we have two main indications for heart transplantation. We have two etiologies for heart failure. One cause of heart failure is ischemia. These are patients with coronary artery disease. They have a myocardial infarction, then develop heart failure. I would say this is 40% of the patients who require heart transplantation.

Another 40 to 45% of the patients who need heart transplantation have idiopathic dilated cardiomyopathy. "Idiopathic" means we don't know why these patients have cardiomyopathy. Many of them have familial cardiomyopathy. Some patients have multiple family members with bad cardiomyopathy. Some patients have a genetic mutation that causes dilated cardiomyopathy. In some, we don't know why they have dilated cardiomyopathy.

These are the main causes of heart failure in adults. They represent 85 to 90% of the reasons for heart transplantation in adults. Other reasons for cardiac transplantation include amyloidosis. There are two types of amyloidosis. It starts to be very technical. I don't even understand the details of amyloidosis subtypes.

There are also arrhythmic cardiomyopathy and hypertrophic cardiomyopathy that results in heart failure. This then requires heart transplantation. These are the main reasons for heart transplantation in adult patients.

One thing about heart transplantation I have been repeating for many years now. Let's look at the patients who need heart transplantation because they have terminal heart failure. In the cohort of patients for heart transplantation here in Pitie Salpetriere Hospital, at least 25 to 30% of patients have terminal heart disease because they did not follow treatment advice that could have prevented terminal heart failure.

This is crazy because it is easy to get medical care in France. There are countries where access to medical care is not easy. But in France, the cost of medical care for the patient is almost nothing. Everyone can go to a hospital in France.

It is amazing, as France is ideal even among European health care systems. France has the most advanced healthcare. Physicians and patients in France have the highest satisfaction marks in health care in entire Europe. I agree.

But even if it is easy to get medical care in France, some patients are so much away from getting care by socio-economical status or intellectual status. They don't think about medical care. They would not go to medical doctors. Even it is easy to go to medical doctors, they will not go to the medical doctor.

They do not understand that taking pills is very important. They do not understand that drinking ten beers a day is bad. They don't understand all that. I don't blame them. They maybe are not educated enough.

This is a pity because when you see these patients coming to heart transplantation because previously they didn't have enough information, they did not get enough medical care to prevent terminal heart failure. This is something important that everyone should be able to understand.

Yesterday I was discussing it with one of our cardiologists. He is a very good cardiologist. He is looking at public health indicators. He fully agrees with me on this topic.

Even in Paris, in the greater Paris area, there are some parts of greater Paris where the quality of life of patients is not so good; the social, economic status of the patients is not so good. In those areas, the rate of heart failure is greater than in the center of Paris. Medical second opinion is important. This is important to me.