Transplantation In Germany Research Articles

Volume and outcome relation in German liver transplant centers: what lessons can be learned?

BackgroundThe volume and outcome relationship for transplant procedures has become one of the major topics during discussions about consequences following the organ transplantation scandal of wait-list manipulations in Germany during the past year. Proponents of reducing the number of centers argue in favor of increasing quality at highly specialized transplant centers while disregarding the wish of patients for regionally available medical service.MethodsThe homepage of the German Organ Procurement Organization (DSO) was screened for the annual reports of transplant programs for the years 2007 to 2010. Results were extracted from these reports. Additionally, an analysis of volume per million people per number of transplant centers for each German federal state was made to give an overview of the density of transplant programs for the years 2009 to 2011.ResultsIn-house mortality (R2 = 0.005, P = 0.518), 3-year survival (R2 = 0.068, P = 0.085), and a ROC analysis for in-house mortality (AUC 0.55, CI: 0.41; 0.68, P = 0.53), did not show volume-outcome relation. Definition of a threshold for good centers was impossible. One-year survival indicated better outcome in high volume centers. R2 = 0.106, P = 0.009. Outcome data in Germany, as provided by Institute für angewandte Qualitätsförderung und Forschung im Gesundheitswesen (AQUA) or the DSO, are not risk adapted for the investigated time period. The factor of transplants per year per million people per transplant centers is 0.6 for Germany. Some Federal States (for example, Bavaria and Northrhine Westfalia) have an oversupply of transplant centers, which means that the average number transplanted per center and year is very low.Discussion and conclusionWe propose a risk-adapted prospective analysis of outcome and definition of a quality catalogue for liver transplant centers. Volume and outcome relation is not conclusive for liver transplantation in Germany. Data should be collected, for example, for a time period of 3 to 5 years, and decisions influencing the regulation of numbers of transplant centers should be based upon the findings, weighing federal state sovereignty and regional medical requirements against an optimal patient supply while respecting a plausible risk adaption for each center.

The joint impact of donor and recipient parameters on the outcome of heart transplantation in Germany after graft allocation

Organ shortage in heart transplantation (HTx) results in increased use of grafts from donors with substantial risk factors. It is discussed controversially which donor characteristics may be detrimental. Therefore, we evaluated the joint impact of donor- and patient-related risk factors in HTx on patient survival by multiple analysis in a nationwide multicentre study after donor selection was carried out. The research database consists of data concerning hearts donated and transplanted in Germany between 2006 and 2008 as provided by Deutsche Stiftung Organtransplantation and the BQS Institute. Multiple Cox regression (significance level 5%, hazard ratio [95% CI]) was conducted (n = 774, recipient age ≥ 18 years). Survival was significantly decreased by donor age (1.021 [1.008-1.035] per year), nontraumatic cause of death (1.481 [1.079-2.034]), troponin >0.1 ng/ml (2.075 [1.473-2.921]), ischaemia time (1.197 [1.041-1.373] per hour), recipient age (1.017 [1.002-1.031] per year) and in recipients with pulmonary vascular resistance ≥ 320 dyn*s*cm(-5) (1.761 [1.115-2.781]), with ventilator dependency (3.174 [2.211-6.340]) or complex previous heart surgery (1.763 [1.270-2.449]). After donor selection had been conducted, multiple Cox regression revealed donor age, nontraumatic cause of death, troponin and ischaemia time as well as recipient age, pulmonary hypertension, ventilator dependency and previous complex heart surgery as limiting risk factors concerning patient survival.

Lebertransplantation als Therapie von seltenen Erkrankungen beim Erwachsenen

In addition to the main indications pertaining to 95 % of all patients receiving liver transplantation in Germany, there are numerous other diseases that may become clinically evident in the adult age and may lead to the decision for liver transplantation. These may be metabolic diseases with their main defect located in the liver, malformations of liver cells, hepatic vascular diseases and rare tumours of the liver. Standard exceptions for the listing are in place only for a limited number of diseases. Exact diagnostics and the point in time for transplantation are crucial for the prognosis.

PCN100 - Cost-Effectiveness of Induction Treatment with Bortezomib Added to Thalidomide and Dexamethasone in Newly Diagnosed Multiple Myeloma Patients Eligible for Autologous Stem Cell Transplantation in Germany

Van Beurden-Tan C1, Rosinol L2, Diels J3, Wirth D4, Chirita O5, Lahuerta JJ6, Gaugris S5, Marsh S5, San Miguel J7, Spencer M5, Treur M1 and Blade J2 1Pharmerit International, Rotterdam, The Netherlands, 2Hospital Clinic de Barcelona, Barcelona, Spain, 3Janssen Pharmaceutica NV, Beerse, Belgium, 4Janssen-Cilag GmbH, Germany, 5Janssen-Cilag Limited, United Kingdom, 6Hospital Universitario 12de Octubre, Madrid, Spain 7Hospital Clinico Universitario de Salamanca, Salamanca, Spain

Biology of xenogeneic cell and organ transplantation – from bench to bedside – the new German research foundation (DFG) transregio collaborative research centre for the next 4 (ultimately 12) years

Discordant xenotransplantation research started in Hanover/Mariensee and in Munich in the late nineties – the latter receiving a substantial grant from the Bavarian Research Foundation. In 2003 both groups were invited by the German Research Foundation (DFG) to make a joint application to further develop xenotransplantation technology. This was peer‐reviewed, approved and continued with considerable success from 2004 to 2012. The Paul‐Ehrlich and Robert‐Koch Institutes, the official bodies responsible for microbiological safety in Germany, were subsequently included.Our unique interdisciplinary consortium combines basic scientists, animal biotechnologists and clinicians demonstrating an excellent co‐operation over the last 8 years. The tool box available to us includes pigs transgenic for human thrombomodulin, hemoxygenase‐1, A20, LEA 29Y, HLA‐E and TRAIL; key enabling technologies include gene targeting, large transgene vectors, transposon mediated transgenesis, zinc finger and TALE nuclease mediated gene targeting.In July 2012 our new Collaborative Research Centre (again supported by the DFG) commenced, continuing in the first instance to 2016 and ultimately until 2024. The strong Diabetes group at the University of Dresden, which currently runs the only successful allogeneic pancreatic islet transplantation in Germany, has now been incorporated.Our main goal is to translate preclinical studies into benefits for patients as quickly as possible. The consortium focuses on islet, cardiac and renal xenotransplantation; new biological heart valves for paediatric cases and young adults will be developed. Our endeavours will be supported by two ethicists to ensure best practice and promote public dialogue.

Der Diskurs über die rechtliche Regelung der Organtransplantation in West- und Ostdeutschland (1960–1989). Eine vergleichende Studie

The debate on the legal frameworks of organ transplantation in Germany began in the 1960s with the upcoming of new medical treatments. Since there were two German States at that time, the Federal Republic of Germany (FRG) and the German Democratic Republic (GDR), the process of the discussion on the way to legislation took place under two very different circumstances. In 1975 the GDR implemented a decree regarding the legal aspects of organ transplantation. Meanwhile the discussion in the FRG proceeded with no result until 1997. The analysis of articles in German medical and juridical journals in the period 1960-1989 showed that the discussion in the GDR was less intensive than in the FRG and nearly stopped after the decree from 1975. The majority of the East-German authors preferred an arrangement that will keep the next of kin of a deceased person out of the process of organ transplantation. They argued for the so-called “Widerspruchslosung” (dissent solution): During his lifetime, the donor must have denied organ removal after his death; otherwise organ explantation will be performed. The law of 1975 was consistent with this preference. In West-Germany the motifs concerning the legal aspects of organ transplantation changed over the time. The discussion started with the same arguments that were used in East-Germany. The physicians wished some kind of “Widerspruchslosung” manifested by a draft law, but their requests changed over time. In the early 1980s, most of the West-German authors pleaded for what had become the code of practice because no bill was passed by the politicians: the “Zustimmungslosung” (consent solution). The physician was obliged to ask the next of kin if there was any statement of the potential donor towards organ donation. Some authors even considered a bill unnecessary, as the system organ transplantation in West-Germany was working well without it. A massive change in the West-German medical society from fighting for a “Widerspruchslosung” to acceptance of a “Zustimmungslosung” or even no legal frame at all was observed.

Organ Transplantation in Germany: Regulating Scandals and Scandalous Regulation

Organ Transplantation in Germany: Regulating Scandals and Scandalous Regulation

Lebertransplantation – aktuelle Aspekte der Allokation, Indikation und Strategien zur Erweiterung des Spenderpools

Liver transplantation is nowadays an established treatment option for end-stage liver disease and the associated complications. In this article, we summarise the actual aspects of allocation, indication for transplantation as well as approaches for donor pool expansion in the field of liver transplantation in Germany. Beside the maintenance of long-term survival and quality of life, the actual donor organ shortage is the most important issue worldwide. While trying to control this shortage, there is a lot of discussion about the transplantation for malignant liver disease. In our opinion, the focus in this topic should be the utilisation and expansion of the donor pool. There are many logistic and medical aspects which could be optimised. Furthermore, there are open questions in public and political discussions (up to the revision of the transplantation law) which should be improved for the purpose of the waiting list patients.

Univariate Analyses of the Impact of Donor and Recipient Related Parameters on Early Outcome of Kidney Transplantation in Germany

Introduction: The aim of kidney transplantation is to provide renal replacement therapy by functioning grafts at low recipient mortality. Thereby the rate of delayed graft function should be low (DGF definition: post-operative dialysis>1). In this analysis, the impact of several donor (D) and recipient (R) related parameters on in-hospital mortality (M), death-censored graft survival (GS) and the incidence of DGF was investigated. Methods: Data concerning kidney donation (provided by Deutsche Stiftung Organtransplantation) and kidney transplantation (provided by BQS Institute for Quality and Patient Safety) were merged. In the resulting database, 4471 anonymized datasets of deceased D kidneys donated and transplanted in Germany into adult R during 2006 to 2008 are available. R with combined transplantations were excluded. To obtain independent observation units necessary for statistical analyses, for each R only the first (if more than one) transplantation in the study period as well as only one randomly selected kidney per D were considered. For later model building and validation purposes, data were randomly subdivided into a learning (n = 1621, 66%) and a validation sample (n = 810, 33%). Based on the learning sample, the impact of several D and R related parameters on M, GS and DGF was analysed by means of univariate logistic regression at a significance level of 5% (OR; p-value). Results: In the learning sample 1621 R were analysed with a mean age of 53.98y (SD=12.58), (62.6% m, 37.4% f). The mean age of D was 52.59y (SD=16.74), (52.6% m, 47.4% f), mean value of donor Serum-creatinine (S-creaa) on admission and before organ retrieval (S-crear) was 83.55mmol/l (SD=42.71) and 96.47mmol/l (SD=68.73), respectively. In-hospital mortality (M) was 1.4%, the incidence of delayed graft function (DGF) 28.1% and death-censored graft survival (GS) 94.3%. In-hospital mortality is significantly influenced by R age (1.069; 0.004) and to a lesser degree by D age (1.032; 0,040). DGF was determined by D age (1.010; 0.005) and D S-crea, particularly by S-crear before organ retrieval (1.003; < 0.001), but also by cold ischemia time (1.001; < 0.001). Concerning recipient-related factors, immunised patients (1.006; 0.007) seem to have a higher rate of DGF. Graft survival (GS), however, is influenced by D age (0.984; 0.019) and D S-crea (0.998; 0.049). Interestingly, the use of arterenol (1.676; 0.034) and steroids (1.739; 0.030) in the D before explantation of the organs had a positive impact on GS. Conclusion: In-hospital mortality after kidney transplantation was low and related to R and D age. The effect of D age might disappear in a multiple logistic regression model, as due to the European-Senior-Programme in Germany a strong relation between R and D age exists. Graft survival was determined by donor factors, such as D age and S-crea. Moreover our results indicate, that the incidence of DGF may be reduced by shortening cold ischemia time. These preliminary results are based on univariate analyses. Multivariate analysis considering the above described and several other risk factors simultaneously is currently performed and needed for further conclusions.

PSU35 Epidemiological Modeling of Patient Survival After Heart Transplantation in Germany

PSU35 Epidemiological Modeling of Patient Survival After Heart Transplantation in Germany

PSU34 Epidemiological Modeling of Patient Survival After Liver Transplantation in Germany

PSU34 Epidemiological Modeling of Patient Survival After Liver Transplantation in Germany

Organspendebereitschaft: Interventionsstudie bei 974 Befragten

Due to the lack of donor organs many patients cannot be helped in time with the necessary transplantation in Germany. At the same time, there is an organ donor potential that is not being exploited. A high refusal rate with a low rate of organ donor card holders remains problematic. The objective of this study was to collect the rate of holders of organ donor cards in a collective and to evaluate the collective according to other attributes in the context of a targeted trial. In 2009, a three-part questionnaire including an educational text regarding the topic of "organ donation" was sent out to the employees of the Sparkasse Essen (a savings bank). Altogether, 974 out of 1480 (65.8 %) completely answered questionnaires were evaluated. 21.3 % of the respondents had an organ donor card at the time the survey was carried out. A statistically significant association between gender (p value, 0.0438), age (p value, 0.0267) and the possession of a donor card could be determined. 22.1 % of the respondents who participated in sports regularly or donated blood (p value, < 0.0049), were holding an organ donor card. 60 % of the respondents found the brief information to be sufficient, 22.6 % could imagine acquiring an organ donor card for them based on the presented information alone. The spread of information and transparency in transplant medicine are essential for the facilitation of "willingness to donate organs". In the framework of this trial, besides data analysis, also fundamental information on "organ donation" could be conveyed. After all, 95.3 % of the respondents have read the information material and hence document the success of the study.

Joint Impact of Donor and Recipient Parameters on the Outcome of Liver Transplantation in Germany

The shortage of donor organs in Germany has led to the use of organs from donors with extended donor criteria (EDC). EDC have been defined on the basis of expert opinions, but their clinical relevance is controversial. This may cause loss of organs otherwise available for transplantation. We evaluated the impact of donor and recipient factors in liver transplants on patient and graft survival in a nationwide multicenter analysis, with special focus on EDC and donor risk index. A database was created from data on livers donated and transplanted in Germany between 2006 and 2008 as provided by Deutsche Stiftung Organ transplantation and BQS Institute. Cox regression (significance level 5%, risk ratio [95% confidence interval]) was used for calculating the impact on patient survival (n=2095) and on graft survival (n=2175). Patient and graft survival were significantly affected only by donor age (1.012 and 1.011/year), recipient age (1.019 and 1.014/year), creatinine (1.248 and 1.205/mg/dL), bilirubin (1.022 and 1.023/mg/dL), and high urgency status (1.783 and 1.809). Inferior organ quality resulted in lower graft survival (1.243) and donor history of smoking in lower patient survival (1.249). Multiple Cox regression revealed no significant impact of EDC or donor risk index on patient and graft survival except for donor age after donor selection at recovery. Among recipient variables, only age, creatinine and bilirubin, and high urgency status were associated with poorer outcome.

Presence of Cardiovascular Disease in Patients on a Waiting List for Renal Transplantation and in Patients After Kidney Transplantation in a Single Center

Background Cardiovascular risk in hemodialysis patients is enhanced, resulting in a higher mortality rate compared with the general population, yet the average wait time for renal transplantation in Germany is 5–7 years. The age of wait-listed patients has risen progressively. The aim of this study was to evaluate the prevalence of cardiovascular disease in patients on the waiting list in our center before and after renal transplantation as well as the extent to which invasive treatment was required in these patients. Methods The study investigated 2 groups: 350 patients on the renal transplantation waiting list at our center in 2008 and 324 patients who underwent renal transplantation at the same center in the years 2003–2007. Results In 2008, 141 women and 209 men with a mean age of 48.6 years (range 13–71 years) were on the waiting list. In the years 2003–2007, 98 women and 226 men with a mean age of 54.3 years (range 16–78 years) received renal transplants. One hundred six patients on the waiting list for renal transplantation had to undergo coronary angiography. There is no upper age limit for donors or recipients in our program. Mean age at admission on the waiting list was 48.6 years (range 13–71 years). Mean age at transplantation was 54.3 years (range 16–78 years) in our center. Most of these patients were asymptomatic but presented a risk profile that included diabetes mellitus, severe general atherosclerosis, a pathologic ergometric test, or abnormal myocardial scintigraphy. Only in 1 case could coronary heart disease be excluded. Seventy patients (20%) suffered from mild to moderate coronary heart disease without the need for intervention. In 5 patients (1.4%) coronary bypass surgery was necessary due to severe 3-vessel coronary heart disease. In 2 cases (0.6%) replacement of the aortic valve was performed because of aortic valvular stenosis. Coronary angioplasty without implantation of stents was done in 2 patients (0.6%). Twenty-two patients (6.8%) were treated with implantation of bare metal stents and 6 patients (1.7%) with drug-eluting stents. After renal transplantation, 22 patients (6.8%) suffered from peripheral arterial occlusive disease. In 58 patients, coronary heart disease was documented by angiography. 16 patients (4.9%) had 1-vessel disease, 23 patients (7%) 2-vessel disease, and 19 patients (5.8%) 3-vessel disease. Myocardial infarction was documented in 18 patients (5.5%) before and in 5 patients (1.5%) after renal transplantation. Bare metal stent implantation was performed in 6 patients (1.8%) after transplantation. One patient received a drug-eluting stent after renal transplantation. In the years 2003–2007, 22 patients underwent coronary bypass surgery before kidney transplantation. Conclusion The prevalence of coronary heart disease is high in patients on the waiting list and after renal transplantation. The majority of these patients are clinically asymptomatic. One-third of the patients with coronary heart disease had to be treated invasively. Nevertheless, many diabetic patients are very sick from multiple complications after the waiting time, making theme unsuitable for transplantation.

Multicentric evaluation of model for end-stage liver disease-based allocation and survival after liver transplantation in Germany - limitations of the ‘sickest first’-concept

Since the introduction of model for end-stage liver disease (MELD) in 2006, post-orthotopic liver transplantation (OLT) survival in Germany has declined. The aim of this study was to evaluate risk factors and prognostic scores for outcome. All adult OLT recipients in seven German transplant centers after MELD implementation (December 2006-December 2007) were included. Recipient data were analyzed for their influence on 1-year outcome. A total of 462 patients (mean calculated MELD = 20.5, follow-up: 1 year) were transplanted for alcoholic cirrhosis (33.1%), hepatocellular carcinoma (26.6%), Hepatitis-C (17.1%), Hepatitis-B (9.5%), primary sclerosing cholangitis (5.6%) and late graft-failure after first OLT before December 2006 (8.7%). 1-year patient survival was 75.8% (graft survival 71.2%) correlating with MELD parameters and serum choline esterase. MELD score >30 [odds ratio (OR) = 4.17, confidence interval: 2.57-6.78, 12-month survival = 52.6%, c-statistic = 0.669], hyponatremia (OR = 2.07), and pre-OLT hemodialysis (OR = 2.35) were the main death risk factors. In alcoholic cirrhosis (n = 153, mean MELD = 21.1) and hepatocellular carcinoma (n = 123, mean MELD = 13.5), serum bilirubin and the survival after liver transplantation score were independent outcome parameters, respectively. MELD >30 currently represents a major risk factor for outcome. Risk factors differ in individual patient subgroups. In the current German practice of organ allocation to sicker patients, outcome prediction should be considered to prevent results below acceptable standards.

Considerations for Patients Awaiting Heart Transplantation

The aim of this study is to provide a description of patients on the waiting list for heart transplants in Germany; the focus is on comparing the era after implementation of the new transplant law with the former era. This study used data from the Eurotransplant registry. The population consisted of all patients who registered for heart transplantation in Germany between January 1990 and May 2009. Patients were followed up to the earliest of the following events: heart transplantation, death, or end of the observation period. The actual mortality rates were calculated using a competing risk methodology. The proportion of patients on the waiting list aged 65 years or older has increased from 1.9 % in 1990 to 8.3 % in 1997, 7.8 % in 2000 and 12.6 % on December 31, 2008. The 1-year waiting list mortality rate, expressed as the proportion of patients who die within 1 year after being listed for heart transplantation decreased in the period 2001-2009 compared to the period 1991-2000. Patients registered in the period from 1991-2000 had a 25.9 % chance of dying prior to heart transplantation compared to 18.9 % for patients who were registered in the years 2001-2009. In the registration period 1981-1990, a transplant candidate had a 64.3 % chance of undergoing heart transplantation within the first year after being listed, while for patients who were registered in the period 2001-2009 this probability has been reduced to 40.2 %. Despite the fact that patient profiles have worsened and access to transplantation decreased, mortality rates of patients on the heart transplant waiting list have decreased. These data show that treatment of patients with advanced heart disease has improved in Germany.

Impact of allocation rules on outcome after heart transplantation in Germany

Before 2000, high urgency (HU) listing for heart transplantation (HTx) was only possible in cases of acute retransplantations; special urgency requests were limited to 15% of the listed patients. Since August 23, 2000, each center can submit for all patients fulfilling specific HU criteria unlimited, but audited HU requests to Eurotransplant. This study examines the impact of the preferential urgency allocation on transplantation outcome.

Who Should be Delisted from Urgent Heart Transplantation in Germany?

When German heart transplant candidates receive a ventricular assist device (VAD), the indication for Eurotransplant urgency listing is no longer given unless assist device complications occur. We studied survival rates in these patients and compared them with those of patients with urgency listing. The study cohort consists of 377 heart transplant candidates who were listed in urgent status or received a VAD in our center between 2000 and 2007. We defined the following patient groups: group U (n = 193), patients listed in urgent status primarily; group VADinT (n = 219), patients actively listed without urgency (transplantable) after VAD implantation, and group VADinU (n = 99), patients listed in urgent status after VAD implantation. The survival rates during urgent status in groups U and VADinU and those during VAD support without urgency listing in group VADinT were studied. The survival curves of groups U and VADinU were similar, and 1-month survival rates were 97.7% and 95.9%, respectively. One-month survival rate in group VADinT (85.9%) was worse than in group U (p < 0.0001). Survival rates in patients in urgent status both with and without VAD are satisfactory. However, patients with a VAD in "transplantable" status should be rescued under an urgency-based resource allocation algorithm.

Heart Transplant and Artificial Heart Systems

Heart transplantation (HTx) and the implantation of ventricular assist devices (VAD) are effective surgical treatment options for patients with end-stage heart failure. Nonetheless, for various reasons, they are usually among the last treatments to be used among all treatments that are available for heart failure (medications, implantable defibrillation systems, cardiac resynchronization therapy, and alternative surgical methods) (1). The article by Struber et al. appearing in this issue of the Deutsches Arzteblatt International (2) provides an important and comprehensive overview of the current potential and limitations of HTx and VAD. Major developments in the last five to ten years have led to significant changes in the indications for surgery, as well as in the optimal time point for referral to a specialized center. Recent years have seen a marked improvement in the pharmacotherapy of heart failure. The introduction of cardiac resynchronization therapy has led to clinical improvement in some patients. Furthermore, new surgical methods (conventional cardiac surgery in high-risk patients, e.g., coronary and valve operations, left ventricular reconstructions) have proven useful in appropriate patients (3). HTx remains the gold standard of treatment for end-stage heart failure (NYHA III–IV). The main disadvantage of transplantation in Germany is the long waiting period for a transplant. As Struber et al. discuss in their article (2), the number of patients waiting for a transplant has risen steadily since 2002, while, at the same time, the number of transplantations actually performed in Germany per year has steadily fallen. Thus, in 2008, 815 patients were awaiting transplants, but only 382 transplantation procedures were performed. There is no good reason why only 382 hearts should be available for transplantation each year in a country with 82 million inhabitants. Even this low number was only attained through the loosening of criteria for acceptable donors and the toleration of long transport times. As the life expectancy of the population rises, we can expect heart failure to become an even more common problem, particularly among the elderly. Thus, the need for organs will only rise in future, and we must do all we can to encourage potential donors to donate. One-minute commercials on prime-time television and newspaper advertising campaigns are certainly important ways of doing this. Ventricular assist devices are increasingly being used to enable patients at risk of death on the waiting list to survive long enough to obtain a transplant. In 2008, in Freiburg alone, 24 heart and combined heart-and-lung transplantations were performed, while, in the same year, 38 VADs were implanted. 25% of the 24 HTx patients had the support of a VAD. More than 60% of the transplanted hearts went to patients on the highly urgent (HU) or urgent (U) list. More than half of the patients had undergone cardiac surgery previously. A glance at the criteria required to put a patient on the HU waiting list quickly reveals that waiting times of up to eight weeks, and even longer, are simply too long for many of these patients. VAD implantation as a bridge to transplantation is, for some, their only chance of survival. It is important, therefore, to implant a VAD in timely fashion to enable survival before the impending multi-organ failure takes place. Ultimately, however, the use of VADs as a bridge to transplantation cannot solve the problem of organ scarcity. Furthermore, HTx is contraindicated in a rapidly increasing number of heart-failure patients, because of age over 75 years, a history of cancer, fixed pulmonary hypertension, or other reasons. HTx is thus a therapeutic option only for a fraction of patients in heart failure. VADs are a steadily improving form of treatment, not just for temporary implantation as a bridge to transplantation, but also for implantation as a bridge to recovery. Even in patients with so-called fixed pulmonary hypertension (>4 on the Wood scale), the implantation of a VAD can be followed by a decline of pulmonary resistance within 3 to 9 months (4). Thus, already today, many centers for the treatment of heart failure perform more VAD implantations than heart transplantations. It remains unclear, however, what permanent really means in terms of years. The two patients sharing the world record → 7.5 years—for survival with a VAD (of the Jarvik 2000 type) were treated at Oxford (England) and in Freiburg (Germany). The quality of life is not the same after VAD implantation as it is after HTx, as Struber et al. point out (2): the emotional stress after VAD implantation is greater. Nonetheless, the possibilities for surgical treatment have now reached a gratifyingly high standard that enables many patients in heart failure to be treated successfully.

The Current Status of Heart Transplantation and the Development of „Artificial Heart Systems“

In view of the major technical advances in ventricular assist devices (VAD) in recent years, the authors discuss the question whether these "artificial hearts" are still no more than a temporary measure for patients awaiting heart transplantation (HTx), or whether they can already be used as an independent form of long-term treatment. Statistics from Eurotransplant regarding heart transplantations and transplant waiting lists in Germany are presented. Technical developments in cardiac support systems, the variation in results depending on the indication, and the findings with respect to quality of life are all discussed on the basis of a selective review of the literature and the authors' own clinical experience. The waiting list for heart transplantation in Germany has grown to a record size of nearly 800 patients, while fewer than 400 hearts are transplanted each year. Technical advances have improved outcomes in VAD therapy, but the outcome depends on the patient's preoperative condition. The physical performance of patients who have received VAD is comparable to that of HTx patients; nonetheless, HTx patients have a better quality of life. Chronic VAD therapy has become a clinical reality. Because of the greater number of patients awaiting HTx, many will not receive their transplants in time. When the decision to treat with VAD is made early, it can be used as an alternative form of treatment with a comparable one-year survival (>75%).