- Email: [email protected]
The future
The Future Stephen R. Large, FRCS, MBA
There is no doubt that transplant Figure 1 graphically portrays heart for the United States and non-US International Society for Heart and
activity is falling. transplant activity centers from the Lung Transplanta-
From the Surgical Unit, Papworth Hospital, Cambridge, United Kingdom. Submitted January 27, 2004; accepted June 6, 2004. Reprint requests: Stephen Large, FRCS, MBA, Surgical Unit, Papworth Hospital, Cambridge CB3 8RE, UK. Telephone: 0044-1480364478. E-mail: [email protected] J Heart Lung Transplant 2004;23:S263– 64. Copyright © 2004 by the International Society for Heart and Lung Transplantation. 1053-2498/04/$–see front matter. doi:10.1016/ j.healun.2004.06.014
tion (ISHLT) database. Interestingly, there appears to be a greater decline in donor organ usage outside the US across time. Many enterprises experience a life cycle made up of 3 phases: growth, maturity, and decline. The transplant enterprise shows a clear growth phase (1982 to 1987 or so), followed by a mature phase (1987 to 1995 or so), and then a decline phase (non-US from 1995 or so and not yet evident to date 2001 for the US). It would be good to understand why this disparity exists, but whatever the reason (which may in part be due to under-reporting from non-US centers), we must develop strategies to halt further decline. What strategies are available?
Figure 1. A. Heart transplant activity across time from the International Society for Heart and Lung Transplantation (2001) and (B) a log plot of heart transplantation activity across time (ISHLT). S263
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The Journal of Heart and Lung Transplantation September (Suppl) 2004
numbers of brain dead donors. The “poor” donor heart is our dog, though some have questioned that even these hearts may be possible to turn around with resuscitation. What of our star? It would appear that these are hearts from brain intact donors free of the insult of brain death. Khagani and colleagues [see article on page XXXX of this supplement] describe their use of the domino heart that comes from a brain-intact recipient of heart and lung transplantation. However, this bright innovation will not yield an increase in market share, as heart and lung transplantation has witnessed a more dramatic decline in activity than heart transplantation.
Figure 2. In this management tool model, the cash cow represents good “donor hearts” that dominate the market; however, declining numbers of brain dead donors threaten its availability. The dog (lost leader) represents the “poor” donor heart. The star represents hearts from brain intact donors (domino hearts). The question mark indicates donor hearts from those with coronary disease.
STRATEGIC ANALYSIS With this in mind, it is useful to review another management tool offered by the Boston Consulting Group (West’s Publishing 1979). These strategists compare the impact of various enterprises on market share and market growth. Their cash cow maintains a high share of the market but little in the way of growth of that market, the bright innovation or star assists by maintaining market share and market growth. A lost leader or dog fails to help in either domain and is best disposed of, but the question mark brings interest for the prospect of market growth, albeit with an element of doubt (Figure 2). This model can be used as a template to explore the heart transplant market. Here, our cash cow is the “good” donor heart that dominates the “donor heart market,” but its availability is threatened by declining
CONCLUSIONS What has not been addressed by this Fall meeting is the possibility of growing the market by exploring the use of donor hearts (a dog) from non-beating heart donors. This is not as ridiculous as it sounds, remembering that this was the source of the first heart donation for clinical transplantation by Christian Barnard in 1969. Such a source is truly a question mark in our model. Within this quarter also lie many possible bright stars of the future, and these include: 1. Recipient heart replacement with xenograft hearts, and 2. Re-powering the patients flagging heart. Re-powering failing hearts with assist devices has already been explored in the Rematch trial. This area therefore would still seem to currently lie in the question mark zone. However, it may develop to a point where we will rely on this rather than solid organ transplantation. 3. Promise also lies in re-energizing failing hearts with stem cells or compatible myocytes, perhaps liberating the recipient from immunosuppression and so becoming a very bright star indeed. It will be very interesting to review the state of heart transplantation in the future, in part to reflect on how the widening gap between supply of and demand for useable hearts has been managed.
There is no doubt that transplant Figure 1 graphically portrays heart for the United States and non-US International Society for Heart and
activity is falling. transplant activity centers from the Lung Transplanta-
From the Surgical Unit, Papworth Hospital, Cambridge, United Kingdom. Submitted January 27, 2004; accepted June 6, 2004. Reprint requests: Stephen Large, FRCS, MBA, Surgical Unit, Papworth Hospital, Cambridge CB3 8RE, UK. Telephone: 0044-1480364478. E-mail: [email protected] J Heart Lung Transplant 2004;23:S263– 64. Copyright © 2004 by the International Society for Heart and Lung Transplantation. 1053-2498/04/$–see front matter. doi:10.1016/ j.healun.2004.06.014
tion (ISHLT) database. Interestingly, there appears to be a greater decline in donor organ usage outside the US across time. Many enterprises experience a life cycle made up of 3 phases: growth, maturity, and decline. The transplant enterprise shows a clear growth phase (1982 to 1987 or so), followed by a mature phase (1987 to 1995 or so), and then a decline phase (non-US from 1995 or so and not yet evident to date 2001 for the US). It would be good to understand why this disparity exists, but whatever the reason (which may in part be due to under-reporting from non-US centers), we must develop strategies to halt further decline. What strategies are available?
Figure 1. A. Heart transplant activity across time from the International Society for Heart and Lung Transplantation (2001) and (B) a log plot of heart transplantation activity across time (ISHLT). S263
S264
Large
The Journal of Heart and Lung Transplantation September (Suppl) 2004
numbers of brain dead donors. The “poor” donor heart is our dog, though some have questioned that even these hearts may be possible to turn around with resuscitation. What of our star? It would appear that these are hearts from brain intact donors free of the insult of brain death. Khagani and colleagues [see article on page XXXX of this supplement] describe their use of the domino heart that comes from a brain-intact recipient of heart and lung transplantation. However, this bright innovation will not yield an increase in market share, as heart and lung transplantation has witnessed a more dramatic decline in activity than heart transplantation.
Figure 2. In this management tool model, the cash cow represents good “donor hearts” that dominate the market; however, declining numbers of brain dead donors threaten its availability. The dog (lost leader) represents the “poor” donor heart. The star represents hearts from brain intact donors (domino hearts). The question mark indicates donor hearts from those with coronary disease.
STRATEGIC ANALYSIS With this in mind, it is useful to review another management tool offered by the Boston Consulting Group (West’s Publishing 1979). These strategists compare the impact of various enterprises on market share and market growth. Their cash cow maintains a high share of the market but little in the way of growth of that market, the bright innovation or star assists by maintaining market share and market growth. A lost leader or dog fails to help in either domain and is best disposed of, but the question mark brings interest for the prospect of market growth, albeit with an element of doubt (Figure 2). This model can be used as a template to explore the heart transplant market. Here, our cash cow is the “good” donor heart that dominates the “donor heart market,” but its availability is threatened by declining
CONCLUSIONS What has not been addressed by this Fall meeting is the possibility of growing the market by exploring the use of donor hearts (a dog) from non-beating heart donors. This is not as ridiculous as it sounds, remembering that this was the source of the first heart donation for clinical transplantation by Christian Barnard in 1969. Such a source is truly a question mark in our model. Within this quarter also lie many possible bright stars of the future, and these include: 1. Recipient heart replacement with xenograft hearts, and 2. Re-powering the patients flagging heart. Re-powering failing hearts with assist devices has already been explored in the Rematch trial. This area therefore would still seem to currently lie in the question mark zone. However, it may develop to a point where we will rely on this rather than solid organ transplantation. 3. Promise also lies in re-energizing failing hearts with stem cells or compatible myocytes, perhaps liberating the recipient from immunosuppression and so becoming a very bright star indeed. It will be very interesting to review the state of heart transplantation in the future, in part to reflect on how the widening gap between supply of and demand for useable hearts has been managed.