James K. Kirklin, James B. Young, David C. McGiffin
883 pp. New York: Churchill Livingstone; 2002. $229.00. ISBN 0-443-07655-3
Transplantation is a highly specialized area of medicine that allows physicians to turn tragic deaths into lifesaving opportunities. It is as much concerned with philosophy and medical ethics as with science. The science of transplantation is complicated and crosses the boundaries of many disciplines. Heart Transplantation is a large, imposing book that presents a comprehensive analysis of this field while admirably capturing its spirit.
In the foreword, pioneer transplantation surgeon Dr Norman Shumway states that the text is authored, not edited, and therefore has a certain constancy. I believe that this constancy, however, is a double-edged sword. Whereas the text is very readable and its overall flow is excellent, the views presented are fairly narrow. Because the number of transplant patients has been so small, few large multicenter trials have been performed, few consensus guidelines are available for patient management, and management protocols vary considerably from one institution to another. Nevertheless, Heart Transplantation presents the viewpoints of essentially only 2 centers, the University of Alabama at Birmingham (Drs Kirkland and McGiffin) and the Cleveland Clinic (Dr Young). Of the 17 authors represented, 12 are from these 2 institutions. Certainly, they are among the most successful transplant centers in the United States. I would like to have seen counterpoint arguments from other centers, however, especially European centers, which use very different approaches.
Heart Transplantation is the product of an interesting collaboration between transplantation cardiologists and transplantation surgeons. Historically, these 2 groups have used different approaches, with the cardiologists being relatively dogmatic and the surgeons being relatively empirical. Transplantation requires both camps to come together in an “empirically dogmatic” approach, and I think that this goal has been achieved in Heart Transplantation. The book presents a large volume of dogmatic data, including basic science studies and statistical analyses, as well as voluminous references for each chapter. However, when necessary, the authors have created admirable arguments on the basis of sparse or only inferential data.
Today’s heart failure patients are surviving longer, and thus often have worsening dysfunction of other organs. In addition, the widening role of cardiac defibrillators and bi-ventricular pacemakers has added a new factor in treatment of heart failure and consideration for transplant. As a result, transplantation candidate selection and perioperative management has become much more difficult. Although the chapters on heart failure and perioperative management (chapters 4, 5, and 6) are quite good, they do not adequately address these important trends.
With respect to individual chapters, the material on heart failure and its history (chapter 4) is very interesting; I especially like the earliest description of a cure for heart failure, as promulgated in the New Testament by Jesus Christ.
Although important and useful, the information about statistics (chapter 3) is not necessarily related to transplantation and might have been better presented as an appendix.
Chapter 4, which concerns the pathophysiology and clinical features of heart failure (and was probably written by Dr Young), is excellent, providing many new ways of thinking about this disease.
The material about recipient evaluation and selection (chapter 6) is outstanding — some would even say bold — giving a great deal of opinion rather than strongly supported fact. The author of this section was probably mainly Dr Young, and I am more comfortable with his opinions than with the facts given by many other experts.
Another excellent, inclusive chapter (chapter 8) is the one on mechanical support of the failing heart, which benefits greatly from the outstanding experience of Dr Robert Kormos.
Chapter 12, which concerns transplant recipient management during hospitalization, is also exceptionally useful. It provides numerous guidelines, tips, and interesting theories, such as the belief that preoperative amiodarone therapy may increase post-transplant pulmonary complications.
The chapter on allograft rejection (chapter 14) is very inclusive and presents a lot of statistics that can help predict which patients are at risk. This information must be taken with a grain of salt because some of it is outdated. Modern antirejection drugs, including immunomodulators like pravastatin, have lowered rejection rates in general, so there may now be a tendency toward over-immunosuppression.
In chapter 16, the cardiac transplant research database data are outdated (1999). The reader can use it as a guideline to understand the data but should get current data from the web site of the International Society for Heart and Lung Transplantation (http://www.ishlt.org/). It is interesting that the University of Alabama at Birmingham and the Cleveland Clinic published their own survival data. Such referral centers often have a higher mortality because the sickest patients are sent to them.
Chapter 17, which concerns vasculopathy, is exceptionally well written and complete, including 351 references.
Chapter 23, which is on xenotransplantation, is particularly interesting. This technology needs much more refinement and may never be clinically applicable, but it lends insight into other areas of transplantation and into the host-organ interaction.
One area in which the text may be lacking concerns new (and changing) indications for referral to transplantation centers, as well as recent evidence that the heart failure population which may benefit from transplant may be changing. Although the incidence and prevalence of heart failure is increasing dramatically, the number of heart transplantations done in the United States remains less than 3000 per year. The shortage of donor organs is the biggest problem in heart transplantation. Perhaps the book should have included some discussion of this problem, as well as ideas and recommendations for improving organ donation and utilization.
Overall, Heart Transplantation is a superb text that belongs on the shelf of every physician, nurse, administrator, and medical student involved in the care of transplant patients. The book’s unusual format and presentation succeed because of the remarkable competence and experience of the authors. I congratulate them on undertaking such an ambitious publishing project. Heart Transplantation will aid in the care of patients, the teaching of students, and the management of transplant programs for years to come.