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Overview

A heart transplant is an operation in which a failing heart is replaced with a healthier donor heart. Heart transplant is a treatment that's usually reserved for people whose condition hasn't improved enough with medications or other surgeries.

While a heart transplant is a major operation, your chance of survival is good with appropriate follow-up care.

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Why it's done

Heart transplants are performed when other treatments for heart problems haven't worked, leading to heart failure. In adults, heart failure can be caused by:

A weakening of the heart muscle (cardiomyopathy)

Coronary artery disease

Heart valve disease

A heart problem you're born with (congenital heart defect)

Dangerous recurring abnormal heart rhythms (ventricular arrhythmias) not controlled by other treatments

Failure of a previous heart transplant

In children, heart failure is most often caused by either a congenital heart defect or cardiomyopathy.

Another organ transplant may be performed at the same time as a heart transplant (multiorgan transplant) in people with certain conditions at select medical centers.

Multiorgan transplants include:

Heart-kidney transplant. This procedure may be an option for some people with kidney failure in addition to heart failure.

Heart-liver transplant. This procedure may be an option for people with certain liver and heart conditions.

Heart-lung transplant. Rarely, doctors may suggest this procedure for some people with severe lung and heart diseases if the conditions cannot be treated with only a heart transplant or a lung transplant.

A heart transplant is not right for everyone, however. You might not be a good candidate for a heart transplant if you:

Are at an advanced age that would interfere with the ability to recover from transplant surgery

Have another medical condition that could shorten your life, regardless of receiving a donor heart, such as a serious kidney, liver or lung disease

Have an active infection

Have a recent personal medical history of cancer

Are unwilling or unable to make lifestyle changes necessary to keep your donor heart healthy, such as not using recreational drugs, not smoking and limiting alcohol use

Ventricular assist devices

For some people who cannot have a heart transplant, another option may be a ventricular assist device (VAD). A VAD is a mechanical pump implanted in your chest that helps pump blood from the lower chambers of your heart (ventricles) to the rest of your body.

VADs are commonly used as temporary treatments for people waiting for heart transplants. These devices are increasingly being used as long-term treatment for people who have heart failure but are not eligible for heart transplants. If a VAD doesn't help your heart, doctors may sometimes consider a total artificial heart - a device that replaces the ventricles of your heart - as an alternative short-term treatment while you're waiting for a heart transplant.

Risks

Besides the risks of having open-heart surgery, which include bleeding, infection and blood clots, risks of a heart transplant include:

Rejection of the donor heart. One of the most worrying risks after a heart transplant is your body rejecting the donor heart.

Your immune system may see your donor heart as a foreign object and try to reject it, which can damage the heart. Every heart transplant recipient receives medications to prevent rejection (immunosuppressants), and as a result, the rate of organ rejection continues to decrease. Sometimes, a change in medications will halt rejection if it occurs.

To help prevent rejection, it's critical that you always take your medications as prescribed and keep all your appointments with your doctor.

Rejection often occurs without symptoms. To determine whether your body is rejecting the new heart, you'll have frequent heart biopsies during the first year after your transplant. After that, you won't need biopsies as often.

Primary graft failure. With this condition, the most frequent cause of death in the first few months after transplant, the donor heart doesn't function.

Problems with your arteries. After your transplant, it's possible that the walls of the arteries in your heart could thicken and harden, leading to cardiac allograft vasculopathy. This can make blood circulation through your heart difficult and can cause a heart attack, heart failure, heart arrhythmias or sudden cardiac death.

Medication side effects. The immunosuppressants you'll need to take for the rest of your life can cause serious kidney damage and other problems.

Cancer. Immunosuppressants can also increase your risk of developing cancer. Taking these medications can put you at a greater risk of skin cancer and non-Hodgkin's lymphoma, among others.

Infection. Immunosuppressants decrease your ability to fight infection. Many people who have heart transplants have an infection that requires them to be admitted to the hospital in the first year after their transplant.

How you prepare

Preparations for a heart transplant often begin weeks or months before you receive a donor heart.

Taking the first steps

If your doctor recommends a heart transplant, you'll likely be referred to a heart transplant center for evaluation. Or you can select a transplant center on your own. Check your health insurance to see which transplant centers are covered under your plan.

When evaluating a heart transplant center, consider the number of heart transplants a center performs each year and the survival rates. You can compare transplant center statistics using a database maintained by the Scientific Registry of Transplant Recipients.

You should also check to see if a transplant center offers other services you might need. These include coordinating support groups, assisting with travel arrangements, helping you find local housing for your recovery period or directing you to organizations that can help with these concerns.

Once you decide on a center, you'll need to have an evaluation to see if you're eligible for a transplant. The evaluation will check to see if you:

Have a heart condition that would benefit from transplantation

Might benefit from other, less aggressive treatment options

Are healthy enough to undergo surgery and post-transplant treatments

Will agree to quit smoking, if you smoke, and stop using alcohol and recreational drugs

Are willing and able to follow the medical program outlined by the transplant team

Can emotionally handle the wait for a donor heart

Have a supportive network of family and friends to help you during this stressful time

Waiting for a donor organ

If the transplant center medical team determines that you're a good candidate for a heart transplant, the center will put you on a waiting list. The wait can be long since there are more people who need hearts than donors. Finding a donor depends on your size, your blood type and how sick you are.

While you're on the waiting list, your medical team will monitor your heart and other organs and adjust your treatment as necessary. The team will help you learn to care for your heart by eating well and being active.

If medical therapy fails to support your vital organs as you wait for a donor heart, your doctors might recommend that you have a ventricular assist device (VAD) implanted to support your heart while you wait for a donor organ. The devices are also referred to as bridges to transplantation because they gain you some time to wait until a donor heart is available.

Immediately before your transplant surgery

A heart transplant usually needs to occur within four hours of organ removal for the donor organ to remain usable. As a result, hearts are offered first to a transplant center close by and then to centers within certain distances of the donor hospital.

The transplant center can provide you with a pager or cellphone to notify you when a potential heart is available. You must keep your cellphone or pager charged and turned on at all times.

Once you're notified, you and your transplant team have limited time to accept the donation. You'll have to go to the transplant hospital immediately after being notified.

As much as possible, make travel plans ahead of time. Some heart transplant centers provide private air transportation or other travel arrangements. Have a suitcase packed with everything you'll need for your hospital stay, as well as an extra 24-hour supply of your medications.

Once you arrive at the hospital, your doctors and transplant team will conduct a final evaluation to determine if the donor heart is suitable for you and if you're ready for surgery. If your doctors and transplant team decide that either the donor heart or surgery isn't appropriate for you, you might not be able to have the transplant.

Transporting donor organs for transplant

Mayo doctors and staff can receive donor organs from other locations and transport them to prepare them for transplantation.

What you can expect

During the procedure

Heart transplant surgery

Mayo Clinic cardiac surgeons work with a team to perform heart transplant surgery.

Heart transplant surgery is an open-heart procedure that takes several hours. If you've had previous heart surgeries, the surgery is more complicated and will take longer.

You'll receive medication that causes you to sleep (general anesthetic) before the procedure. Your surgeons will connect you to a heart-lung bypass machine to keep oxygen-rich blood flowing throughout your body.

Your surgeon will make an incision in your chest. Your surgeon will separate your chest bone and open your rib cage so that he or she can operate on your heart.

Your surgeon then removes the diseased heart and sews the donor heart into place. He or she then attaches the major blood vessels to the donor heart. The new heart often starts beating when blood flow is restored. Sometimes an electric shock is needed to make the donor heart beat properly.

You'll be given medication to help with pain control after the surgery. You'll also have a ventilator to help you breathe and tubes in your chest to drain fluids from around your lungs and heart. After surgery, you'll also receive fluids and medications through intravenous (IV) tubes.

After the procedure

You'll initially stay in the intensive care unit (ICU) for a few days, then be moved to a regular hospital room. You're likely to remain in the hospital for a week or two. The amount of time spent in the ICU and in the hospital varies from person to person.

After you leave the hospital, your transplant team will monitor you. Due to the frequency and intensity of the monitoring, many people stay close to the transplant center for the first three months. Afterward, the follow-up visits are less frequent, and travel is easier.

You'll also be monitored for any signs or symptoms of rejection, such as shortness of breath, fever, fatigue, not urinating as much or weight gain. It's important to let your transplant team know if you notice any signs or symptoms of rejection or infection.

To determine whether your body is rejecting the new heart, you'll have frequent heart biopsies in the first few months after heart transplantation, when rejection is most likely to occur. The frequency of necessary biopsies decreases over time.

During a heart biopsy, a doctor inserts a tube into a vein in your neck or groin and directs it to your heart. The doctor runs a biopsy device through the tube to remove a tiny sample of heart tissue, which is examined in a lab.

You'll need to make several long-term adjustments after you have had your heart transplant. These include:

Taking immunosuppressants. These medications decrease the activity of your immune system to prevent it from attacking your donated heart. You'll take some of these medications for the rest of your life.

Because immunosuppressants render your body more vulnerable to infection, your doctor might also prescribe antibacterial, antiviral and antifungal medications. Some drugs could worsen - or raise your risk of developing - conditions such as high blood pressure, high cholesterol, cancer or diabetes.

Over time, as the risk of rejection decreases, the doses and number of anti-rejection drugs can be reduced.

Managing medications and a lifelong care plan. After a heart transplant, taking all your medications as your doctor instructs and following a lifelong care plan are vital.

A daily routine for taking your medications may be helpful. Keep a list of all your medications with you at all times for medical appointments and in case you need emergency care. Check with your doctor before you use any nonprescription medicines, vitamins, supplements or herbal products.

Your doctor might give you instructions regarding your lifestyle. Recommendations may include wearing sunscreen, exercising, eating a healthy diet and being careful to lower your risk of infection. You doctor may also recommend that you not use tobacco products or recreational drugs and limit alcohol use.

Follow all of your doctor's instructions, see your doctor regularly for follow-up appointments, and let your doctor know if you have signs or symptoms of complications.

Cardiac rehabilitation. This program incorporates exercise and education to help you improve your health and recover after a heart transplant. Cardiac rehabilitation can help you regain your strength and improve your quality of life. You may start it before you leave the hospital.

Results

Most people who receive a heart transplant enjoy a good quality of life. Depending on your condition, you may be able to resume many of your daily life activities, such as work, hobbies and sports, and exercising. Discuss with your doctor what activities are appropriate for you.

Some women who have had heart transplants can become pregnant. However, talk to your doctor if you're thinking about having children after your transplant. You'll likely need medication adjustments before becoming pregnant, as some medications can cause pregnancy complications.

Survival rates after heart transplantation vary based on a number of factors. Survival rates continue to improve despite an increase in older and higher risk heart transplant recipients. Worldwide, the overall survival rate is about 90% after one year and about 80% after five years for adults.

What if your new heart fails?

Heart transplants aren't successful for everyone. Your new heart can fail for a number of reasons. Your doctor might then suggest adjusting your medications or, in more extreme cases, having another heart transplant.

If additional treatment options are limited, you might choose to stop treatment. Discussions with your heart transplant team, doctor and family should address your expectations and preferences for treatment, emergency care and end-of-life care.

Clinical trials

Explore Mayo Clinic studies of tests and procedures to help prevent, detect, treat or manage conditions.

Coping and Support

It's normal to feel anxious or overwhelmed while waiting for a transplant or to have fears about rejection, returning to work or other issues after a transplant. Seeking the support of friends and family members can help you cope during this stressful time.

Join a support group for transplant recipients. Talking with others who share your experience can ease fears and anxiety.

Set realistic goals and expectations. Recognize that life after transplant might not be the same as life before transplant. Having realistic expectations about results and recovery time can help reduce stress.

Educate yourself. Read as much as you can about your procedure and ask questions about things you don't understand. Knowledge is empowering.

Diet and nutrition

After your heart transplant, you may need to adjust your diet to keep your heart healthy and functioning well. Maintaining a healthy weight through diet and exercise can help you avoid complications such as high blood pressure, heart disease and diabetes.

A nutrition specialist (dietitian) can discuss your dietary needs and answer your questions after your transplant. You'll have several healthy food options and ideas to use in your eating plan. Your dietitian's recommendations may include:

Eating a healthy, balanced diet and including plenty of plant-based foods

Eating plenty of fruits and vegetables each day

Eating lean meats, such as fish or poultry

Choosing foods that are low to moderate in sodium (salt), fat and added sugar

Choosing foods high in fiber, such as fruits, vegetables and whole grains

Choosing heart-healthy fats, such as avocados, salmon and nuts

You might also:

Drinking low-fat or fat-free milk or eating other low-fat or fat-free dairy products, to help maintain enough calcium in your body

Avoiding fruits that can affect the medications you take after your transplant. Examples include grapefruit, Seville oranges and pomegranates

Reaching and staying at a healthy weight

Following food safety guidelines to reduce the risk of infection

Avoiding excessive alcohol

Staying hydrated by drinking adequate water and other fluids each day

Exercise

After your transplant, your doctor may recommend that you make exercise and activity a regular part of your life to continue to improve your overall physical and mental health.

Exercising regularly can help you control your blood pressure, reduce stress, maintain a healthy weight, strengthen your bones and increase your physical function.

Your treatment team will create an exercise program designed to meet your individual needs and goals. You'll participate in cardiac rehabilitation to help improve your endurance, strength and energy. Cardiac rehabilitation helps you improve your health and recover after your heart transplant.

Your exercise program may include warm-up exercises such as stretching or slow walking. Your treatment team may suggest walking, bicycling, strength training and other exercise. Specialists in the treatment team will likely suggest that you cool down after you exercise, perhaps by walking slowly. Discuss with your treatment team what may be appropriate for you.

Take a break from exercising if you feel tired. If you feel symptoms such as shortness of breath, nausea, irregular heart rate or dizziness, stop exercising. If your symptoms don't go away, contact your doctor right away.

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https://www.ssa.gov/oact/STATS/table4c6.html

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The etymology of the word "Charles" means "man, husband."  He could be a potential husband.

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Abstract

INTRODUCTION

Heart failure is a major public health burden, being the patient population of at least 10 millions in Europe and ∼5 millions in North America, with an estimated growth rate of 25% by 2030 [1].

Owing to the more recent improvement in the heart failure treatment, the proportion of patients reaching an advanced phase of the disease, so-called end-stage heart failure, is steadily growing, this representing one of the leading causes of hospitalization and death (1-year mortality rate of ∼50%) [1].

Cardiac transplantation has been considered the gold standard of end-stage heart disease and achieves long-term patient survival.

At the beginning of heart transplantation (HTx) experience, indications were restricted to recipients aged <60 years.

However, the continuous improvement of clinical results has encouraged the expansion of selection criteria, enrolling patients older than 60 and even 70 years of age. To date, solid data of the age impact on long-term HTx outcome are limited and controversial. Moreover, owing to a donor shortage, the debate still remains whether HTx is justified for older recipients [2-12].

We analysed the impact of recipients' age on long-term outcome in terms of survival and rate of major complications following HTx in our institution.

PATIENTS AND METHODS

Between 1999 and 2014, 364 consecutive HTxs in patients ≥18 years were performed at the University Hospital of Udine, Italy. Patients transplanted before 1999 were not included, due to non-homogeneous surgical techniques and immunosuppression protocols but, since 1999, the bicaval surgical technique was generally adopted and immunosuppression standardized with steroids, cyclosporine and mycophenolate. The study was approved by the Review Board of the University of Udine.

Patients were divided into three groups according to age: Group 1 (patients ≥18 and <40 years of age), Group 2 (patients >40 and <60 years), Group 3 (≥60 years), and data were prospectively collected and retrospectively analysed. There was no significant difference concerning age distribution during the considered period of recruitment. The mean follow-up was 6.7 ± 4.5 years (range 1-15.7 years).

All HTx recipients met the same eligibility criteria [13]. Recipient's evaluation included the assessment of clinical conditions commonly related to advanced age, such as malignancies, diabetes mellitus, peripheral vascular disease and end-organ dysfunction. Donor and recipient were matched on ABO blood type compatibility and body weight, considering clinical status and time on waiting list as prioritization criteria. There was a tendency to pair young donors to young recipients, but recipient age was not a prioritization criterion. Donor hearts were harvested from beating-heart, brain-dead patients. Graft procurement and preservation was achieved by the combination of cold cardioplegic arrest with St Thomas cardioplegia and topical hypothermia. Organ Care System Transmedics was used in 11 donors.

Postoperative and long-term follow-up protocol in our centre has been previously published [14]. Endomyocardial biopsies were made every week during the first month, every 15 days in Months 2 and 3, and monthly or bimonthly up to 12 months, and if required thereafter. Coronary angiography was performed at the first year and every 2 years afterwards or on clinical requirement. Clinical follow-up was conducted by a dedicated team including a cardiac surgeon, a cardiologist, a nurse and a psychologist every 15 days during the first 3 months, every month between Months 3 and 12, every 3 months between 1 and 3 years, every 4 months between 3 and 5 years and every 6 months after 6 years from transplantation.

Rejection and coronary allograft vasculopathy (CAV) were defined according to the guidelines of the International Society of Heart and Lung Transplantation (ISHLT) [ 15, 16]. Rejections ≥ 2R were treated with 1 gr methylprednisolone for 3 days. If a lower rejection level was detected, the treatment was tailored depending on precocity and recurrence.

Apart from recipient age, the following potential determinants were assessed: donor age, gender, New York Heart Association (NYHA) class, priority status, diabetes mellitus, pulmonary hypertension, arterial hypertension, hypercholesterolaemia, renal failure, donor age, preoperative mechanical assist devices, ischaemic time (Table 1).

Statistical analysis

Continuous variables are described with mean ± standard deviation, median and inter-quartile range, while the absolute frequency and percentage are reported for categorical variables. Comparisons among age groups for continuous variables were performed using parametric (analysis of variance) or non-parametric (Kruskal-Wallis) tests, according to the normality of the distribution, as checked using the Kolmogorov-Smirnov test. Categorical variables were compared using the χ ² test or the Fisher's exact test when at least one cell of the table had expected counts less than 5.

The outcomes evaluated were: overall survival, CAV as detected at angiography, need for coronary angioplasty, development of renal failure, need for dialysis, transplant acute rejection (≥2R), infections requiring specific intravenous treatment, number of hospital admissions, solid neoplasms and post-transplant lymphoproliferative diseases.

Time-to-event analyses were performed to assess the effect of potential determinants on outcomes taking into account the effect of time. Kaplan-Meier survival curves were plotted, and compared through the log-rank test. To estimate the effect of recipient age while simultaneously controlling for potential confounders, a multivariable proportional hazard Cox regression model was run. The recipient age variable was built as categorical and included in models as continuous. Adjustment was made for potential confounders, defined as those variables commonly identified as risk factors and known to be associated to age. Univariable models were also used to exclude, from multivariable analysis, those variables not revealing any confounding effect, thus allowing a model efficiency gain. Potential confounders assessed were as follows: (i) for long-term survival: patient gender, diabetes, arterial hypertension, hypercholesterolaemia, pulmonary hypertension, renal failure, donor age, aetiology, need for reintervention; (ii) for CAV ≥2 incidence: patient gender, diabetes, hypercholesterolaemia, arterial hypertension, renal failure, donor age; (iii) for infections: diabetes, pulmonary hypertension, renal failure.

The final models included the following terms (i) for long-term survival: patient age and gender, diabetes, arterial hypertension, pulmonary hypertension, renal failure, donor age; (ii) for CAV ≥2 incidence: patient age and gender, diabetes, hypercholesterolaemia, arterial hypertension, renal failure, donor age; (iii) for infections: patient age, diabetes, pulmonary hypertension, renal failure.

The hazard ratio (HR) is reported with a 95% confidence interval.

Statistical analysis was performed using the statistical package SAS Enterprise Guide Version 7.1 (SAS Institute, Inc., Cary, NC, USA).

RESULTS

Recipient and donor data

Distribution of preoperative data is presented in Table 1. In brief, renal failure (2.9, 16.1, 39.5%, P < 0.01) and cardiovascular factors such as diabetes (1.2, 17.1, 36.4%, P < 0.01), systemic hypertension (5.9, 31.5, 40.8%, P < 0.01) and dyslipidaemia (5.9, 40.3, 42.9%, P < 0.01) were more frequent in older patients, as well as ischaemic cardiopathy (0, 42.6, 49.7%, P < 0.01). Donor age was lower in younger patients (33 ± 15, 39 ± 14, 45 ± 14 years, P < 0.01).

Early outcomes

There were 32 deaths within 30 days after transplantation, for an overall 30-day postoperative mortality of 0% in Group 1, 7% in Group 2 and 8% in Group 3 ( P = 0.31). The main causes of early death (Table 2) were infection in 11 patients (34%), early graft failure in 16 (50%) and cerebrovascular disease in 3 (9.4%). A similar distribution of early death causes was seen in each of the three groups ( P = 0.16) and the proportion of complications during the hospitalization was similar, as well (Table 3).

Long-term survival

During the 15-year follow-up (mean 6.7 ± 4.5 years) 112 patients died, resulting in a mortality rate of 49/1000 patient-years: 32 patients died during the index hospitalization, while 80 patients died during the follow-up (resulting in a mortality rate of 35/1000 patient-years). The 15-year survival was 100% in Group 1, while at 1, 5, 10 and 15 years survival was 88, 78, 69 and 56% in Group 2 and 87, 68, 49 and 43% in Group 3 (log-rank test P < 0.01), respectively (Fig. 1). The main causes of long-term death were infections (21.3%), malignancy (27.5%) and cardiac disease (25%) (Table 2). Uncommon causes of death were acute rejection in 5 patients and renal failure in 3. Older patients more frequently died due to malignancy ( P = 0.02), while no difference in mortality due to infections and CAV was detected, according to age (Table 2).

At multivariable analysis, recipient age showed to be positively associated to the risk of death [HR 1.67 (1.12-2.49); P = 0.01] after adjusting for gender, hypertension, diabetes, pulmonary hypertension, renal failure and donor age.

Long-term complications

The incidences of long-term major complications in the three groups are described in Table 4. Forty-one solid neoplasms, 12 post-transplant lymphoproliferative diseases and 79 cutaneous tumours developed in 90 patients, overall (25%). These complications were less frequent in younger patients, with the following freedom from neoplasms in the three age classes: 100 vs 98 vs 94% at 1 year, 96 vs 85 vs 69% at 5 years, 96 vs 75 vs 42% at 10 years and 53 vs 64 vs 24% at 15 years (Fig. 2). The log-rank test P-value was <0.01 and the HR for recipient age from the unadjusted Cox regression model was 2.71 (1.85-3.98) ( P < 0.01).

Seventy-two rejections ≥ 2R (10 3R) were recorded in 59 patients, with 7 multiple rejections and a rate of 29.5 rejections/1000 patients/year, with no difference in the 3 groups. Only 3R rejections were more frequent in young people (6.9 vs 3.5 vs 1.6%, P = 0.03).

Three hundred and eighty infections requiring specific treatment developed in 213 patients (59%), with a rate of 155 infections/1000 patients/year and with a tendency to lower infection rate in Group 1. Most frequent infections were viral (134 patients) and bacterial (121 patients), while mycotic infections were detected in 4 patients. There was a lower rate of cytomegalovirus infection in Group 1 (8.8, 29.1, 25%, P = 0.05).

Patients of Group 2 had a tendency to a higher incidence of CAV and need for coronary angioplasty: freedom from CAV ≥ 2 was 100 vs 99 vs 99% at 1 year, 95 vs 92 vs 97% at 5 years, 89 vs 80 vs 88% at 10 years and 89 vs 51 vs 82% at 15 years; log-rank test P = 0.06. After correction for cardiovascular risk factors, the recipient age showed to be protective (HR 0.54, 0.30-0.97). Overall, 46 percutaneous coronary interventions (PCIs) were performed in 22 patients; among these procedures, 14 were re-PCIs due to restenosis. A total of 71 stents were implanted: 69 drug-eluting stents, 1 bare-metal stent and 1 bioresorbable scaffold; four PCIs were performed without stent implantation. The more treated vessel was the left anterior descending artery ( n = 29), followed by the circumflex artery ( n = 15), the right coronary ( n = 11) and the left main coronary ( n = 3), with no difference in the three groups.

The three groups were also similar for renal failure, which developed in 79 patients (21.7%); nevertheless, dialysis (12 patients) was more frequently required in Group 3 ( P = 0.04).

Overall, 651 hospital admissions were recorded in 245 patients, less frequent in young people (58.8 vs 63.9 vs 73.5%, P = 0.01), with a rate of hospital admission/patients/year of 0.19 ± 0.27 vs 0.27 ± 0.33 vs 0.45 ± 0.40, ( P < 0.01).

DISCUSSION

Since HTx has been recognized as the most effective treatment for end-stage cardiac disease and its clinical application is limited by poor donor availability, complex ethical debate has grown about appropriate patient selection [12].

Initially, HTx was restricted to people younger than 55 years to assure the best possible results, but the advances in surgical and immunosuppressive therapies have encouraged the enrolment of older recipients [ 12]. These patients, affected from end-stage heart disease and previously excluded from HTx listing due to age, should represent an unlimited number of potential candidates far exceeding the availability of cardiac donors. The enlargement of selection criteria to older patients has doubled the number of recipients >60 years receiving HTx (from 14 to 25% of total recipients in the ISHLT registry) without a correspondent increase of cardiac donors and remained stable for the last 10 years [ 17, 18]. So, considering the partial shift of available organs to aged population and the constant high mortality in waiting list (17% per year and 45% for status 1 patients), the debate remains whether HTx is justified in older patients and the policy of organ allocation should be regulated accordingly [ 6, 19].

As well known, age has always represented a risk factor for early and late mortality in cardiac surgery; moreover, in HTx the mandatory long-term immunosuppression increases the risk of complications as tumours, renal failure and infections, often fatal, in older and more fragile patients.

Despite satisfactory results at mid-term have been reported so far also in transplant patients over 60 and 70 years old, other studies have reported a reduced survival in the same classes of age (40-50% at 10 years and 25-35% at 15 years) [ 7, 9, 12].

In our study, recipient age has been a strong risk factor for mortality, even if results in terms of survival were quite good at any time in all groups (Fig. 1). Early mortality post-HTx was low even in older patients, but there was a great difference in long-term survival when young recipients were compared with older ones. Interestingly, no patients younger than 40 years died during the follow-up, disclosing a survival similar to general population of the same age. Impressively, comparing the overall amount of years of saved life after HTx, a double number of HTx and also of donors should be required to reach the same results in both groups. Several recipient and donor variables have been recognized to influence late survival [ 20]: generally older patients have more often a history of cardiac surgery or malignancy and a worse renal function, but they are less frequently hospitalized or taking inotropes at the time of transplant [ 17]. Even in our experience, the incidence of renal failure and the presence of cardiovascular factors were higher in older patients, which were also preferentially matched with older donors. During the follow-up, mortality was directly related to the recipient age, even after correction for these confounders, and recipient age resulted to be an important, independent risk factor.

Looking to the causes of death reported by the large ISHLT registry, both CAV and acute rejection become less common with the increasing of age, whereas non-lymphoma malignancy, renal failure and infection represent the main cause of late mortality [ 17]. In our overall population, the most frequent causes of death at long-term were infections (21.3%), malignancy (27.5%) and cardiovascular disease (25%), but in older patients the main cause was cancer with a significant difference among groups (0 vs 21 vs 33%, P = 0.02).

Little is known about the quality of life in aged transplanted people, but despite increased comorbidities it seems to be good. In same reports quality of life is similar to the general population of the same age, in others, older patients demonstrate better quality of life, psychosocial adjustment, and adherence after HT than middle-aged and younger patients [ 21, 22].

Although a lower incidence of acute cellular rejection has been reported by others in older recipients [ 3], we could not find a difference in the rate of acute rejection based upon patient age, except for the most severe 3R grade that was more frequent in young people. The side effects of immunosuppression, particularly the risk of infection and malignancy, have been demonstrated to be more common in older patients [ 4, 17]. Indeed, our aged populations showed a higher incidence of tumours and a tendency to a higher rate of infections and renal failure. As rejection is a rare event after the first-year post-HTx, attempt to dismiss steroid and reduce cyclosporine levels, especially in old patients, could favour the implementation of more specific immunosuppression, having the potential of reducing the immunosuppression complications.

The incidence of CAV in our study was similar to that of previous reports [ 15, 17]. The apparent protective effect of recipient's age on CAV development may be partially related to the difference in follow-up periods among groups; in fact, older recipients register a higher mortality and their follow-up could be too short to allow the development of a graft vasculopathy.

Recently, an alternate recipient list has been proposed to increase donor-organ availability. Some concerns exist, however, about the degree of post-transplantation mortality and morbidity in alternate-list recipients, particularly in older patients that usually have greater baseline comorbidities than patients undergoing standard HTx. In fact, matching high-risk recipients and marginal donors offers outcomes considerably lower than those of the overall transplant ones with a median survival of 5 years, but considerably better than life expectancy of end-stage heart failure patients without HTx [ 23, 24]. When considering the results of other standard treatments such as surgery for pancreatic or oesophageal cancer, where the median survival for patients is less than 18 months, alternate listing provides significantly greater survival benefit [ 25]. Even if the adoption of alternate lists has increased the use of marginal donors, it has been demonstrated that it did not improve the availability of organs to younger recipients, which could have benefit more in outcome [ 23, 24].

The United Network for Organ Sharing has made a policy decision regarding the use of paediatric-age donor hearts for paediatric-age recipients [18]. In the same way, allocation for age classes could be considered in adult patients.

In the absence of specific guidelines of organ allocation prioritization, it is a challenge for transplant physicians to establish objective parameters which accurately predict the recipient's response to the stress of the operation and the need for lifelong immunosuppression. The introduction of a heart allocation score that includes the possible survival benefits after transplantation and takes into account recipient comorbidities, including age, could be a reasonable solution to guarantee organs to better recipients.

Permanent mechanical support, new drugs and biventricular pacing are potential solutions to overcome the current organ shortage. Presently, left ventricular assist device (LVAD) seems to be the most effective strategy in alternative to HTx and its employment has increased significantly, mainly in the elderly [17]. The mid-term survival in these patients is similar to that of alternate list, so the expansion and the optimization of LVAD therapy will offer an alternative to the treatment of end-stage heart failure, without any negative impact on the donor pool for younger patients.

Limitations

This is a retrospective single-centre study, with all limitations of this kind of investigation even if data have been collected prospectively. Because of the relatively small study population overall in Group 1 at long-term, results cannot bring to definitive conclusions and data should be confirmed by larger studies.

CONCLUSIONS

Our results showed a significant different outcome according to the recipient age even after correction for major risk factors and donor age. Notably, patients younger than 40 years showed a 100% long-term survival, representing a subgroup of patients with an expectancy of life at 15 years after transplantation similar to general population of the same age. These patients seem to be less affected by immunosuppression complications, too. Since 15-year survival in patients ≤40 year is twice if compared with patients aged ≥60 years, recipient age should be taken into account in organ allocation. Even though the indication to HTx and donor-recipient matching needs to be tailored case by case, HTx community should assess and define guidelines to optimize organ utilization.

Conflict of interest: none declared.

REFERENCES

APPENDIX. CONFERENCE DISCUSSION

Dr E. Ferrari(Lausanne, Switzerland): As you underlined very well with your presentation, recipients older than 60 years of age are becoming more and more popular in our transplant waiting list. However, papers like yours are very important because they confirm that, in any case younger patients, let's say below 60 years of age, have larger survival curves, and these findings are more or less in line with real life and daily practice where 'younger' patients are still privileged during organ allocation.

Now, the questions. Could you please comment on the age distribution of your three groups according to the follow-up time? Patients over 60 years of age were probably more common during the last 5-10 years while younger patients have probably a more flat distribution in your groups. Is this the case in your population and does it affect your results? This is the first question.

Dr Sponga: In our population, the distribution of patients' during the study cannot be considered a bias. For sure, at the beginning of our experience (from 1985 to 1999) we transplanted younger people, but after 1999 we have a homogeneous population. Also for this reason we decided to consider consecutive patients only after 1999. In group 1 we transplanted 2-4 people per year and in the other two groups around 12 patients per year.

At the beginning of the study, there was a couple more patients in group 2 but at the end the situation has changed with a couple of patients more in group 3, without statistical difference. Indeed, there was a difference in the urgency status. We had more emergency patients and more patients on extracorporeal membrane oxygenation in group 1 and group 2 in the last years.

Dr Ferrari: Also then, a comment about your clinical practice and if these findings will change, maybe change your practice in the future or the practice of transplant allocation in your country? For example what happens when you have two recipients with the same clinical comorbidities and different age, let's say, 50 and 65? What is your suggestion?

Dr Sponga: Of course, we usually allocate organ considering the ABO group urgency status, waiting list time, and usually we reserve better donors to younger recipients. But until now, we didn't give priority in the allocation to younger recipients. Now, we pay more attention to the good results that can be reached by younger patients, but from a practical point of view I cannot say that our policy changed during the last months, maybe, because we always had an emergency candidate who was privileged.

I think, that in the future, it could be interesting to have an allocation score, I mean, a value that can be useful for the whole team to choose which patient should be transplanted first. We should do the same thing that was recently done for liver, and design a model to estimate the possible benefit that can be reached for every class of patients considering age, aetiology and every risk factor. For every class of patients the difference of the areas under the survival curve without transplant, allows to calculate the benefit given by heart transplantation. This number should later be matched with the degree of urgency and with the waiting list time to obtain the best potential candidate even if at the end, the decision should be made patient by patient.

Also we learn another thing maybe, that older people have less rejection, have a lot of complications related to immunosuppressive therapy. So maybe we should balance in a different way the immunosuppression in these patients. We found that in old people with long follow-up, even the level of cyclosporine was important, was a predictor of mortality, so I think, that in these particular patients we should reduce the immunosuppressive level.

(Padova, Italy): I, too, congratulate you for your excellent results, but I was astonished by your conclusion. So we can consider heart transplant as a strong protective factor for long-term survival for patients younger than 40, because you said that that's comparable for the general population, 100% survival.

Dr Sponga: We considered a small subgroup of only 40 patients with a follow-up limited to 15 years and so it is difficult to find definitive conclusions. We also have been impressed by the results in young people. But in that conclusion I wanted to suggest that if you replace the heart in a young recipient, in good general conditions apart from the heart, this patient will tend to have a survival similar to a normal person.

Dr J. Gummert(Bad Oeynhausen, Germany): What I would like to know is the follow-up rate of the group younger than 40. What was the median follow-up rate?

Dr Sponga: The median follow-up in group 1 was 8 years and 5.8 years in group 2 and 4.8 years in group 3. This can be interesting, not for survival but for morbidity as for example coronary allograft vasculopathy. We have seen that we had more patients affected by coronaropathy in group 2 then in group 3. Also, I think, that is not due to a protective effect of age, but patients in group 3 have a lower incidence of cardiac allograft vasculopathy because the follow-up was shorter and so they had not enough time to develop coronaropathy.

Dr Gummert: How many people were at risk after 10 years in this group younger than 40, because on your slide you didn't mention a number.

Dr Sponga: You are right. There were only eight people.

Dr Gummert: Eight people. So, therefore maybe the number is really too low to decline patients over 40 transplantation even because maybe I am over 40 and so I could be personally involved there. But thank you very much for the presentation. Unfortunately we have to move on even though we can discuss this probably much longer.

Author notes

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Recipient age impact on outcome after cardiac transplantation: should it still be considered in organ allocation? †

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Heart failure is a major public health burden, being the patient population of at least 10 millions in Europe and ∼5 millions in North America, with an estimated growth rate of 25% by 2030 [1].

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Heart transplant patients who receive new organs before the age of 55 and get them at hospitals that perform at least nine heart transplants a year are significantly more likely than other people to survive at least 10 years after their operations, new Johns Hopkins research suggests.

Examining data from the more than 22,000 American adults who got new hearts between 1987 and 1999, researchers found that roughly half were still alive a decade after being transplanted and further analysis identified factors that appear to predict at least 10 years of life after the operations.

"There are 2,000 to 2,500 heart transplants a year in the U.S. and many people die waiting," says Arman Kilic, M.D., a surgical resident at The Johns Hopkins Hospital and leader of the study published in The Annals of Thoracic Surgery. "We have to be very smart about how to allocate scarce organs, and our research suggests we can predict which patients will live longer with a new heart."

Kilic and his colleagues used information collected by the United Network of Organ Sharing (UNOS) and compared the 9,404 heart transplant recipients who survived for 10 or more years with the 10,373 who did not. Some 3,000 were lost to follow-up.

The researchers found that patients 55 and younger had a 24 percent greater chance of 10-year survival than older patients; those treated at hospitals performing nine or more heart transplants a year had a 31 percent greater chance of 10-year survival than those at lower volume centers; and white patients were 35 percent more likely to survive a decade than minority patients.

Kilic says that nearly half of heart transplant recipients in the study were over 55 and there is debate over how old is too old to undergo the surgery. "After the age of 55, we see the biggest difference in long-term survival," he says. "The chance of surviving for 10 years drops precipitously."

Patients at high-volume centers do better not only because their surgeons likely have more experience with heart transplants, but also because the staff and facilities are likely better equipped to manage the complex post-operative care of these patients and promote good outcomes, Kilic says.

The researchers noted that patients who were on ventilators before their transplants were 47 percent more likely to die within 10 years of surgery. People who require breathing machines before surgery are much sicker than those who do not, so it makes sense that those patients would do poorly, Kilic says. In addition, diabetics were one-third more likely to die within 10 years of transplant.

The study results also show the impact on long-term survival of ischemic time, or how long the heart is out of the body as it travels from donor to recipient. For every hour ischemic time was reduced, the researchers found an 11 percent increase in the chance that the recipient would survive for a decade or more.

The age of the donor was also significant. For every decade younger the donor was, the recipient was 10 percent more likely to survive long term, Kilic says.

Under current regulations and policies, UNOS gives available hearts to the sickest patients on its national waiting list, typically those whose doctors predict they will not survive a month without a new organ. Kilic agrees with the policies, but suggests it may be useful to give priority within this sickest group to patients who - using his data - would likely survive the longest.

"These data could be used for both prognosis and allocation purposes," Kilic says. "They help predict which patients have the best chance to derive the longest and most sustainable benefit from the limited number of hearts that become available each year. It also identifies areas that need further research, such as why racial disparities exist in long-term survival following heart transplant."

More than five million Americans suffer from heart failure and, while the majority of these patients can be managed with lifestyle modifications and medication, for those who suffer from severe, end-stage heart failure, transplantation remains the gold standard treatment.

Other Hopkins researchers involved in the study include Timothy J. George, M.D.; George J. Arnaoutakis, M.D.; Ashish S. Shah, M.D.; and John V. Conte, M.D.

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Younger Patients More Likely to Live a Decade or Longer After Heart Transplant - 02/27/2012

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Heart transplant patients who receive new organs before the age of 55 and get them at hospitals that perform at least nine heart transplants a year are significantly more likely than other people to survive at least 10 years after their operations, new Johns Hopkins research suggests.

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Data subject to change based on future data submission or correction. Totals may be less than the sums due to patients included in multiple categories.

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Michel Makaroun, MD, has been hard-pressed finding vascular surgeons. As chief of the division of vascular surgery at the University of Pittsburgh Medical Center (UMPC) Department of Surgery, he helps hire these much-needed specialists. But despite a generous compensation package, five vascular surgeon positions at UPMC hospitals remain unfilled.

Meanwhile, a hospital 120 miles away has lacked a vascular surgeon for several years, getting by with a cardiac surgeon and interventional radiologist. UMPC sends one of its vascular surgeons to the hospital each week, which means a four-hour drive round trip for the specialist.

"It's always an issue of supply and demand, and currently there is a huge demand for vascular services but unfortunately not as much supply," says Makaroun, president of the Society for Vascular Surgery.

Vascular surgeons are not the only surgeons in short supply. An April 2019 report prepared for the AAMC by the health care consulting firm IHS ., titled The Complexities of Physician Supply and Demand, estimates a shortage of 14,300 to 23,400 surgical specialists by 2032. And a 2016 Department of Health and Human Services workforce analysis projected shortages in nine out of 10 surgical specialties by 2025, with the greatest shortages in ophthalmology, orthopedic surgery, urology, and general surgery.

Those figures are especially alarming considering the growing, aging population in the United States. The number of people 65 and older is expected to reach 83.7 million in 2050, almost twice the 2012 level of 43.1 million, according to the U.S. Census. In addition, many surgeons are edging closer to retirement or contemplating cutting back.

"Fewer surgeons mean greater access issues for patients and delays in care, leading to morbidity and mortality," says Janis Orlowski, MD, AAMC chief health care officer. "Academic medicine leaders are concerned about this growing problem and are exploring various solutions to ensure that America's health care needs are met."

Communities in need of surgeons

Cardiothoracic surgeon J. Michael DiMaio, MD, practices in the Dallas-Fort Worth metropolitan area of Texas, a hub of distinguished heart surgery facilities. As is often the case for surgical specialties, complicated cardiothoracic procedures require the support of well-resourced hospitals, notes DiMaio. But those institutions tend to be clustered in metropolitan regions.

"It's certainly harder in a small market and sometimes in a medium market to have the sufficient support you may need," says DiMaio, who is also chief of staff and medical director for publications and postgraduate cardiovascular education at the Baylor Scott and White Research Institute and program director for thoracic residency and surgical services at Baylor Scott and White Health.

That's worrisome in light of the projected growth in the need for cardiothoracic procedures. For example, heart surgery cases will likely increase by 54% and lung cancer cases by 70% in less than two decades, according to a 2016 report.

According to the American Urological Association's (AUA) 2017 workforce report, nearly 90% of urologists work in metropolitan areas. Urology is one surgical specialty being stretched thin. "We are relatively a small group, maybe less than 1% of all doctors in the United States, but the disease burden is enormous," says Christopher Gonzalez, MD, public policy council chair at the AUA. He notes that three of the six most common cancers in men - bladder, kidney, and prostate - are all urologic.

Another shortage hitting rural areas hard is general surgery. Many routine surgeries performed in emergency departments, from abscess removals to appendectomies, are often handled by general surgeons, says Patrick Bailey, MD, medical director for the American College of Surgeons (ACS). And in rural hospitals - many of which have closed in recent years - general surgeons are vital.

"They are what's in the name - they are generalists," says Bailey. "And for those folks who are in smaller communities, they have a very broad practice so that they're able to serve their patient population."

"Rural surgical practices have been struggling, with under-resourced hospitals unable to provide more complex surgical procedures," says Orlowski. "In addition, because general surgeons in rural areas are older and approaching retirement faster, these ranks need to be filled by younger physicians who care passionately about their field of work and want to bring care to rural areas."

Looking for solutions

The shortages have set off alarm bells among leaders in surgery and academic medicine, and they have set out to find solutions.

One way the AAMC, the ACS, and others are working to combat the problem is by educating policymakers on the federal government's critical role in physician training and advocating that Congress should responsibly lift the current caps on federally supported residency slots. "Increasing the resident cap in hospitals would be tremendous in improving all physician shortages, including surgery," says DiMaio, who has developed graduate medical education policy for the Society of Thoracic Surgeons.

Groups are also exploring ways to address the problem of burnout among surgeons as its prevalence tops 50%, according to a 2016 systematic review. The ACS, for example, leads initiatives aimed at reducing contributors to burnout, including administrative burdens that can curtail physicians' time with patients.

Despite burnout, surgery can be an incredibly rewarding career, say experts, but students need to experience it up close and early if they are going to develop a passion for it.

According to the AAMC's 2018 Medical School Graduation Questionnaire, medical school graduates' specialty choice was most greatly influenced by whether it "fit with personality, interests, and skills," with almost 88% indicating a "strong influence."

"Particularly for those who rotate with medical students who have their first exposure to surgery, that's really where you want to work on having the love of the field," says Orlowski. "You need to have people who have a positive focus and a balance to their life. That is what's attractive to a medical student."

While working at the Case Western Reserve University School of Medicine, Gonzalez, who is now chair of the department of urology at the Loyola University Chicago Stritch School of Medicine, worked closely with the dean to bring urology to the forefront of education. That process involved him advocating for urology as a required rotation and reaching out to students early and regularly to share the benefits of a career in the field. "A lot of [attracting students to surgery] is going to be boots on the ground in individual medical schools, just getting students excited," Gonzales notes.

Bringing care to underserved populations

Because residents tend to practice where they trained, medical schools and teaching hospitals are working to educate future physicians in areas hit by shortages. The University of Nevada, Las Vegas School of Medicine (UNLV) is one such institution.

"We would like to create a medical community here that's on par with some of the other things the city is known for," says John Fildes, MD, professor and inaugural chair of the UNLV department of surgery. "It's a world-class destination for entertainment, world-class destination for art and architecture. People move here expecting that there's going to be world-class medical services, and we intend to build them."

Established in 2017, the school opts for applicants with ties to Nevada who want to live and work in the state. Increasing the number of general surgeons aligns with that priority. According to a 2018 Nevada physician workforce report, the state ranked 49th in the country for general surgeons per 100,000 people.

"General surgery really is the foundation of procedural medicine, and most general surgeons can support the procedural needs of large numbers of patients, and that's what makes them very valuable," says Fildes.

Halfway across the country, in the department of surgery at the University of Wisconsin (UW) School of Medicine and Public Health, the rural general surgery residency track is also helping fill the need for surgeons in underserved parts of the state, giving students the training necessary to serve patients in rural and community practices.

The life of a general surgeon isn't for everyone, but there is something special about the opportunity to serve an esteemed role in small communities, getting to know patients personally and caring for them throughout their lives, says Jacob Greenberg, MD, EdM, director of the general surgery residency program at the UW School of Medicine and Public Health.

"The more we can focus on this the better," Greenberg says. "I would use this as a call to arms."

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Michel Makaroun, MD, has been hard-pressed finding vascular surgeons. As chief of the division of vascular surgery at the University of Pittsburgh Medical Center (UMPC) Department of Surgery, he helps hire these much-needed specialists. But despite a generous compensation package, five vascular surgeon positions at UPMC hospitals remain unfilled.

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(Reuters Health) - The shortage of general surgeons in the U.S. is projected to get worse as the number of these doctors entering the workforce each year fails to keep pace with population growth, a U.S. study suggests.

Researchers predict shortages based on their estimates of population growth by 2050 and the number of medical schools and hospital-sponsored general surgery trainee positions in the U.S.

By 2050, there will be a deficit of 7,047 general surgeons nationwide, researchers calculated. That's higher than the shortage of 6,000 they projected a decade ago based on the pace of population growth and new surgeons entering the job market at that point in time.

"Leaders in surgery have predicted a pending shortage in the general surgery workforce for more than 10 years," said lead study author Dr. E. Christopher Ellison of the Ohio State University College of Medicine in Columbus.

"The impact of the general surgeon shortages on patients is measured in the timeliness of care and the consequences of delays in care," Ellison said by email.

To maintain acceptable access to surgical care, there should be about 7.5 general surgeons for every 100,000 people, researchers note in the journal Surgery.

In fact, the number of general surgery resident positions and the number of residents who complete their training have been rising in the U.S. But these increases have been insufficient to maintain the ideal number of surgeons for the population.

If anything, the projected shortage is an underestimate, the authors say.

"We have not considered the impact of the aging population on the surgeon's workload," Ellison said. "Patients 65 years and older are more likely to need general surgery services, and as that segment of the population increases, there will be a corresponding increase in the demands for general surgeons."

Because most general surgeons practice in metropolitan areas, the impact of the shortage will be more keenly felt by rural communities, Ellison added.

In calculating the projected shortage, researchers assumed that some young trainees will choose subspecialties like vascular surgery or transplant surgery instead of general surgery. They also assumed that general surgeons would choose to work for 30 years before retiring.

It's possible the researchers have over- or under-estimated how many general surgeons will enter the profession each year and how many years they will remain on the job. It's also possible that population growth estimates might change again, altering the projected shortage.

"Because there are high fixed costs to developing a general surgical practice in a more remotely populated area, we observe fewer practices in these areas. I wouldn't call this a shortage per se, but I do think it's a problem that as a society we need to figure out solutions to," said Dr. Anupam Jena, a researcher at Harvard Medical School and a physician at Massachusetts General Hospital in Boston who wasn't involved in the study.

Solutions might include identifying ways for rural patients who need surgical care to be promptly evaluated and treated at medical centers several hours away, Jena said. Or, it might involve encouraging graduates of both American and foreign medical training programs to work in remote parts of the country.

"We need to identify better ways to provide surgical care in regions where that care is difficult to obtain, either because the distance that needs to be traveled is prohibitive or because the existing surgical care in the region isn't high quality," Jena said. "These projections shed some light on how big an issue this problem is likely to be in the next 30 years."

SOURCE: bit.ly/2Lp5tvZ Surgery, online August 8, 2018.

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General surgeon shortage growing in U.S.

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(Reuters Health) - The shortage of general surgeons in the U.S. is projected to get worse as the number of these doctors entering the workforce each year fails to keep pace with population growth, a U.S. study suggests.

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Occupational Employment and Wages, May 2018 (Surgeons)

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Occupational Employment and Wages, May 2018 (Surgeons)

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Several interesting maps...

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29-1067 Surgeons

Physicians who treat diseases, injuries, and deformities by invasive, minimally-invasive, or non-invasive surgical methods, such as using instruments, appliances, or by manual manipulation. Excludes "Oral and Maxillofacial Surgeons" (29-1022).

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About May 2018 National, State, Metropolitan, and Nonmetropolitan Area Occupational Employment and Wage Estimates
These estimates are calculated with data collected from employers in all industry sectors, all metropolitan and nonmetropolitan areas, and all states and the District of Columbia. The top employment and wage figures are provided above. The complete list is available in the downloadable XLS files.

The percentile wage estimate is the value of a wage below which a certain percent of workers fall. The median wage is the 50th percentile wage estimate--50 percent of workers earn less than the median and 50 percent of workers earn more than the median. More about percentile wages.

(1) Estimates for detailed occupations do not sum to the totals because the totals include occupations not shown separately. Estimates do not include self-employed workers.

(2) Annual wages have been calculated by multiplying the hourly mean wage by a "year-round, full-time" hours figure of 2,080 hours; for those occupations where there is not an hourly wage published, the annual wage has been directly calculated from the reported survey data.

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(5) This wage is equal to or greater than $100.00 per hour or $208,000 per year.

(7) The value is less than .005 percent of industry employment.

(8) Estimate not released.

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May 2018 National Occupational Employment and Wage Estimates May 2018 State Occupational Employment and Wage Estimates May 2018 Metropolitan and Nonmetropolitan Area Occupational Employment and Wage Estimates May 2018 National Industry-Specific Occupational Employment and Wage Estimates May 2018 Occupation Profiles Technical Notes

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Physicians who treat diseases, injuries, and deformities by invasive, minimally-invasive, or non-invasive surgical methods, such as using instruments, appliances, or by manual manipulation. Excludes "Oral and Maxillofacial Surgeons" (29-1022).

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Ten-year reassessment of the shortage of general surgeons...

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Ten-year reassessment of the shortage of general surgeons...

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"Updated census projections estimate a 2050 U.S. population of 439 million, a 19million increase over prior census projections...General surgical workforce shortage in 2050 is projected to be 7,047 (21%) based on American Board of Surgery certificates; 4,917(15%) based on General Surgery Residency completions; 5,037 (15%) based on combined American Board of Surgery and American Osteopathic Association certificates; and 57 (0%) based on hypothetical expansion of general surgeons training by 75 positions by 2021."

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Abstract

Background

In 2008, we projected that a deficit in the general surgical workforce would grow to 19% by 2050. We reexamined population-based general surgical workforce projections to determine the impact of recent changes in population estimates and trends in certification and General Surgery Residency.

Methods

We reviewed the Census Bureau data and the potential pool of general surgeons defined by American Board of Surgery certificates, residents completing Accreditation Council for Graduate Medical Education-approved General Surgery Residency and combined American Board of Surgery and osteopathic certificates averaged from 2007-2016. The model included removal of 150 surgeons/year who subspecialize and 729 retirements/year.

Results

Updated census projections estimate a 2050 U.S. population of 439 million, a 19 million increase over prior census projections. From 2007-2016, the American Board of Surgery granted 10,173 certificates, averaging 1,017/year; General Surgery Residency graduations were 10,088, averaging 1,088/year; combined American Board of Surgery and osteopathic (American Osteopathic Association) certificates were 10,084, averaging 1,084/year. General surgical workforce shortage in 2050 is projected to be 7,047 (21%) based on American Board of Surgery certificates; 4,917(15%) based on General Surgery Residency completions; 5,037 (15%) based on combined American Board of Surgery and American Osteopathic Association certificates; and 57 (0%) based on hypothetical expansion of general surgeons training by 75 positions by 2021.

Conclusions

Without increasing future general surgeons training numbers, the projected future general surgical workforce shortage will continue to grow.

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Ten-year reassessment of the shortage of general surgeons: Increases in graduation numbers of general surgery residents are insufficient to meet the future demand for general surgeons

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JavaScript is disabled on your browser. Please enable JavaScript to use all the features on this page. In 2008, we projected that a deficit in the general surgical workforce would grow to 19% by 2050. We reexamined population-based general surgical workforce projections to determine the impact of recent changes in population estimates and trends in certification and General Surgery Residency.

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The impact of the aging population...on future projections of general surgical workforce needs

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The impact of the aging population...on future projections of general surgical workforce needs

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"The total number of new patients with cancers treated by general surgeons is projected to increase 56% (511,450 in 2010 to 798,070 in 2035). To maintain the same patient census per surgeon, it is estimated that 34,698 general surgeons will be needed. This is an increase of 9,198 over that based on current training numbers and 5,300–7,400 greater than the need projected by population growth alone."

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JavaScript is disabled on your browser. Please enable JavaScript to use all the features on this page.

Abstract

Background

Assessments of the future general surgery workforce continue to project substantial shortages of general surgeons. The general surgery workforce is targeted currently to maintain a surgeon/population ratio of 6.5-7.5/100,000.

Methods

We examined population and age-associated incidence of cancer to estimate the number of general surgeons needed for initial surgical treatment of the patient with cancer in the year 2035 compared with 2010. We hypothesized that the number of general surgeons needed to provide future cancer care will exceed the projections of available general surgeons based on current training numbers, as well as on population-based ratios alone.

Results

The total number of new patients with cancers treated by general surgeons is projected to increase 56% (511,450 in 2010 to 798,070 in 2035). To maintain the same patient census per surgeon, it is estimated that 34,698 general surgeons will be needed. This is an increase of 9,198 over that based on current training numbers and 5,300-7,400 greater than the need projected by population growth alone.

Conclusion

The analysis supports the hypothesis that an increasing incidence of cancer in the future will exceed the potential capacity of the general surgeon workforce. Regionalization of cancer care may be one solution to projected access issues.

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The impact of the aging population and incidence of cancer on future projections of general surgical workforce needs

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Assessments of the future general surgery workforce continue to project substantial shortages of general surgeons. The general surgery workforce is ta...

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A Review of Trends in Attrition Rates for Surgical Faculty

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A Review of Trends in Attrition Rates for Surgical Faculty

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A Review of Trends in Attrition Rates for Surgical Faculty: A Case for a Sustainable Retention Strategy to Cope with Demographic and Economic Realities

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Our aim was to compare trends in retention of academic surgeons by reviewing surgical faculty attrition rates (leaving academic surgery for any reason...

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https://padlet.com/dogden9/xflihlq1hmsq

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If I can stop one heart from breaking,
I shall not live in vain;
If I can ease one life the aching,
Or cool one pain,
Or help one fainting robin
Unto his nest again,
I shall not live in vain.

Emily Dickinson