• Heart transplant
• transplantation

Irving et al (see page 1217) present the Freeman hospital experience with transplant for adult congenital heart disease in this issue of Heart.1 Only 38 operations were performed in over 20 years. Overall, 30-day mortality was 30%. The initial postoperative mortality results are concerning, with a mortality of 50% in the early era, but this fell to 18% in the more recent era. Heart transplantation is a successful treatment, providing a good quality of life and survival of over 10 years in most cases. But it is a treatment that is only available for a minority of patients. In the UK, cadaveric organ donation is in decline and heart transplantation is in crisis. Heart transplantation in adults fell to an all time low of 92 transplants in 2008–9. This is less than half of the activity reported in the earlier era, 1996–2002. If organs are in such short supply is it appropriate to give them to patients at high risk of death early after the transplant operation? Early mortality grabs the headlines in the press and is rigorously monitored in the UK, with units being investigated if early mortality creeps above statistical signals with headlines like ‘Harefield Heart Unit calls in inspectors after four deaths’, Guardian 10 October 2008, and ‘Heart transplants halted after seven die at Papworth Hospital’, Daily Mail 7 November 2007.

Clearly, it is not fair to consider early mortality in isolation. In the Freeman paper the steep mortality rate over the early period declined subsequently, with 58% survival at 5 years and 53% survival at 10 and 15 years. A recent report in the US showed that the outcome of 488 congenital patients who survived the …